Nurturing next generation physicians: A new Israeli healthtech fellowship.

The Israeli Society for HealthTech aims at advancing the integration of innovation and healthcare entrepreneurship into medical practice and across traditional health professions, to benefit patients and improve quality of care. In 2021, the Society launched the first fellowship for board certified physicians in HealthTech. This backstory discusses the motivation of launching the program and reviews the design of the fellowship, including curriculum, the expertise of the lecturers, and initial tangible results of the program.

Global longitudinal strain and long-term outcome in patients presenting to the emergency department with suspected acute coronary syndrome.

AIMS: We have previously shown that 2-dimentional strain is not a useful tool for ruling out acute coronary syndrome (ACS) in the emergency department (ED). The aim of the present study was to determine whether in patients with suspected ACS, global longitudinal strain (GLS), measured in the ED using 2-dimensional strain imaging, can predict long-term outcome. METHODS: Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure, or atrial fibrillation) and all-cause mortality data were available in 525/605 patients (87%) enrolled in the Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. GLS was computed using echocardiograms performed within 24 hours of chest pain. MACE of patients with worse GLS (>median GLS) were compared to patients with better GLS (≤ median GLS). RESULTS: Median GLS was -18.7%. MACE occurred in 47/261 (18%) of patients with worse GLS as compared with 45/264 (17%) with better GLS, adjusted HR 0.87 (95% CI 0.57-1.33, P = .57). There was no significant difference in all-cause mortality or individual endpoints between groups. GLS did not predict MACE even in patients with optimal 2-dimensional image quality (n = 164, adjusted HR=1.51, 95% CI 0.76-3.0). CONCLUSIONS: Global longitudinal strain did not predict long-term outcome in patients presenting to the ED with chest pain and suspected ACS, supporting our findings in the 2DSPER study.

Peer-teaching cardiac ultrasound among medical students: A real option.

INTRODUCTION: Teaching cardiac ultrasound (CU) image acquisition requires hands-on practice under qualified instructors supervision. We assessed the efficacy of teaching medical students by their previously trained classmates (teaching assistants [TAs]) compared to teaching by expert trainers (cardiologists or diagnostic medical sonographers. METHODS: Sixty-six students received 8-hour CU training: 4-hour lectures on ultrasound anatomy and imaging techniques of 6 main CU views (parasternal long [PLAV] and short axis [PSAV]; apical 4-chamber [4ch], 2-chamber [2ch], and 3-chamber [3ch]; and sub costal [SC]) followed by 4 hours of hands-on exercise in groups of ≤5 students under direct supervision of a TA (group A: 44 students) or a qualified trainer (group B: 22 students). Students' proficiency was evaluated on a 6-minute test in which they were required to demonstrate 32 predetermined anatomic landmarks spread across the 6 views and ranked on a 0-100 scale according to a predetermined key. RESULTS: The 6-minute test final grade displayed superiority of group A over group B (54±17 vs. 39±21, respectively [p = 0.001]). This trend was continuous across all 6 main views: PLAV (69±18 vs. 54±23, respectively), PSAV (65±33 vs. 41±32, respectively), 4ch (57±19 vs. 43±26, respectively), 2ch (37±29 vs. 33±27, respectively), 3ch (48±23 vs. 35±25, respectively), and SC (36±27 vs. 24±28, respectively). CONCLUSIONS: Teaching medical students CU imaging acquisition by qualified classmates is feasible. Moreover, students instructors were superior to senior instructors when comparing their students' capabilities in a practical test. Replacing experienced instructors with TAs could help medical schools teach ultrasound techniques with minimal dependence on highly qualified trainers.

Effect of image quality on accuracy of two-dimensional strain echocardiography for diagnosing ischemic chest pain: a 2DSPER multicenter trial substudy.

Few data exist regarding the effect of image quality on measurements of two-dimensional longitudinal strain (2DLS). In the 2DLS for Diagnosing Chest Pain in the Emergency Room (2DSPER) multicenter study, 2DLS was not useful for ruling out acute coronary syndromes (ACS) in the emergency department (ED). The aim of this substudy was to determine the effect of 2D image quality on the diagnostic accuracy of 2DLS for ACS. We reviewed apical views used for 2DLS analysis in all 605 patients included in the 2DSPER study. Studies with the best image quality (HighQ, n = 177), were compared to the lower quality group (LowQ, n = 428). Abnormal 2DLS was defined as PSS20% > - 17% (PSS20% being the peak left ventricular systolic strain value identifying the 20% worst strain values). Global longitudinal strain (GLS) and PSS20% were significantly worse in LowQ compared to HighQ patients. LowQ independently predicted abnormal 2DLS (OR 1.9, 95% CI 1.3-2.9, P = 0.003). The sensitivity of PSS20% > - 17% for ACS was 85% for LowQ vs. 73% for HighQ (P = 0.2), specificity 22% vs. 38% (P < 0.0001) and overall accuracy 29% vs. 44% (P = 0.0004). Despite better overall accuracy in the HighQ group there was no significant difference between the receiver operating characteristic curves of either GLS or PSS20% in the two groups and abnormal 2DLS did not predict ACS even in HighQ patients (OR 1.7, 95% CI 0.7-4.3, P = 0.3). LowQ echo is associated with worse 2DLS. Abnormal 2DLS was not clinically useful for excluding ACS in the ED even in patients with optimal 2D image quality.Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT01163019.

Unanesthetized Rodents Demonstrate Insensitivity of QT Interval and Ventricular Refractory Period to Pacing Cycle Length.

Aim: The cardiac electrophysiology of mice and rats has been analyzed extensively, often in the context of pathological manipulations. However, the effects of beating rate on the basic electrical properties of the rodent heart remain unclear. Due to technical challenges, reported electrophysiological studies in rodents are mainly from ex vivo preparations or under deep anesthesia, conditions that might be quite far from the normal physiological state. The aim of the current study was to characterize the ventricular rate-adaptation properties of unanesthetized rats and mice. Methods: An implanted device was chronically implanted in rodents for atrial or ventricular pacing studies. Following recovery from surgery, QT interval was evaluated in rodents exposed to atrial pacing at various frequencies. In addition, the frequency dependence of ventricular refractoriness was tested by conventional ventricular programmed stimulation protocols. Results: Our findings indicate total absence of conventional rate-adaptation properties for both QT interval and ventricular refractoriness. Using monophasic action potential recordings in isolated mice hearts we could confirm the previously reported shortening of the action potential duration at fast pacing rates. However, we found that this mild shortening did not result in similar decrease of ventricular refractory period. Conclusion: Our findings indicate that unanesthetized rodents exhibit flat QT interval and ventricular refractory period rate-dependence. This data argue against empirical use of QT interval correction methods in rodent studies. Our new methodology allowing atrial and ventricular pacing of unanesthetized freely moving rodents may facilitate more appropriate utility of these important animal models in the context of cardiac electrophysiology studies.

Overview of mitral regurgitation in Europe: results from the European Registry of mitral regurgitation (EuMiClip).

Aims: To determine the prevalence of mitral regurgitation (MR) in a large cohort of consecutive patients undergoing clinically indicated echocardiography and to examine the distribution of primary and secondary MR. Methods and results: All patients undergoing an echocardiographic study in 19 European centres within a 3-month period were prospectively included. MR assessment was performed as recommended by the European Association of Cardiovascular Imaging (EACVI). MR was classified according to mechanism as primary or secondary and aetiologies were reported. A total of 63 463 consecutive echocardiographic studies were reviewed. Any degree of MR was described in 15 501 patients. Concomitant valve disease of at least moderate grade was present in 28.5% of patients, being tricuspid regurgitation the most prevalent. In the subgroup of moderate and severe MR (n = 3309), 55% of patients had primary MR and 30% secondary MR. Both mechanisms were described in 14% of the studies. According to Carpentier's classification, 26.7% of MR were classified as I, 19.9% of MR as II, 22.4% of MR as IIIa, and 31.1% of MR as IIIb. Conclusion: To date, this is the largest echocardiography-based study to analyse the prevalence and aetiology distribution of MR in Europe. The burden of secondary MR was higher than previously described, representing 30% of patients with significant MR. In our environment, degenerative disease is the most common aetiology of primary MR (60%), whereas ischaemic is the most common aetiology of secondary MR (51%). Up to 70% of patients with severe primary MR may have a Class I indication for surgery. However, the optimal therapeutic approach for secondary MR remains uncertain.

QT Prolongation as an Isolated Long-Term Cardiac Manifestation of Dichlorvos Organophosphate Poisoning in Rats.

Organophosphates (OP) are used extensively as pesticides and as chemical weapons. Cardiotoxicity is a major concern in survivors of the acute poisoning. To characterize the delayed cardiac effects of OP, rats were poisoned by intraperitoneal administration of dichlorvos. In group I, poisoning (0.25-, 0.75-, 1.4-LD50) was followed by application of atropine and obidoxime. In group II, poisoning (0.35-, 0.5-LD50) was done without antidotes. Cardiac evaluation included electrocardiography and echocardiography 2- and 6-week post-exposure, arrhythmia susceptibility following administration of Isoproterenol (150 mcg/kg), and histological evaluation. All poisoned animals displayed cholinergic symptoms. In group I, all animals exposed to 1.4-LD50 (n = 3) had profound convulsions and died despite antidote treatment. However, in the lower doses, all animals survived and no cardiac abnormalities were noted during follow-up. In group II, six animals had convulsions and died. Surviving animals had mild but significant prolongation of corrected QT at both 2 and 6 weeks, compared to shams. There were no notable echocardiographic, gravimetric, or histological differences between poisoned and sham animals. Our data indicate that dichlorvos poisoning is associated with QT prolongation without anatomical or histopathological abnormalities. This new model can be used to elaborate the molecular mechanism\s of QT prolongation following OP poisoning.

Prominent differences in left ventricular performance and myocardial properties between right ventricular and left ventricular-based pacing modes in rats.

Biventricular pacing is an important modality to improve left ventricular (LV) synchronization and long-term function. However, the biological effects of this treatment are far from being elucidated and existing animal models are limited and demanding. Recently, we introduced an implanted device for double-site epicardial pacing in rats and echocardiographically demonstrated favorable effects of LV and biventricular (LV-based) pacing modes typically observed in humans. Here, this new animal model was further characterized. Electrodes were implanted either on the right atria (RA) and right ventricle (RV) or on the RV and LV. Following recovery, rats were either used for invasive hemodynamic measurements (pressure-volume analysis) or exposed to sustained RV vs. biventricular tachypacing for 3 days. RV pacing compromised, while LV-based pacing modes markedly enhanced cardiac performance. Changes in LV performance were associated with prominent compensatory changes in arterial resistance. Sustained RV tachypacing increased the electrocardiogram QTc interval by 7.9 ± 3.1 ms (n = 6, p < 0.05), dispersed refractoriness between the right and left pacing sites and induced important molecular changes mainly in the early-activated septal tissue. These effects were not observed during biventricular tachypacing (n = 6). Our results demonstrate that the rat is an attractive new model to study the biological consequences of LV dyssynchrony and resynchronization.

The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum.

BACKGROUND: Teaching cardiac ultrasound to medical students in a brief course is a challenge. We aimed to evaluate the feasibility of teaching large groups of medical students the acquisition and interpretation of cardiac ultrasound images using a pocket ultrasound device (PUD) in a short, specially designed course. METHODS: Thirty-one medical students in their first clinical year participated in the study. All were novices in the use of cardiac ultrasound. The training consisted of 4 hours of frontal lectures and 4 hours of hands-on training. Students were encouraged to use PUD for individual practice. Finally, the students' proficiency in the acquisition of ultrasound images and their ability to recognize normal and pathological states were evaluated. RESULTS: Sixteen of 27 (59%) students were able to demonstrate all main ultrasound views (parasternal, apical, and subcostal views) in a six-minute test. The most obtainable view was the parasternal long-axis view (89%) and the least obtainable was the subcostal view (58%). Ninety-seven percent of students correctly differentiated normal from severely reduced left ventricular function, 100% correctly differentiated a normal right ventricle from a severely hypokinetic one, 100% correctly differentiated a normal mitral valve from a rheumatic one, and 88% correctly differentiated a normal aortic valve from a calcified one, while 95% of them correctly identified the presence of pericardial effusion. CONCLUSIONS: Training of medical students in cardiac ultrasound during the first clinical year using a short, focused course is feasible and enables students with modest ability to acquire the main transthoracic ultrasound views and gain proficiency in the diagnosis of a limited number of cardiac pathologies.

Two-dimensional strain echocardiography for diagnosing chest pain in the emergency room: a multicentre prospective study by the Israeli echo research group.

AIMS: Left ventricular (LV) two-dimensional longitudinal strain (2DLS) analysis by echocardiography has been suggested as a useful tool for the detection of acute coronary syndromes (ACS). Our aim was to determine whether 2DLS analysis could assist in triage of patients with chest pain (CP) in the emergency department (ED). METHODS AND RESULTS: We prospectively enrolled patients presenting to the ED with CP and suspected ACS but without a diagnostic ECG or elevated troponin. An echocardiogram was performed within 24 h of CP. For each patient, a histogram of LV myocardial peak systolic strain (PSS) was generated and the value identifying the 20% worst strain values (PSS20%) was determined. A predefined value of greater than -17% was considered abnormal. 2DLS analysis was available for 605 patients (mean age 58 ± 9 years, 70% males), of which 74 (12.2%) had ACS. During a 6-month follow-up, MACE occurred in 4 (5.8%) patients with and in 3 (0.6%) without ACS. An abnormal PSS20% was present in 60/74 patients with ACS (sensitivity 81%, negative predictive value 91%), but also in 391/531 patients without ACS (specificity 26%, positive predictive value 13%). Similar results were found for global longitudinal strain (GLS). Receiver-operating characteristic curves showed an area under curve of 0.59 for PSS20% and 0.6 for GLS (P= 0.3). Independent predictors of abnormal 2DLS were male gender, body mass index, heart rate, and mean tissue Doppler e', but not ACS. CONCLUSION: In this large multicentre prospective study, 2DLS was not a useful tool to rule out ACS in the ED. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov. UNIQUE IDENTIFIER: NCT01163019.

Impact of Point-of-Care Ultrasound Examination on Triage of Patients With Suspected Cardiac Disease.

Complementing the physical examination with a point-of-care ultrasound study (POCUS) can improve patient triage. We aimed to study the impact of POCUS on the diagnosis and management of outpatients and hospitalized patients with suspected cardiac disease. In this multicenter study, a pocket-sized device was used to perform POCUS when the diagnosis or patient management was unclear based on anamnesis, physical examination, and basic diagnostic testing. Eighteen physicians (cardiac fellows 49%, cardiologists 30%, and echocardiographers 21%) performed physical examinations extended by POCUS on 207 patients (inpatients 83% and outpatients 17%). POCUS findings resulted in a change in the primary diagnosis in 14% of patients. In patients whose diagnosis remained unchanged, POCUS results reinforced the initial diagnosis in 48% of the cases. In 39% of the patients, the diagnostic plan was altered, including referral (16%) or deferral (23%) to other diagnostic techniques. Alteration in medical treatment (drug discontinuation or initiation) occurred in 11% of the patients, and in 7% POCUS results influenced the decision whether to perform a therapeutic procedure. Hospitalization or discharge was determined after POCUS in 11% of the patients. In conclusion, during patient triage, extension of the physical examination by POCUS can cause physicians to alter their initial diagnosis, resulting in an immediate change of diagnostic and therapeutic procedures. Based on POCUS results, physicians altered the diagnostic plan either by avoiding or referring patients to other diagnostic procedures in almost half of the studied population.

[Portable ultrasound devices: a novel bedside approach for diagnosing cardiovascular disease].

Bedside cardiovascular diagnosis by examination, palpation and auscultation is sub-optimal, even when performed by experts. While the diagnostic accuracy of imaging techniques is superior to physical examination, the feasibility of its integration into bedside examination has been precluded by the size and cost of imaging technology. Beyond these practical limitations, expertise in image acquisition and assessment is required. Nonetheless, these problems could be resolved by a low cost, easy to use, portable imaging device that could be used routinely at the bedside. Small, high-resolution cardiac ultrasound units have been developed. Published studies have demonstrated a remarkable increase in the accuracy of cardiovascular diagnosis by cardiologists and non-cardiologists when they added a brief cardiac ultrasound study to their conventional physical examination. This new diagnostic methodology is becoming common practice among cardiologists and non- cardiologists. As its use is becoming more popular, several factors must be resolved, such as: Which personnel may use it? Is the training necessary or compulsory? Which entities are responsible for training and continuous education? decisions regarding documentation, of findings and exams, and more. In this review, we will provide the latest literature updates and discuss whether there is enough evidence to justify the use of ultrasound mobile devices for a focused ultrasound examination to complement the traditional physical examination.

Speckle-tracking echocardiography elucidates the effect of pacing site on left ventricular synchronization in the normal and infarcted rat myocardium.

BACKGROUND: Right ventricular (RV) pacing generates regional disparities in electrical activation and mechanical function (ventricular dyssynchrony). In contrast, left ventricular (LV) or biventricular (BIV) pacing can improve cardiac efficiency in the setting of ventricular dyssynchrony, constituting the rationale for cardiac resynchronization therapy (CRT). Animal models of ventricular dyssynchrony and CRT currently relay on large mammals which are expensive and not readily available to most researchers. We developed a methodology for double-site epicardial pacing in conscious rats. Here, following post-operative recovery, we compared the effects of various pacing modes on LV dyssynchrony in normal rats and in rats with ischemic cardiomyopathy. METHODS: Two bipolar electrodes were implanted in rats as follows: Group A (n = 6) right atrial (RA) and RV sites; Group B (n = 7) RV and LV sites; Group C (n = 8) as in group B in combination with left coronary artery ligation. Electrodes were exteriorized through the back. Following post-operative recovery, two-dimensional transthoracic echocardiography was performed during pacing through the different electrodes. Segmental systolic circumferential strain (Ecc) was used to evaluate LV dyssynchrony. RESULTS: In normal rats, RV pacing induced marked LV dyssynchrony compared to RA pacing or sinus rhythm, as measured by the standard deviation (SD) of segmental time to peak Ecc, SD of peak Ecc, and the average delay between opposing ventricular segments. LV pacing and, to a greater extend BIV pacing diminished the LV dyssynchrony compared to RV pacing. In rats with extensive MI, the effects of LV and BIV pacing were markedly attenuated, and the response of individual animals was variable. CONCLUSIONS: Rodent cardiac pacing mimics important features seen in humans. This model may be developed as a simple new tool to study the pathophysiology of ventricular dyssynchrony and CRT.

Prognostic value of myocardial ischemic electrocardiographic response in patients with normal stress echocardiographic study.

The prognostic value of ST-segment depression on exercise electrocardiogram (eECG) in the setting of a normal wall motion response in a stress echocardiographic study is not well defined. The aim of the study was to compare outcomes among patients with normal wall motion during stress echocardiography with and without ischemic exercise electrocardiographic changes. A total of 4,233 patients underwent stress echocardiography from 2007 to 2010. The primary outcomes were a composite of all-cause mortality and myocardial infarction. Coronary revascularization was a secondary outcome. A Cox regression model was used for the primary analysis. Ischemic exercise electrocardiographic changes were defined as ST-segment depression of at least 1 mm, on at least 3 consecutive beats, and in at least 2 contiguous leads. A normal stress echocardiogram was present in 2,975 patients; of them, 2,228 (74%) had a normal eECG and 747 (26%) had ischemic changes on eECG. Patients with and without ischemic changes during exercise electrocardiography were similar in age and gender. At 4-years follow-up, 36 patients (2.8%) with a normal eECG experienced a primary end point versus 12 patients (1.9%) in the group with an ischemic exercise electrocardiographic response (p = 0.56). The rate of coronary revascularization was similar between the groups (7.0% and 5.7%, respectively, p = 0.2). There were no differences in the primary outcomes of patients with and without exercise electrocardiographic changes and normal stress echocardiogram (hazard ratio 1.33, 95% confidence interval 0.69 to 2.58). In conclusion, a normal wall motion response even in the setting of an ischemic exercise electrocardiographic response portends a benign prognosis in patients undergoing stress echocardiography.

Briefly trained medical students can effectively identify rheumatic mitral valve injury using a hand-carried ultrasound.

BACKGROUND: Rheumatic heart disease (RHD) is common and remains a major cause of morbidity, particularly in developing countries. Its diagnosis relies on expertise-dependent echocardiographic studies. We evaluated the accuracy of briefly trained examiners in identifying RHD utilizing a hand-carried cardiac ultrasound (HCU) device. METHODS: Three medical students received 8 hours of training in cardiac ultrasound, focused on assessment of rheumatic valve injury and its complications, using a prototype of HCU device, OptiGo. The students, blinded to the patients' medical condition, performed an auscultation-based physical examination and a focused HCU study on volunteers and patients with known RHD. A standard echocardiography study was used to validate the results. RESULTS: Each student performed a physical examination followed by an HCU study on 45 subjects (mean age 57 ± 14 years, 52% men), 14 of whom (31%) had rheumatic mitral valve injury. The students' averaged sensitivity for diagnosing RHD by HCU examination was 81%, while specificity was 95%. The interrater agreement (kappa) of the 3 students' HCU study and the standard echocardiography examination were between 0.55 and 0.88 (P < 0.01), and among the students themselves between 0.57 and 0.74 (P < 0.01), as students 1 and 2 had better results than student 3. Auscultation-based physical examination rendered low sensitivity (16%) for diagnosing rheumatic valve complications, namely mitral regurgitation and stenosis; however, it improved by 26% when students based their diagnosis on an HCU study. CONCLUSIONS: The ability to detect rheumatic valve injury using a portable ultrasound device by operators who only received brief echocardiographic training is remarkably high. However, the diagnosis of RHD complications is only modest. This result highlights the utility of portable cardiac ultrasound devices operated by basically trained personnel as a valuable diagnostic tool for RHD.

Use of an automatic application for wall motion classification based on longitudinal strain: is it affected by operator expertise in echocardiography? A multicentre study by the Israeli Echocardiography Research Group.

AIMS: Assessing the quality of wall motion (WM) on echocardiograms remains a challenge. Previously, we validated an automated application used by experienced echocardiographers for WM classification based on longitudinal two-dimensional (2D) strain. The aim of this study was to show that the use of this automatic application was independent of the user's experience. METHODS AND RESULTS: We compared the WM classifications obtained by the application when used by 12 highly experienced readers (Exp-R) vs. 11 inexperienced readers (InExp-R). Both classifications were compared with expert consensus classifications using the standard visual method. Digitized clips of cardiac cycles from three apical views in 105 patients were used for these analyses. Reproducibility of both groups was high (overall intra-class correlation coefficient: InExp-R = 0.89, Exp-R = 0.83); the lowest was noted for hypokinetic segments (InExp-R = 0.79, Exp-R = 0.72). InExp-R scores were concordant with Exp-R mode scores in 88.8% of segments; they were overestimated in 5.8% and underestimated in 3.2%. The sensitivity, specificity, and accuracy of InExp-R vs. Exp-R for classifying segments as normal/abnormal were identical (87, 85, and 86%, respectively). CONCLUSION: Classification of WM from apical views with an automatic application based on longitudinal 2D strain by InExp-R vs. Exp-R was similar to visual classification by Exp-R. This application may be useful for inexperienced echocardiographers/technicians and may serve as an automated 'second opinion' for experienced echocardiographers.

Left ventricular geometric abnormality screening in hypertensive patients using a hand-carried ultrasound device.

The authors assessed the validity of a hand-carried cardiac ultrasound device operated by an internal medicine resident for left ventricular geometric abnormalities (LVGAs) in mild hypertensive patients. LVGAs were diagnosed when at least one of the following was present: left ventricular mass index exceeding 125 g/m(2) and 110 g/m(2) for men and women, respectively; intraventricular septum thickness > or = 10 mm; posterior wall thickness > or = 10 mm; and left ventricular end-diastolic diameter > or = 5.3 mm. For validation, a cardiologist performed standard echocardiography in all patients. A total of 85 patients completed both echocardiographic studies. LVGAs were diagnosed in 19 (22.4%) cases, 18 of which were confirmed by standard echocardiography. Standard echocardiography did not detect any case of LVGA among the hand-carried cardiac ultrasonography LVGA-negative patients. The sensitivity and specificity of the resident's examination were 100% and 98.78%, respectively. Agreement between the two studies was 99% (kappa 0.97, 95% confidence interval). Hand-carried cardiac ultrasonography may be used as a screening tool for LVGA in hypertensive patients.

A rare complication of infective endocarditis: left main coronary artery embolization resulting in sudden death.

Whilst systemic septic embolization is a common complication of infective endocarditis, a second, less frequently reported, complication is the embolization of vegetative material to the coronary arteries that rarely results in acute myocardial infarction and sudden death. The case is presented of an acute cardiac death in a patient with aortic valve endocarditis, caused by acute occlusion of the left main coronary artery with vegetative material.

Dietary intervention to reverse carotid atherosclerosis.

BACKGROUND: It is currently unknown whether dietary weight loss interventions can induce regression of carotid atherosclerosis. METHODS AND RESULTS: In a 2-year Dietary Intervention Randomized Controlled Trial-Carotid (DIRECT-Carotid) study, participants were randomized to low-fat, Mediterranean, or low-carbohydrate diets and were followed for changes in carotid artery intima-media thickness, measured with standard B-mode ultrasound, and carotid vessel wall volume (VWV), measured with carotid 3D ultrasound. Of 140 complete images of participants (aged 51 years; body mass index, 30 kg/m(2); 88% men), higher baseline carotid VWV was associated with increased intima-media thickness, age, male sex, baseline weight, blood pressure, and insulin levels (P<0.05 for all). After 2 years of dietary intervention, we observed a significant 5% regression in mean carotid VWV (-58.1 mm(3;) 95% confidence interval, -81.0 to -35.1 mm(3); P<0.001), with no differences in the low-fat, Mediterranean, or low-carbohydrate groups (-60.69 mm(3), -37.69 mm(3), -84.33 mm(3), respectively; P=0.28). Mean change in intima-media thickness was -1.1% (P=0.18). A reduction in the ratio of apolipoprotein B(100) to apolipoprotein A1 was observed in the low-carbohydrate compared with the low-fat group (P=0.001). Participants who exhibited carotid VWV regression (mean decrease, -128.0 mm(3); 95% confidence interval, -148.1 to -107.9 mm(3)) compared with participants who exhibited progression (mean increase, +89.6 mm(3); 95% confidence interval, +66.6 to +112.6 mm(3)) had achieved greater weight loss (-5.3 versus -3.2 kg; P=0.03), greater decreases in systolic blood pressure (-6.8 versus -1.1 mm Hg; P=0.009) and total homocysteine (-0.06 versus +1.44 mumol/L; P=0.04), and a higher increase of apolipoprotein A1 (+0.05 versus -0.00 g/L; P=0.06). In multivariate regression models, only the decrease in systolic blood pressure remained a significant independent modifiable predictor of subsequent greater regression in both carotid VWV (beta=0.23; P=0.01) and intima-media thickness (beta=0.28; P=0.008) levels. CONCLUSIONS: Two-year weight loss diets can induce a significant regression of measurable carotid VWV. The effect is similar in low-fat, Mediterranean, or low-carbohydrate strategies and appears to be mediated mainly by the weight loss-induced decline in blood pressure. Clinical Trial Registration- http://www.clinicaltrials.gov. Unique Identifier: NCT00160108.