Protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en el diagnóstico del dolor torácico: una revisión sistemática / Accelerated Diagnostic Protocols Based on High-Sensitivity Troponin in the Diagnosis of Thoracic Pain: A Systematic Review

RESUMEN Introducción: Los protocolos de diagnóstico acelerado de dolor torácico, con el avance de la troponina de alta sensibilidad, permiten identificar a los pacientes que ingresan al servicio de urgencias con dolor torácico de bajo riesgo para un evento cardiovascular adverso mayor, que podrían ser dados de alta de forma temprana y segura, con ahorro de tiempo y recursos. Objetivo: Evaluar ensayos clínicos que utilicen protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad. Material y métodos: se realizó una búsqueda de ensayos clínicos aleatorizados que evaluaran protocolos de diagnóstico acelerado basados en troponina de alta sensibilidad en los servicios de urgencias, en las bases de datos MEDLINE/Ovid, Cochrane y EMBASE utilizando los criterios de evaluación del manual Cochrane y la estrategia PRISMA Resultados: Tras una tamización de 3509 estudios se incluyeron 5 ensayos clínicos que incluyeron 1513 pacientes; se identificaron 409 (27%) altas tempranas, el 91% para el protocolo 0/3 h ESC, 72% para el 0/1 h, 48% para el EDACS, 40% para el HEART, 19 y 32% para ADAPT y 8 y 18% para el cuidado usual. El valor predictivo negativo fue alto, en un rango de 99,1 al 100% La duración media de la estancia hospitalaria fue más baja para los protocolos 0/1 h y 0/3 h ESC, con 4,6 y 5,6 horas respectivamente. Conclusiones: Los protocolos de diagnóstico acelerado en dolor torácico que implementan el uso de troponina de alta sensibilidad permiten lograr alta proporción de altas tempranas con baja tasa de eventos cardiovasculares mayores, con disminución del tiempo de estancia y recursos consumidos.

ABSTRACT Background: Accelerated diagnostic protocols for chest pain, with the advancement of high-sensitivity troponin, make it possible to identify patients admitted to the emergency department with chest pain and low risk for a major adverse cardiovascular event, who could be discharged immediately, early and safely, saving time and resources. Objective: The aim of this study was to assess clinical trials using accelerated diagnostic protocols based on high-sensitivity troponin. Methods: A search of randomized clinical trials evaluating accelerated diagnostic protocols based on high-sensitivity troponin in emergency services was carried out in MEDLINE/Ovid, Cochrane and EMBASE database, using the assessment criteria of the Cochrane manual and the PRISMA strategy. Results: After screening 3509 studies, 5 clinical trials, including 1513 patients, were analyzed. Early discharges were identified in 409 (27%) of patients, in 91% of cases for ESC 0/3-h protocols, 72% for 0/1-h, 48% for EDACS, 40% for HEART, 19% and 32% for ADAPT and 8% and 18% for standard care protocols. The negative predictive value was high, in the 99.1-100% range. Mean length of hospital stay was lower for the 0/1-h and ESC 0/3-h protocols, with 4.6 and 5.6 hours, respectively. Conclusions: Accelerated diagnostic protocols in chest pain using high-sensitivity troponin allow a higher proportion of early discharges with a low rate of major cardiovascular events, with reduction in length of hospital stay and resources used.

Criptococosis y linfocitopenia T CD4 idiopática: Reporte de un caso / Cryptococcosis and idiopathic CD4 T lymphocytopenia: A case report

Resumen La linfocitopenia T CD4 idiopática (LCI) es un síndrome clínico inusual que se caracteriza por un déficit de células T CD4+ circulantes en ausencia de infección por VIH u otra condición de inmunosupresión. Los pacientes con dicha enfermedad pueden presentarse asintomáticos o con infecciones oportunistas, las más frecuentes son por criptococo, micobacterias o virales como herpes zoster. Presentamos el caso de un hombre de 32 años, sin antecedentes, en quien se descartó infección por retrovirus, con recuento de linfocitos T CD4+ menor a 300 células/m3; se diagnosticó LCI posterior al diagnóstico de criptococomas cerebrales mediante hallazgos imagenológicos los cuales fueron congruentes con estudios microbiológicos.

Summary Idiopathic CD4 T lymphocytopenia (ICL) is an unusual clinical syndrome characterized by a deficit of circulating CD4 + T cells in the absence of HIV infection or another immunosuppression condition. Patients with this disease may present asymptomatic or with opportunistic infections, the most frequent are cryptococcus, mycobacteria or viral such as herpes zoster. We present a case of a 32-year-old man with no prior disease, in whom retrovirus infection was discarded, with CD4 + T lymphocyte count less than 300 cells/m3; ICL was diagnosed after the diagnosis of brain cryptococomas by imaging findings which were consistent with microbiological studies.

Volatile and sensory characterization of roast coffees - Effects of cherry maturity.

Immature coffee cherries produce roast coffees with lower hedonic scores than those produced from mature cherries, but variation in volatile and sensory characteristics over a range of maturities is not well studied. In this work, cherries from two coffee cultivars (Caturra, Catimor) were sorted into seven maturity stages from fully immature (Stage 1, green) to fully overripe (Stage 7, purple). Volatile profiles of Stage 1 roast coffee had lower concentrations of carbohydrate degradation products and higher concentrations of N-heterocycles and phenols. Differences in volatiles among Stage 2 (partially immature, yellow-green) and subsequent stages were insignificant (p > 0.05) or else minor. Principle component analysis of the volatile data set also distinguished Stage 1 from other stages. Similarly, a trained cupping panel reported significantly lower sensory scores for Stage 1 as compared to Stages 2-7, but few differences among Stages 2-7. Thus, partially mature and overripe cherries may be appropriate for specialty coffee.

Simple mathematical law benchmarks human confrontations.

Many high-profile societal problems involve an individual or group repeatedly attacking another - from child-parent disputes, sexual violence against women, civil unrest, violent conflicts and acts of terror, to current cyber-attacks on national infrastructure and ultrafast cyber-trades attacking stockholders. There is an urgent need to quantify the likely severity and timing of such future acts, shed light on likely perpetrators, and identify intervention strategies. Here we present a combined analysis of multiple datasets across all these domains which account for >100,000 events, and show that a simple mathematical law can benchmark them all. We derive this benchmark and interpret it, using a minimal mechanistic model grounded by state-of-the-art fieldwork. Our findings provide quantitative predictions concerning future attacks; a tool to help detect common perpetrators and abnormal behaviors; insight into the trajectory of a 'lone wolf'; identification of a critical threshold for spreading a message or idea among perpetrators; an intervention strategy to erode the most lethal clusters; and more broadly, a quantitative starting point for cross-disciplinary theorizing about human aggression at the individual and group level, in both real and online worlds.

Common ecology quantifies human insurgency.

Many collective human activities, including violence, have been shown to exhibit universal patterns. The size distributions of casualties both in whole wars from 1816 to 1980 and terrorist attacks have separately been shown to follow approximate power-law distributions. However, the possibility of universal patterns ranging across wars in the size distribution or timing of within-conflict events has barely been explored. Here we show that the sizes and timing of violent events within different insurgent conflicts exhibit remarkable similarities. We propose a unified model of human insurgency that reproduces these commonalities, and explains conflict-specific variations quantitatively in terms of underlying rules of engagement. Our model treats each insurgent population as an ecology of dynamically evolving, self-organized groups following common decision-making processes. Our model is consistent with several recent hypotheses about modern insurgency, is robust to many generalizations, and establishes a quantitative connection between human insurgency, global terrorism and ecology. Its similarity to financial market models provides a surprising link between violent and non-violent forms of human behaviour.

Anomalously slow attrition times for asymmetric populations with internal group dynamics.

The many-body dynamics exhibited by living objects include group formation within a population and the nonequilibrium process of attrition between two opposing populations due to competition or conflict. We show analytically and numerically that the combination of these two dynamical processes generates an attrition duration T whose nonlinear dependence on population asymmetry x is in stark contrast to standard mass-action theories. A minority population experiences a longer survival time than two equally balanced populations, irrespective of whether or not the majority population adopts such an internal grouping. Adding a third population with predefined group sizes allows T(x) to be tailored. Our findings compare favorably to real-world observations.

Chemokine receptor expression on infiltrating lymphocytes from abdominal aortic aneurysms: role of CXCR4-CXCL12 in lymphoid recruitment.

This is a study to define the profile of chemokine receptors expressed on isolated infiltrating lymphocytes in human abdominal aortic aneurysms (AAAs), and to examine their role in lymphoid recruitment. AAA T-lymphocytes were CXCR4-positive, CCR7-negative and partially CXCR3 and CCR5-positive. Functionally, AAA T-cells were proinflammatory effector cells, as they produced IFN-gamma and granzyme A. AAA B-lymphocytes were CXCR4-positive and exhibited low CXCR5 expression. A relevant feature of infiltrating T- and B-lymphocytes was the high intensity of CXCR4 expression and the capability to migrate to CXCL12. CXCL12-producing cells were found in the adventitia of AAA. These cells were CD45-negative and partially VCAM-1 and DR-positive. In summary, the present results suggest that CXCR4, expressed on infiltrating lymphocytes, and CXCL12, expressed on stromal cells, is involved in the recruitment of lymphocytes within the arterial wall in AAA.

Organellar proteomics of human platelet dense granules reveals that 14-3-3zeta is a granule protein related to atherosclerosis.

Dense granules, a type of platelet secretory organelle, are known to accumulate high concentrations of small molecules such as calcium, adenine nucleotides, serotonin, pyrophosphate, and polyphosphate. Protein composition of these granules has been obscure, however. In this paper, we use proteomics techniques to describe, for the first time, the soluble protein composition of platelet dense granules. We have isolated highly enriched human platelet dense granule fractions that have been analyzed using two proteomics methods. Using this approach, we have identified 40 proteins, and most of them, such as actin-associated proteins, glycolytic enzymes, and regulatory proteins, have not previously been related to the organelle. We have focused our efforts on studying 14-3-3zeta, a member of a conserved family of proteins that interact with hundreds of different proteins. We have demonstrated that 14-3-3zeta is localized mostly on dense granules and that it is secreted after platelet activation. As some proteins secreted from activated platelets could promote the development of atherosclerosis and thrombosis, we have studied the expression of 14-3-3zeta in sections of human abdominal aorta of patients with aneurysm, identifying it at the atherosclerotic plaques. Together, our results reveal new details of the composition of the platelet dense granule and suggest an extracellular function for 14-3-3zeta associated with atherosclerosis.

Characterisation of T and B lymphocytes infiltrating abdominal aortic aneurysms.

Cellular infiltrates consisting mainly of lymphocytes are commonly present in the arterial wall in abdominal aortic aneurysm (AAA). However, despite this, the precise nature of these populations has to date not been described in detail. The aim of this study was to perform an exhaustive phenotypic characterisation of the infiltrating lymphocytes in order to define the inflammatory process that develops in AAA. For this purpose, AAA-infiltrating lymphocytes from 25 fresh aneurysm wall samples and, as a control, peripheral blood (PB) lymphocytes from the same patients were purified. The expression of lineage specific markers, maturation molecules, activation antigens and adhesion molecules on T and B lymphocytes was examined by triple-colour immunofluorescence and flow cytometry analysis. The phenotype of AAA-infiltrating lymphocytes was compared with that of PB of the patients with AAA. The results reveal that AAA-infiltrating B and T lymphocytes consist of activated memory cells, with specific homing properties. In addition, they express molecules of B-T co-stimulation and, occasionally, exhibit phenotypical features indicative of the ectopic formation of lymphoid structures. These findings are discussed in the light of the similarities shared with the lymphoid infiltration occurring in other chronic autoimmune/inflammatory disorders.