Severe Aortic Stenosis Associated with Other Valve Diseases: Open Surgery or Percutaneous Treatment?

Treatment decisions in the context of severe aortic stenosis (AS) associated with other valvular heart diseases (VHDs) have become a major challenge in recent years. Transcatheter aortic valve replacement (TAVR) in AS has increased significantly in younger patients with lower surgical risk, which has complicated the choice of the best treatment in cases of other associated valvulopathies. The most frequently associated lesions in this clinical scenario are mitral regurgitation (MR), mitral stenosis, and tricuspid regurgitation (TR). Furthermore, it should be noted that different percutaneous techniques are now available to accommodate any associated valvulopathies, which has considerably broadened the range of therapeutic options. The management of AS treated in isolation, especially by TAVR, has also shown that many cases of significant MR or TR are substantially reduced without any intervention. However, although some parameters have been described as potential risk factors in predicting the poor outcome of untreated VHDs, which cases will progress in a clinically more aggressive way remains uncertain. This review aimed to evaluate the most recent publications to provide the pathophysiology and prognosis of severe AS associated with other significant VHDs and to evaluate the best invasive therapeutic approach depending on the associated valvular disease.

A Second Fungal Outbreak in Castañar Cave, Spain, Discloses the Fragility of Subsurface Ecosystems.

Castañar is a cave with strict visitor control measures since it was open to public visits in 2003. However, in recent years, the cave suffered two fungal outbreaks, the first in 2008 and controlled by cleaning the contaminated sediments and subsequent closure of the cave until 2014. The cave was reopened but limited to a maximum of 450 visitors/year. Despite these restrictions on visit, the cave experienced a second outbreak in 2021, originating from the installation of a steel grating walkway, aiming at protecting the ground sediments from the visitors' footsteps. Here, we conducted an analysis using Next-Generation Sequencing and culture-dependent techniques to investigate the fungal communities related to the second outbreak and compare with those present before the cave suffered the outbreak. The results show that the most abundant fungi involved in the 2021 outbreak were already detected in 2020, and even in 2008 and 2009, although the main species that originating both outbreaks were different, likely due to the different carbon sources introduced into the cave.

Gypsum Cave Biofilm Communities are Strongly Influenced by Bat- And Arthropod-Related Fungi.

The Gypsum Karst of Sorbas, Almeria, southeast Spain, includes a few caves whose entrances are open and allow the entry and roosting of numerous bats. Caves are characterized by their diversity of gypsum speleothems, such as stalactites, coralloids, gypsum crusts, etc. Colored biofilms can be observed on the walls of most caves, among which the Covadura and C3 caves were studied. The objective was to determine the influence that bat mycobiomes may have on the fungal communities of biofilms. The results indicate that the fungi retrieved from white and yellow biofilms in Covadura Cave (Ascomycota, Mortierellomycota, Basidiomycota) showed a wide diversity, depending on their location, and were highly influenced by the bat population, the guano and the arthropods that thrive in the guano, while C3 Cave was more strongly influenced by soil- and arthropod-related fungi (Ascomycota, Mortierellomycota), due to the absence of roosting bats.

Impact of a Cardiogenic Shock Program on Mortality in a Non-Transplant Hospital.

INTRODUCTION: Cardiogenic shock is associated with high in-hospital morbidity and mortality. Improvements in this care process could lead to better outcomes. METHODS: This retrospective study of patients with cardiogenic shock compared two periods: no specific program to address cardiogenic shock and implementation of a cardiogenic shock program. This program included the establishment of a multidisciplinary team (shock team), early alert to the transplant hospital, initiation of a ventricular assist extracorporeal membrane oxygenation (ECMO) program, and extension of continuous care by acute cardiovascular care specialists. The primary objective was to analyse whether there were differences between in-hospital mortality and mortality during follow-up. Predictors of in-hospital mortality were examined as a secondary objective. RESULTS: A total of 139 patients were enrolled: 69 of them in the previous period and 70 in the cardiogenic shock program period. There was a significant reduction in in-hospital mortality (55.1% vs 37.1%; p=0.03) and mortality during follow-up (62.7% vs 44.6%; p=0.03) in the second period. Diabetes mellitus, ejection fraction, out-of-hospital cardiac arrest, and implementation of the cardiogenic shock program were independent predictors of in-hospital mortality. CONCLUSIONS: The implementation of a comprehensive cardiogenic shock program in a non-transplanting hospital improved in-hospital and follow-up mortality of patients in cardiogenic shock.

Current Evidence on the Benefit of Exercise in Cancer Patients: Effects on Cardiovascular Mortality, Cardiotoxicity, and Quality of Life.

Cancer and its treatments affect cardiovascular (CV) health, including an increased risk of CV death, decreased cardiorespiratory fitness (CRF), and cardiac dysfunction. Moreover, cancer-related fatigue and worse quality of life (QoL) are highly prevalent adverse effects experienced by patients during treatment and can persist years after therapy ends. Physical exercise has been proposed as a strategy to improve different aspects of life of cancer patients, and is recommended as a therapy in cardio-oncology guidelines. Exercise interventions reduce fatigue and improve QoL in patients with both solid tumors and hematological malignancies, although there is a lack of awareness of exercise recommendations, timing, and referral to such programs. New evidence indicates that physical activities improve CRF, which can lead to a reduction in CV mortality. Furthermore, cardiac dysfunction is a side effect of many oncological treatments, which may be mitigated by exercise interventions according to preclinical studies and recent publications. Nevertheless, specific physical exercise programs are not widely used in cancer patients. Thus, the goal of this review was to describe the current evidence on the benefits of exercise in cancer patients, the gaps that remain, and an approach to exercise prescription.

Scenarios for the Altamira cave CO2 concentration from 1950 to 2100.

A data-driven approach insensitive to the initial conditions was developed to extract governing equations for the concentration of CO2 in the Altamira cave (Spain) and its two main drivers: the outside temperature and the soil moisture. This model was then reformulated in order to use satellite observations and meteorological predictions, as a forcing. The concentration of CO2 inside the cave was then investigated from 1950 to 2100 under various scenarios. It is found that extreme levels of CO2 were reached during the period 1950-1972 due to the massive affluence of visitors. It is demonstrated that it is possible to monitor the CO2 in the cave in real time using satellite information as an external forcing. For the future, it is shown that the maximum values of CO2 will exceed the levels reached during the 1980s and the 1990s when the CO2 introduced by the touristic visits, although intentionally reduced, still enhanced considerably the micro corrosion of walls and pigments.

Adaptive response of prokaryotic communities to extreme pollution flooding in a Paleolithic rock art cave (Pindal Cave, northern Spain).

A flood event affecting Pindal Cave, a UNESCO World Heritage site, introduced a substantial amount of external sediments and waste into the cave. This event led to the burial of preexisting sediments, altering the biogeochemical characteristics of the cave ecosystem by introducing heightened levels of organic matter, nitrogen compounds, phosphorus, and heavy metals. The sediments included particulate matter and waste from a cattle farm located within the water catchment area of the cavity, along with diverse microorganisms, reshaping the cave microbial community. This study addresses the ongoing influence of a cattle farm on the cave ecosystem and aims to understand the adaptive responses of the underground microbial community to the sudden influx of waste allochthonous material. Here, we show that the flood event had an immediate and profound effect on the cave microbial community, marked by a significant increase in methanogenic archaea, denitrifying bacteria, and other microorganisms commonly associated with mammalian intestinal tracts. Furthermore, our findings reveal that one year after the flood, microorganisms related to the flood decreased, while the increase in inorganic forms of ammonium and nitrate suggests potential nitrification, aligning with increased abundances of corresponding functional genes involved in nitrogen cycling. The results reveal that the impact of pollution was neither recent nor isolated, and it was decisive in stopping livestock activity near the cave. The influence of the cattle farm has persisted since its establishment over the impluvium area, and this influence endures even a year after the flood. Our study emphasizes the dynamic interplay between natural events, anthropogenic activities, and microbial communities, offering insights into the resilience of cave ecosystems. Understanding microbial adaptation in response to environmental disturbances, as demonstrated in this cave ecosystem, has implications for broader ecological studies and underscores the importance of considering temporal dynamics in conservation efforts.

Ventricular Intramyocardial Dissecting Hematoma: What Is its True Clinical Evolution and the Best Treatment?

Intramyocardial dissecting hematoma (IDH), in the setting of an acute coronary syndrome, is a rare type of cardiac rupture. However, the best treatment for IDH in each clinical scenario is not clearly defined. We present a case in which the best approach for IDH and its final outcome are discussed.

Clinical Outcomes in Patients With Bicuspid Aortic Valves and Ascending Aorta ≥50 mm Under Surveillance.

Background: Clinical outcomes of bicuspid aortic valve (BAV) patients with ascending aortic diameters ≥50 mm who are under surveillance are poorly defined. Objectives: The purpose of this study was to assess clinical outcomes in BAV patients with ascending aorta ≥50 mm. Methods: Multicenter retrospective cohort study of BAV adults with ascending aorta diameters ≥50 mm by transthoracic echocardiography (TTE). Patients were categorized into 50 to 54 mm and ≥55 mm groups. Clinical outcomes were aortic dissection (AoD), aorta surgery, surgical mortality, and all-cause death. Results: Of 875 consecutive BAV patients (age 60 ± 13 years, 86% men, aortic diameter 51 mm [interquartile range (IQR): 50-53 mm]), 328 (37%) underwent early surgery ≤3 months from index TTE. Of the remaining 547 patients under surveillance, 496 had diameters 50 to 54 mm and 51 had diameters ≥55 mm and were collectively followed for 7.51 (IQR: 3.98-12.20) years. Of 496 patients with diameters 50 to 54 mm under surveillance, 266 (54%) underwent surgery 2.0 (IQR: 0.77-4.16) years from index TTE. AoD occurred in 9/496 (1.8%) patients for an incidence of 0.4 cases per 100 person-years, surgical mortality was 5/266 (1.9%); and ≥moderate aortic stenosis (but not aorta size) was associated with all-cause death, hazard ratio: 2.05 (95% CI: 1.32-3.20), P = 0.001. Conversely, in 547 total patients under surveillance (including 50-54 mm and ≥55 mm), both aorta size and ≥moderate aortic stenosis were associated with all-cause death (both P ≤ 0.027). AoD rate in patients ≥55 mm under surveillance was 5.9%. Conclusions: In BAV patients with ascending aorta 50 to 54 mm under surveillance, AoD incidence is low and the overall rates of AoD and surgical mortality are similar, suggesting clinical equivalence between surgical and surveillance strategies. Conversely, patients with aortas ≥55 mm should undergo surgery. Aortic stenosis is associated with all-cause death in these patients.

Factores asociados a la presencia de prostatitis aguda bacteriana en pacientes sometidos a biopsia prostática transrectal entre los años 2015 y 2019 en un hospital de las Fuerzas Armadas de Lima, Perú / Factors associated with the presence of acute bacterial prostatitis in patients undergoing transrectal prostate biopsy between 2015 and 2019 at an Armed Forces Hospital in Lima, Peru

RESUMEN Objetivo: determinar los factores asociados a la presencia de prostatitis aguda bacteriana en pacientes sometidos a biopsia prostática transrectal entre los años 2015 y 2019 en un Hospital de las Fuerzas Armadas de Lima, Perú. Materiales y métodos: estudio observacional transversal retrospectivo. Se evaluaron historias clínicas de 142 pacientes, seleccionados por muestreo no probabilístico. Analizamos los factores asociados a la presencia de prostatitis aguda bacteriana (PAB) en pacientes sometidos a biopsia prostática transrectal (modelo-1) y el número de factores asociados a PAB (modelo-2). Resultados: la presencia de prostatitis aguda bacteriana (PAB) fue 15,5%. La PAB fue mayor en pacientes diabéticos, hipertensos y los que padecían de insuficiencia renal crónica. En el modelo-1, el antecedente de diabetes mellitus tipo 2 (razón de prevalencia ajustada (RPa): 3,18; IC 95%: 0,92 - 11,03), la hipertensión arterial (RPa: 1,78; IC 95%: 0,53 - 5,98), la insuficiencia renal (RPa: 2,73; IC 95%: 0,60 - 12,46) y la prostatitis crónica (RPa: 4,5; IC 95%: 0,99 - 20,43) no se encontraron asociados (p >0,05). En el modelo-2, encontramos que aquellos sujetos entre 66-75 años, tienen 50% menor probabilidad de presentar PAB que aquellos sujetos de 50-65 años y que los sujetos mayores de 75 años tienen 2,7 (IC 95%: 0,86 - 8,13) veces mayor probabilidad que el grupo más joven. Finalmente, se observó que un mayor número de comorbilidades incrementa la probabilidad de presentar PAB, siendo 4,80 (IC 95%: 1,86 - 12,42) veces en aquellos con una enfermedad, 5,77 (IC 95%: 1,03 - 32,13) con dos enfermedades y 10,47 (IC 95%: 1,98 - 55,41) veces mayor, en aquellos con tres enfermedades. Conclusiones: en nuestro estudio, el antecedente de diabetes mellitus tipo 2 y el número de comorbilidades crónicas incrementan la probabilidad de presentar PAB. Se recomienda realizar un mayor número de estudios que permitan verificar nuestros resultados.

ABSTRACT Objective : to determine the factors associated with the presence of acute bacterial prostatitis in patients undergoing transrectal prostate biopsy between 2015 and 2019 at an Army Forces Hospital in Lima, Peru. Materials and methods : this is a retrospective observational and cross-sectional study. Clinical records from 142 patients were reviewed, which were selected using non-probabilistic sampling. We analyzed factors associated with the occurrence of acute bacterial prostatitis (ABP) in patients undergoing a transrectal prostate biopsy (model 1), and the number of factors associated with ABP (model 2). Results : the rate of ABP was 15.5%. This condition was more prevalent in subjects with diabetes, high blood pressure and chronic renal failure. In model 1, a past history of type 2 diabetes mellitus (adjusted prevalence ratio (aPR): 3.18; 95% CI: 0.92-11.03), high blood pressure (aPR: 1.78; 95% CI: 0.53-5.98), renal failure (aPR: 2.73; 95% CI: 0.60-12.46), and chronic prostatitis (aPR: 4.5; 95% CI: 0.99-20.43) were not associated (p >0.05). In model 2, we found that subjects between 66-75 years of age had a 50% less likelihood for developing APB compared with those in the 50-65 years old group, and that subjects more than 75 years old have a 2.7-fold (95% CI: 0.86-8.13) likelihood for this condition compared with subjects from younger age groups. Finally, it was observed that a greater number of comorbidities increases the likelihood for developing ABP, being this 4.80-fold (95% CI: 1.86-12.42) in those with one concomitant disease, 5.77-fold (95% CI: 1.03-32.13) in those with two concomitant diseases, and 10.47- fold (95% CI: 1.98-55.41) in those who had three concomitant diseases. Conclusions : in this study, a past history of type 2 diabetes mellitus and the number of concomitant chronic conditions increase the likelihood for developing ABP. It is recommended to perform further research on this topic, so our results may be verified.

Evaluación del flujo retrógrado diastólico en la aorta descendente para cuantificar la insuficiencia aórtica / Descending Aorta Diastolic Retrograde Flow Assessment for Aortic Regurgitation Quantification

Introducción: El flujo diastólico retrógrado en la aorta descendente se ha relacionado con la gravedad de la insuficiencia aórtica; sin embargo, la mayoría de los parámetros vinculados con la velocidad del flujo no se encuentran validados con una técnica de imágenes de referencia. Objetivo: Evaluar la utilidad del flujo retrógrado diastólico en la aorta torácica descendente y la aorta abdominal en la cuan-tificación de la insuficiencia aórtica utilizando como referencia la resonancia magnética. Material y métodos: Se incluyeron 40 pacientes consecutivos en un estudio prospectivo de ecocardiografía y resonancia magnética. Por Doppler pulsado se analizaron los siguientes parámetros: a) la integral velocidad-tiempo del flujo retrógrado diastólico y b) la velocidad máxima telediastólica del flujo regurgitante, ambos en la aorta torácica, y c) el flujo holodiastólico inverso en la aorta abdominal. El protocolo de resonancia magnética incluyó secuencias de contraste de fase para calcular la fracción regurgitante. Valores > 30% se consideraron diagnósticos de insuficiencia aórtica grave. Resultados: Once pacientes (30%) tenían una fracción regurgitante > 30%. La integral velocidad-tiempo del flujo retrógrado diastólico demostró la mayor precisión en el diagnóstico de insuficiencia aórtica grave: ABC = 0,87; p < 0,001. Un punto de corte para la integral velocidad-tiempo del flujo retrógrado diastólico > 15 cm demostró una sensibilidad del 91% y una especificidad del 86% para detectar insuficiencia aórtica grave. El flujo pandiastólico inverso en la aorta abdominal mostró una excelente especificidad (100%) para el diagnóstico de insuficiencia aórtica grave, aunque con baja sensibilidad (50%). Conclusiones: La evaluación del flujo retrógrado diastólico en la aorta torácica descendente permite un diagnóstico adecuado de la insuficiencia aórtica grave. El flujo holodiastólico inverso, aunque es poco sensible, muestra una alta especificidad.