Particle Swarm Optimisation Applied to the Direct Aperture Optimisation Problem in Radiation Therapy.

Intensity modulated radiation therapy (IMRT) is one of the most used techniques for cancer treatment. Using a linear accelerator, it delivers radiation directly at the cancerogenic cells in the tumour, reducing the impact of the radiation on the organs surrounding the tumour. The complexity of the IMRT problem forces researchers to subdivide it into three sub-problems that are addressed sequentially. Using this sequential approach, we first need to find a beam angle configuration that will be the set of irradiation points (beam angles) over which the tumour radiation is delivered. This first problem is called the Beam Angle Optimisation (BAO) problem. Then, we must optimise the radiation intensity delivered from each angle to the tumour. This second problem is called the Fluence Map Optimisation (FMO) problem. Finally, we need to generate a set of apertures for each beam angle, making the intensities computed in the previous step deliverable. This third problem is called the Sequencing problem. Solving these three sub-problems sequentially allows clinicians to obtain a treatment plan that can be delivered from a physical point of view. However, the obtained treatment plans generally have too many apertures, resulting in long delivery times. One strategy to avoid this problem is the Direct Aperture Optimisation (DAO) problem. In the DAO problem, the idea is to merge the FMO and the Sequencing problem. Hence, optimising the radiation's intensities considers the physical constraints of the delivery process. The DAO problem is usually modelled as a Mixed-Integer optimisation problem and aims to determine the aperture shapes and their corresponding radiation intensities, considering the physical constraints imposed by the Multi-Leaf Collimator device. In solving the DAO problem, generating clinically acceptable treatments without additional sequencing steps to deliver to the patients is possible. In this work, we propose to solve the DAO problem using the well-known Particle Swarm Optimisation (PSO) algorithm. Our approach integrates the use of mathematical programming to optimise the intensities and utilizes PSO to optimise the aperture shapes. Additionally, we introduce a reparation heuristic to enhance aperture shapes with minimal impact on the treatment plan. We apply our proposed algorithm to prostate cancer cases and compare our results with those obtained in the sequential approach. Results show that the PSO obtains competitive results compared to the sequential approach, receiving less radiation time (beam on time) and using the available apertures with major efficiency.

Extubation failure after cardiac surgery in children with Down syndrome.

Extubation failure (EF) after cardiac surgery is associated with poorer outcomes. Approximately 50% of children with Down syndrome (DS) have congenital heart disease. Our primary aim was to describe the frequency of EF and identify risk factors for its occurrence in a population of patients with DS after cardiac surgery. Secondary aims were to describe complications, length of hospital stay, and mortality rates. This report was a retrospective case-control study and was carried out in a national reference congenital heart disease repair center of Chile. This study includes all infants 0-12 months old with DS who were admitted to pediatric intensive care unit after cardiac surgery between January 2010 and November 2020. Patients with EF (cases) were matched 1:1 with children who did not fail their extubation (controls) using the following criteria: age at surgery, sex, and type of congenital heart disease. Overall, 27/226 (11.3%) failed their first extubation. In the first analysis, before matching of cases and controls was made, we found association between EF and younger age (3.8 months vs 5 months; p = 0.003) and presence of coarctation of the aorta (p = 0.005). In the case-control univariate analysis, we found association between an increased cardiothoracic ratio (CTR) (p = 0.03; OR 5 (95% CI 1.6-16.7) for a CTR > 0.59) and marked hypotonia (27% vs 0%; p = 0.01) with the risk of EF. No differences were found in ventilatory management. CONCLUSIONS: In pediatric patients with DS, EF after cardiac surgery is associated with younger age, presence of aortic coarctation, higher CTR reflecting the degree of cardiomegaly and hypotonia. Recognition of these factors may be helpful when planning extubation for these patients. WHAT IS KNOWN: • Extubation failure after cardiac surgery is associated with higher morbidity and mortality rates. Some studies report higher rates of extubation failure in patients with Down syndrome. WHAT IS NEW: • In children with Down syndrome, extubation failure after cardiac surgery is associated with younger age, presence of aortic coarctation, higher CTR reflecting cardiomegaly and severe hypotonia.

Short-term complications and post-acute sequelae in hospitalized paediatric patients with COVID-19 and obesity: A multicenter cohort study.

BACKGROUND: Obesity increases the severity of coronavirus disease 2019 illness in adults. The role of obesity in short-term complications and post-acute sequelae in children is not well defined. OBJECTIVE: To evaluate the relationship between obesity and short-term complications and post-acute sequelae of SARS-CoV-2 infection in hospitalized paediatric patients. METHODS: An observational study was conducted in three tertiary hospitals, including paediatric hospitalized patients with a confirmatory SARS-CoV-2 RT-PCR from March 2020 to December 2021. Obesity was defined according to WHO 2006 (0-2 years) and CDC 2000 (2-20 years) growth references. Short-term outcomes were intensive care unit admission, ventilatory support, superinfections, acute kidney injury, and mortality. Neurological, respiratory, and cardiological symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms were considered as post-acute sequalae. Adjusted linear, logistic regression and generalized estimating equations models were performed. RESULTS: A total of 216 individuals were included, and 67 (31.02%) of them had obesity. Obesity was associated with intensive care unit admission (aOR = 5.63, CI95% 2.90-10.94), oxygen requirement (aOR = 2.77, CI95% 1.36-5.63), non-invasive ventilatory support (aOR = 6.81, CI95% 2.11-22.04), overall superinfections (aOR = 3.02 CI95% 1.45-6.31), and suspected bacterial pneumonia (aOR = 3.00 CI95% 1.44-6.23). For post-acute sequalae, obesity was associated with dyspnea (aOR = 9.91 CI95% 1.92-51.10) and muscle weakness (aOR = 20.04 CI95% 2.50-160.65). CONCLUSIONS: In paediatric hospitalized patients with COVID-19, severe short-term outcomes and post-acute sequelae are associated with obesity. Recognizing obesity as a key comorbidity is essential to develop targeted strategies for prevention of COVID-19 complications in children.

Validity and reliability of the measurement instrument of the nursing outcome health-related Physical Fitness (2004), proposed and transculturally adapted to the Spanish context.

BACKGROUND: Presently, physical inactivity is the main public health problem in many countries worldwide. Physical activity promotes the maintenance or improvement of one's physical condition. Physical fitness has been established as the main biological marker of the state of health of an individual, and therefore, there is a clear need to measure health-related physical fitness through the use of a reliable and valid instrument. This study is a continuation of the transcultural adaptation process and a new proposal of the nursing outcome Physical Fitness (2004), found in the 5th Edition of the Nursing Outcomes Classification. The objective of this study was to examine the validity and reliability of the nursing outcome Health-Related Physical Fitness survey, proposed and transculturally adapted to the Spanish context. METHODS: An instrumental study to validate the nursing outcome Physical Fitness (2004), from the 5th Edition of the Nursing Outcome Classification was carried out. It took place between the months of May, 2016 to May, 2017. On the first stage, the instrument proposed Health-Related Physical Fitness survey was administered to 160 adults who used the Health Services of Murcia, Spain by three independent evaluators. After 4 weeks, it was administered again to 33 participants to calculate the intra-rater reliability. Lastly, the SF-12v2 Health Survey was administered to obtain external evidence of validity. RESULTS: The inter-rater reliability of the nursing outcome proposed obtained high values (between 0.91-0.99) in the evaluations performed by the three evaluators. As for the intra-rater reliability, high values were obtained (0.94-1), except for the item "balance", which was moderate (0.56). Lastly, a positive and statistically significant correlation (p < 0.05) was obtained between the Physical Component Summary, and the dimensions Physical Functioning and General Health from the SF-12v2 Health Survey, and the global score of the Health-Related Physical Fitness proposed instrument. CONCLUSIONS: The validity and reliability results of the nursing outcome Health-Related Physical Fitness survey, proposed and transculturally adapted to the Spanish context, were adequate for its use by nurses with adults who use the Health Services of Murcia. However, this instrument must be analyzed with more diverse samples of health services users.

High prevalence of SARS-CoV-2 detection and prolonged viral shedding in stools: A systematic review and cohort study / Elevada detección de SARS-CoV-2 y prolongada excreción viral en deposiciones: Estudio de cohorte y revisión sistemática

Objectives: To: 1. Describe the frequency of viral RNA detection in stools in a cohort of patients infected with SARS-CoV-2, and 2. Perform a systematic review to assess the clearance time in stools of SARS-CoV-2. Methods: We conducted a prospective cohort study in two centers between March and May 2020. We included SARS-CoV-2 infected patients of any age and severity. We collected seriated nasopharyngeal swabs and stool samples to detect SARS-CoV-2. After, we performed a systematic review of the prevalence and clearance of SARS-CoV-2 in stools (PROSPERO-ID: CRD42020192490). We estimated prevalence using a random-effects model. We assessed clearance time by using Kaplan–Meier curves. Results: We included 32 patients; mean age was 43.7±17.7 years, 43.8% were female, and 40.6% reported gastrointestinal symptoms. Twenty-five percent (8/32) of patients had detectable viral RNA in stools. The median clearance time in stools of the cohort was 11[10–15] days. Systematic review included 30 studies (1392 patients) with stool samples. Six studies were performed in children and 55% were male. The pooled prevalence of viral detection in stools was 34.6% (twenty-four studies, 1393 patients; 95%CI:25.4–45.1); heterogeneity was high (I2:91.2%, Q:208.6; p≤0.001). A meta-regression demonstrates an association between female-gender and lower presence in stools (p=0.004). The median clearance time in stools was 22 days (nineteen studies, 140 patients; 95%CI:19–25). After 34 days, 19.9% (95%CI:11.3–29.7) of patients have a persistent detection in stools. Conclusions: Detection of SARS-CoV-2 in stools is a frequent finding. The clearance of SARS-CoV-2 in stools is prolonged and it takes longer than nasopharyngeal secretions.(AU)

Objetivos: 1. Evaluar la detección de ARN viral en deposiciones y su tiempo de excreción en una cohorte de pacientes con SARS-CoV-2; 2. Realizar una revisión sistemática para evaluar el tiempo de excreción en deposiciones del SARS-CoV-2. Métodos: Estudio de cohorte prospectiva en dos centros entre marzo-mayo del 2020. Incluimos pacientes infectados con SARS-CoV-2 de cualquier edad y gravedad. Recolectamos secreciones nasofaríngeas y deposiciones en forma seriada para detectar SARS-CoV-2. También realizamos una revisión sistemática de la prevalencia y excreción del SARS-CoV-2 en deposiciones (PROSPERO-ID: CRD42020192490). Estimamos la prevalencia usando un modelo de efectos aleatorios. Evaluamos el tiempo de excreción usando curvas Kaplan-Meier. Resultados: Incluimos 32 pacientes; edad media 43 ± 17,7 años, 43,8% eran mujeres y 40,6% reportaron síntomas gastrointestinales. Veinticinco por ciento (8/32) tenían ARN viral detectable en deposiciones. La mediana de excreción en deposiciones fue 11 [10-15] días. La revisión sistemática incluyó 30 estudios (1.392 pacientes) con muestras en deposiciones. Seis estudios fueron realizados en niños y 55% eran hombres. La prevalencia estimada de detección viral en deposiciones fue de 34,6% (24 estudios, 1.393 pacientes; IC 95%: 25,4-45,1); la heterogeneidad fue elevada (I2: 91,2%; Q: 208,6; p ≤ 0,001). Una metarregresión demostró una asociación entre el género femenino y menor prevalencia en deposiciones (p = 0,004). La mediana de tiempo de excreción fueron 22 días (19 estudios, 140 pacientes; IC 95%: 19-25). Tras 34 días, 19,9% (IC 95%: 11,3-29,7) de los pacientes tenían detección persistente en deposiciones. Conclusiones: La detección de SARS-CoV-2 en deposiciones es un hallazgo frecuente. La excreción del SARS-CoV-2 en deposiciones es prolongada y es más tardía que en secreciones nasofaríngeas.(AU)

Induction of SARS-CoV-2 neutralizing antibodies by CoronaVac and BNT162b2 vaccines in naïve and previously infected individuals.

BACKGROUND: A major challenge of the SARS-CoV-2 pandemic is to better define "protective thresholds" to guide the global response. We aimed to characterize the longitudinal dynamics of the antibody responses in naturally infected individuals in Chile and compared them to humoral responses induced after immunization with CoronaVac-based on an inactivated whole virus -or the BNT162b2- based on mRNA-vaccines. We also contrasted them with the respective effectiveness and efficacy data available for both vaccines. METHODS: We determined and compared the longitudinal neutralizing (nAb) and anti-nucleocapsid (anti-N) antibody responses of 74 COVID-19 individuals (37 outpatient and 37 hospitalized) during the acute disease and convalescence. We also assessed the antibody boosting of 36 of these individuals who were immunized after convalescence with either the CoronaVac (n = 30) or the BNT162b2 (n = 6) vaccines. Antibody titres were also measured for 50 naïve individuals immunized with two doses of CoronaVac (n = 35) or BNT162b2 (n = 15) vaccines. The neutralizing level after vaccination was compared to those of convalescent individuals and the predicted efficacy was estimated. FINDINGS: SARS-CoV-2 infection induced robust nAb and anti-N antibody responses lasting >9 months, but showing a rapid nAb decay. After convalescence, nAb titres were significantly boosted by vaccination with CoronaVac or BNT162b2. In naïve individuals, the calculated mean titre induced by two doses of CoronaVac or BNT162b2 was 0·2 times and 5.2 times, respectively, that of convalescent individuals, which has been proposed as threshold of protection. CoronaVac induced no or only modest anti-N antibody responses. Using two proposed logistic models, the predicted efficacy of BNT162b2 was estimated at 97%, in close agreement with phase 3 efficacy studies, while for CoronaVac it was ∼50% corresponding to the lowest range of clinical trials and below the real-life data from Chile (from February 2 through May 1, 2021 during the predominant circulation of the Gamma variant), where the estimated vaccine effectiveness to prevent COVID-19 was 62·8-64·6%. INTERPRETATION: The decay of nAbs titres in previously infected individuals over time indicates that vaccination is needed to boost humoral memory responses. Immunization of naïve individuals with two doses of CoronaVac induced nAbs titres that were significantly lower to that of convalescent patients, and similar to vaccination with one dose of BTN162b2. The real life effectiveness for CoronaVac in Chile was higher than estimated; indicating that lower titres and additional cellular immune responses induced by CoronaVac might afford protection in a highly immunized population. Nevertheless, the lower nAb titre induced by two doses of CoronaVac as compared to the BTN162b2 vaccine in naïve individuals, highlights the need of booster immunizations over time to maintain protective levels of antibody, particularly with the emergence of new SARS-CoV-2 variants. FUNDING: FONDECYT 1161971, 1212023, 1181799, FONDECYT Postdoctorado 3190706 and 3190648, ANID Becas/Doctorado Nacional 21212258, PIA ACT 1408, CONICYT REDES180170, Centro Ciencia & Vida, FB210008, Financiamiento Basal para Centros Científicos y Tecnológicos de Excelencia grants from the Agencia Nacional de Investigación y Desarrollo (ANID) of Chile; NIH-NIAD grants U19AI135972, R01AI132633 and contracts HHSN272201400008C and 75N93019C00051; the JPB Foundation, the Open Philanthropy Project grant 2020-215611 (5384); and by anonymous donors. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

High prevalence of SARS-CoV-2 detection and prolonged viral shedding in stools: A systematic review and cohort study.

OBJECTIVES: To: 1. Describe the frequency of viral RNA detection in stools in a cohort of patients infected with SARS-CoV-2, and 2. Perform a systematic review to assess the clearance time in stools of SARS-CoV-2. METHODS: We conducted a prospective cohort study in two centers between March and May 2020. We included SARS-CoV-2 infected patients of any age and severity. We collected seriated nasopharyngeal swabs and stool samples to detect SARS-CoV-2. After, we performed a systematic review of the prevalence and clearance of SARS-CoV-2 in stools (PROSPERO-ID: CRD42020192490). We estimated prevalence using a random-effects model. We assessed clearance time by using Kaplan-Meier curves. RESULTS: We included 32 patients; mean age was 43.7±17.7 years, 43.8% were female, and 40.6% reported gastrointestinal symptoms. Twenty-five percent (8/32) of patients had detectable viral RNA in stools. The median clearance time in stools of the cohort was 11[10-15] days. Systematic review included 30 studies (1392 patients) with stool samples. Six studies were performed in children and 55% were male. The pooled prevalence of viral detection in stools was 34.6% (twenty-four studies, 1393 patients; 95%CI:25.4-45.1); heterogeneity was high (I2:91.2%, Q:208.6; p≤0.001). A meta-regression demonstrates an association between female-gender and lower presence in stools (p=0.004). The median clearance time in stools was 22 days (nineteen studies, 140 patients; 95%CI:19-25). After 34 days, 19.9% (95%CI:11.3-29.7) of patients have a persistent detection in stools. CONCLUSIONS: Detection of SARS-CoV-2 in stools is a frequent finding. The clearance of SARS-CoV-2 in stools is prolonged and it takes longer than nasopharyngeal secretions.

Long-lasting neutralizing antibody responses in SARS-CoV-2 seropositive individuals are robustly boosted by immunization with the CoronaVac and BNT162b2 vaccines.

The durability of circulating neutralizing antibody (nAb) responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their boosting by vaccination remains to be defined. We show that outpatient and hospitalized SARS-CoV-2 seropositive individuals mount a robust neutralizing antibody (nAb) response that peaks at days 23 and 27 post-symptom onset, respectively. Although nAb titers remained higher in hospitalized patients, both study groups showed long-lasting nAb responses that can persist for up to 12 months after natural infection. These nAb responses in previously seropositive individuals can be significantly boosted through immunization with two doses of the CoronaVac (Sinovac) or one dose of the BNT162b2 (BioNTech/Pfizer) vaccines, suggesting a substantial induction of B cell memory responses. Noteworthy, three obese previously seropositive individuals failed to mount a booster response upon vaccination, warranting further studies in this population. Immunization of naïve individuals with two doses of the CoronaVac vaccine or one dose of the BNT162b2 vaccine elicited similar levels of nAbs compared to seropositive individuals 4.2 to 13.3 months post-infection with SARS-CoV-2. Thus, this preliminary evidence suggests that both, seropositive and naïve individuals, require two doses of CoronaVac to ensure the induction of robust nAb titers.

Viral shedding dynamics reveals sputum as a reliable and cost-saving specimen for SARS-CoV-2 diagnosis within the first 10 days since symptom onset: A prospective cohort study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome virus (SARS-CoV-2) is challenging global public health, due to an increasing demand for testing and the shortage of diagnostic supplies. Nasopharyngeal swab (NPS) is considered the optimal sample for SARS-CoV2 diagnosis and sputum (SPT) has been proposed as an economic alternative. However, the temporal concordance of diagnosis in NPS and SPT has not been addressed. METHODS: Through a longitudinal study we compared the shedding dynamics of SARS-CoV-2 RNA evaluated by RT-qPCR in serially collected SPT and NPS obtained from 82 ambulatory and hospitalized patients during acute infection and convalescence. The concordance during the follow-up and cost analysis between both collected specimens was evaluated. FINDINGS: We analyzed 379 samples, 177 NPS and 202 SPT. The highest proportion of positive samples was detected within the first 15 days after the symptoms onset. The median time of positivity was higher for NPS (median= 25 days) than SPT (median= 21 days). There was no significant difference in the median RT-qPCR CT values between both sample types. The temporal categorization of matched-paired samples indicated substantial correlation (r=0.6023) and substantial agreement (87.23%) during the first ten days since symptoms onset (kappa = 0.697). A cost analysis demonstrated a significant saving when the SPT specimen was used. INTERPRETATION: Sputum is a feasible and cost-saving alternative to NPS, providing an equivalent value for the detection and follow-up of SARS-CoV-2 RNA.

Selección de lo mejor del año 2017 en imagen cardiovascular en las cardiopatías familiares / Selection of the best of the year 2017 in cardiovascular imaging in familial cardiopathies

No disponible

Morbimortalidad perinatal en pacientes con rotura prematura ovular ≤24 semanas según cantidad de líquido amniótico al momento del diagnóstico / Perinatal morbidity and mortality in patients with premature ovular rupture ≤24 weeks according to amount of amniotic fluid at diagnosis

Introducción: La rotura prematura ovular (RPO) antes de la viabilidad fetal consiste en una complicación obstétrica de baja incidencia, pero de alta morbimortalidad perinatal asociada. Estudios sugieren que el volumen de líquido amniótico (LA) es un factor importante a considerar. El objetivo de este trabajo es evaluar si en RPO ≤24 semanas, un bolsillo vertical máximo (BVM) <2cm al diagnóstico es un factor de riesgo para aparición de morbimortalidad fetal y neonatal. Métodos: Estudio de cohorte longitudinal retrospectivo de 94 pacientes con RPO ≤24 semanas ingresadas a un hospital terciario para manejo expectante entre los años 2005 y 2014. Embarazo gemelar o malformaciones congénitas fueron criterios de exclusión. Se obtuvieron y compararon 2 grupos según BVM al ingreso (BVM ≥ 2 cm y BVM < a 2 cms) y se comparó la edad gestacional (EG) al momento de la RPO y al parto, la latencia desde la RPO al parto, la presencia de corioamnionitis clínica, el número de óbitos fetales, muerte neonatal precoz (primeros 7 días de vida), tardía (entre los 7 y 28 días) y sobrevida global. Resultados: El 58 por ciento de las pacientes presentó un BVM <2 cm al ingreso, el cual se asoció a menor latencia al parto (p:0,01), menor EG al parto (p:0,02), más óbito fetal (p:0,04), mayor muerte neonatal precoz y tardía (p:0,02 y 0,01 respectivamente) además de menor sobrevida global (p:0,01). Conclusiones: La medición de BVM <2 cm al ingreso en pacientes con RPO ≤24 semanas, es un factor de mal pronóstico y debe ser considerado en el manejo clínico de estas pacientes.(AU)

Introduction: Previable premature rupture of membranes (pPROM) is a low-incidence obstetric complication associated with high perinatal morbidity and mortality. Studies suggest that the volume of amniotic fluid (AL) is an important factor to consider. The aim of this study is to evaluate if in RPO ≤24 weeks, a maximum vertical pocket (MVP) <2 cm to the diagnostic is a risk factor for fetal and neonatal morbidity and mortality. Objectives: Evaluate fetal and neonatal morbidity and mortality according to amniotic fluid (AL) Maximum Vertical Pocket (MVP) ≥ or

Embolia de pulmón con trombo en tránsito y foramen oval permeable: una fuente de embolismo paradójico mortal / Pulmonary embolism with in-transit thrombus and foramen ovale: a source of fatal paradoxical embolism

No disponible

[Value of coronary blood flow pattern as a predictor of functional recovery and short-term left ventricular remodeling after primary coronary angioplasty. A transthoracic Doppler study]. / Valor del patrón de flujo coronario tras angioplastia primaria como predictor de recuperación funcional y remodelado ventricular a corto plazo. Estudio mediante ecocardiografía Doppler transtorácica.

INTRODUCTION AND OBJECTIVES: Coronary blood flow measurement using a Doppler guidewire is the most sensitive way of detecting the no-reflow phenomenon following reperfusion of a myocardial infarction (MI). New high-frequency Doppler probes enable coronary blood flow velocity to be measured noninvasively. Our aims were to study the different patterns of left anterior coronary artery blood flow observed by transthoracic Doppler echocardiography, and to describe their association with functional recovery following reperfusion of an anterior MI. METHODS: The study included 57 patients with a mean age of 60 years (range 30-85 years). An abnormal coronary blo:d flow pattern was defined as one in which there was a high peak diastolic velocity and a short deceleration time (i.e., < or = 500 ms). We compared the regional contractility, ventricular volumes, and left ventricular ejection fraction (LVEF) measured after 72 hours with those measured 1 month after MI. RESULTS: Overall, 31 patients (54%) had a normal coronary blood flow pattern (Group 1) and 26 (46%), an abnormal pattern (Group 2). After one month, regional contractility improved in Group-1 patients, as did LVEF, from 46.8 (8.6) to 52.6 (8.8)% (P=.002). In these patients, left ventricular volumes were unchanged. In contrast, regional contractility and LVEF remained unchanged in Group-2 patients whereas ventricular volumes increased, from 55.8 (12.9) to 62.9 (16.8) ml/m2 (P=.05), and from 32.2 (9.5) to 37.1 (14.9) ml/m2 (P< .05). Coronary blood flow pattern was the most important independent predictor of left ventricular remodeling, odds ratio =6.14 (95% CI, 1.56-24.17). CONCLUSIONS: Transthoracic Doppler echocardiographic assessment of coronary blood flow following reperfusion of an anterior myocardial infarction can be used to identify patients with microvascular damage who are progressing towards ventricular dilatation without recovery of myocardial function.

Valor del patrón de flujo coronario tras angioplastia primaria como predictor de recuperación funcional y remodelado ventricular a corto plazo. Estudio mediante ecocardiografía Doppler transtorácica / Value of coronary blood flow pattern as a predictor of functional recovery and short-term left ventricular remodeling after primary coronary angioplasty. A transthoracic doppler study

Introducción y objetivos. El método más eficaz para detectar el fenómeno de «no reflujo» tras el infarto de miocardio revascularizado es el estudio del flujo mediante guías de Doppler intracoronario. La incorporación de sondas Doppler de alta frecuencia permite evaluar el flujo coronario de forma no invasiva. El objetivo es describir diferentes patrones de flujo coronario mediante Doppler transtorácico y estudiar sus asociaciones con la recuperación funcional del tejido infartado. Métodos. Estudiamos a 57 pacientes de 60 años de edad (rango, 30-85). Describimos un flujo coronario anómalo al caracterizado por onda diastólica de elevada velocidad con tiempo de deceleración rápido (≤ 500 ms). Comparamos la contractilidad regional, los volúmenes ventriculares y la fracción de eyección del ventrículo izquierdo (FEVI) de los pacientes a las 72 h y al mes del episodio agudo. Resultados. En total, 31 pacientes (54%) presentaban un flujo normal (grupo 1) y 26 (46%), un flujo anómalo (grupo 2). Al mes de seguimiento, en los pacientes del grupo 1 mejoró tanto la contractilidad regional como la FEVI (el 46,8 ± 8,6 frente al 52,6 ± 8,8%; p = 0,002), sin aumento en los volúmenes ventriculares. Por el contrario, los pacientes del grupo 2 no experimentaron mejoría en la contractilidad regional ni en la FEVI aumentando sus volúmenes ventriculares de 55,8 ± 12,9 a 62,9 ± 16,8 ml/m² (p = 0,05) y de 32,2 ± 9,5 a 37,1 ± 14,9 ml/m² (p < 0,05). El análisis multivariable mostró que el patrón de flujo era el predictor más importante para el remodelado ventricular (odds ratio = 6,14; intervalo de confianza del 95%, 1,56-24,17). Conclusiones. El estudio del flujo coronario mediante Doppler transtorácico permite identificar a los pacientes con daño microvascular que tras un infarto anterior evolucionarán hacia la dilatación ventricular sin recuperación de la función regional de la zona infartada

Introduction and objectives. Coronary blood flow measurement using a Doppler guidewire is the most sensitive way of detecting the no-reflow phenomenon following reperfusion of a myocardial infarction (MI). New high-frequency Doppler probes enable coronary blood flow velocity to be measured noninvasively. Our aims were to study the different patterns of left anterior coronary artery blood flow observed by transthoracic Doppler echocardiography, and to describe their association with functional recovery following reperfusion of an anterior MI. Methods. The study included 57 patients with a mean age of 60 years (range 30-85 years). An abnormal coronary blood flow pattern was defined as one in which there was a high peak diastolic velocity and a short deceleration time (i.e., ≤ 500 ms). We compared the regional contractility, ventricular volumes, and left ventricular ejection fraction (LVEF) measured after 72 hours with those measured 1 month after MI. Results. Overall, 31 patients (54%) had a normal coronary blood flow pattern (Group 1) and 26 (46%), an abnormal pattern (Group 2). After one month, regional contractility improved in Group-1 patients, as did LVEF, from 46.8 (8.6) to 52.6 (8.8)% (P=.002). In these patients, left ventricular volumes were unchanged. In contrast, regional contractility and LVEF remained unchanged in Group-2 patients whereas ventricular volumes increased, from 55.8 (12.9) to 62.9 (16.8) ml/m² (P=.05), and from 32.2 (9.5) to 37.1 (14.9) ml/m² (P<.05). Coronary blood flow pattern was the most important independent predictor of left ventricular remodeling, odds ratio =6.14 (95% CI, 1.56-24.17). Conclusions. Transthoracic Doppler echocardiographic assessment of coronary blood flow following reperfusion of an anterior myocardial infarction can be used to identify patients with microvascular damage who are progressing towards ventricular dilatation without recovery of myocardial function

[Evolution of severe mitral regurgitation after optimization of pharmacological therapy in non-ischemic dilated cardiomyopathy]. / Evolución de la insuficiencia mitral severa tras optimización del tratamiento médico en la miocardiopatía dilatada no isquémica.

In dilated cardiomyopathy, severe functional mitral regurgitation (MR) is associated with a poor prognosis. In 112 consecutive clinically stable patients with non-ischemic dilated cardiomyopathy, echocardiography identified 15 (14%) patients who had severe MR (age, 53+/-12 years; 80% male; left ventricular ejection fraction, 26 +/- 8%). Existing medical treatment with ACE inhibitors and beta-blockers was increased up to the maximum tolerated doses. At 6 months, MR decreased by at least one grade in 13 (87%) patients (P =.001), as did the effective regurgitant orifice area (from 0.41 [0.05] mm2 to 0.20 [0.15] mm2; P.

Evolución de la insuficiencia mitral severa tras optimización del tratamiento médico en la miocardiopatía dilatada no isquémica / Evolution of severe mitral regurgitation after optimization of pharmacological therapy in non-ischemic dilated cardiomyopathy

En la miocardiopatía dilatada, la insuficiencia mitral (IM) funcional grave se asocia con una peor situación clínica y pronóstica. De 112 pacientes consecutivos con miocardiopatía dilatada no isquémica, 15 (14%) presentaban IM grave funcional por ecocardiografía (53 ± 12 años, 80% varones, FEVI 26 ± 8%). Se optimizó el tratamiento previo hasta dosis máximas toleradas de un inhibidor de la enzima de conversión de la angiotensina (IECA) y un bloqueador beta. A los 6 meses disminuyó el grado de insuficiencia en 13 pacientes (87%) (p = 0,001), el área del orificio regurgitante efectivo (0,41 ± 0,05 frente a 0,20 ± 0,15 mm²; p < 0,001) y del jet (13,6 ± 2,1 frente a 7,4 ± 4,5 cm²; p < 0,001). Estos cambios se correlacionaron con una mayor FEVI (26 ± 8 frente a 35 ± 10%; p = 0,009; r = 0,60, p = 0,01) y un menor volumen telesistólico (168 ± 46 frente 142 ± 72 ml; p = 0,04; r = 0,59, p = 0,02). Se observó una mejoría de la clase NYHA (2,7 ± 0,5 frente a 1,9 ± 0,7; p < 0,001). La IM funcional grave evolucionó hacia la mejoría tras la optimización máxima de IECA y bloqueadores beta, lo que parece correlacionar con una mejora de la función sistólica

In dilated cardiomyopathy, severe functional mitral regurgitation (MR) is associated with a poor prognosis. In 112 consecutive clinically stable patients with non-ischemic dilated cardiomyopathy, echocardiography identified 15 (14%) patients who had severe MR (age, 53±12 years; 80% male; left ventricular ejection fraction, 26 ± 8%). Existing medical treatment with ACE inhibitors and beta-blockers was increased up to the maximum tolerated doses. At 6 months, MR decreased by at least one grade in 13 (87%) patients (P =.001), as did the effective regurgitant orifice area (from 0.41 [0.05] mm² to 0.20 [0.15] mm²; P < .001) and the jet area (from 13.6 [2.1] cm² to 7.4 [4.5] cm²; P<.001). These changes correlated with an increase in left ventricular ejection fraction (from 26 [8]% to 35 [10]%, P=.009; r=0.60, P=.01) and a decrease in end-diastolic volume (from 168 [46] mL to 142 [72] mL, P=.04; r=0.59, P=.02). An improvement in New York Heart Association class was observed (from 2.7 [0.5] to 1.9 [0.7]; P < .001). The severity of functional MR decreased after medical treatment was maximized. The decrease correlated with improvements in left ventricular systolic function