Multimodality imaging of the ischemic right ventricle: an overview and proposal of a diagnostic algorithm.

Right ventricular (RV) involvement is frequently detected in patients presenting with acute left ventricular myocardial infarction. The ischemic right ventricle carries a dismal outcome by predisposing the heart to arrhythmic events and mechanical or hemodynamic complications. A comprehensive RV evaluation by multimodality imaging could guide clinical practice but has always been a conundrum for the imagers. Two-dimensional echocardiography is the best first-line tool due to its availability of bedside capabilities. More advanced imaging techniques provide a more comprehensive evaluation of the complex RV geometry but are mostly reserved for the post-acute setting. Three-dimensional echocardiography has improved the evaluation of RV volumes and function. The recent application of speckle-tracking echocardiography to the right ventricle appears promising, allowing the earlier detection of subtle RV dysfunction. Cardiac magnetic resonance imaging is considered the gold standard for the RV assessment. Cardiac multidetector computed tomography could be a reliable alternative. The aim of this review is to focus on the growing importance of multimodality imaging of the ischemic right ventricle and to propose a diagnostic algorithm, in order to reach a comprehensive assessment of this too frequently neglected chamber.

European cardiovascular mortality over the last three decades: evaluation of time trends, forecasts for 2016.

BACKGROUND: The circulatory diseases, in particular ischemic heart diseases and stroke, represent the main causes of death worldwide both in high income and in middle and low income countries. Our aim is to provide a comprehensive report to depict the circulatory disease mortality in Europe over the last 30 years and to address the sources of heterogeneity among different countries. METHODS: Our study was performed using the WHO statistical information system - mortality database - and was restricted to the 28 countries belonging to the European Union (EU-28). We evaluated gender and age time series of all circulatory disease mortality, ischemic heart diseases, cerebrovascular diseases, pulmonary and other circulatory diseases and than we performed forecast for 2016. Mortality heterogeneity was evaluated by countries using the Cochrane Q statistic and the I-squared index. RESULTS: Between 1985 and 2011 SDR for deaths attributable to all circulatory system diseases decreased from 440.9 to 212.0 x 100,000 in EU-28 and a clear uniform reduction was observed. Heterogeneity among countries was found to be consistent, therefore different analysis were carried out considering geographical area. CONCLUSIONS: We forecast a reduction in European cardiovascular mortality. Heterogeneity among countries could only in part be explained by both geographical and health expenditure factors.

Continuum, la plataforma de Formación Basada en Competencias / Continuum, the continuing education platform based on a competency matrix

La Formación Basada en Competencias es una modalidad formativa que ha cambiado el enfoque tradicional centrado en la enseñanza por otro basado en el aprendizaje. Los alumnos son el centro del proceso, en el que deben aprender a aprender, a resolver problemas y a adaptarse a los cambios en su entorno. El objetivo es lograr un aprendizaje que integre el saber, el saber hacer, el saber ser y el saber estar. A este conjunto de saberes se les denomina competencias. Es fundamental disponer de una referencia de las competencias requeridas para identificar la necesidad de las mismas. Su adquisición se aborda a través de módulos docentes en los que se pueden adquirir una o más competencias. Esta estrategia docente ha sido adoptada por Continuum, la plataforma de formación a distancia de la Asociación Española de Pediatría, que ha desarrollado una matriz de competencias, basada en el programa de formación del Global Pediatric Education Consortium. En este artículo repasaremos los fundamentos de la Formación Basada en Competencias y cómo se aplica en Continuum

Competency-Based Education is a learning method that has changed the traditional teaching-based focus to a learning-based one. Students are the centre of the process, in which they must learn to learn, solve problems, and adapt to changes in their environment. The goal is to provide learning based on knowledge, skills (know-how), attitude and behaviour. These sets of knowledge are called competencies. It is essential to have a reference of the required competencies in order to identify the need for them. Their acquisition is approached through teaching modules, in which one or more skills can be acquired. This teaching strategy has been adopted by Continuum, the distance learning platform of the Spanish Paediatric Association, which has developed a competency matrix based on the Global Paediatric Education Consortium training program. In this article, a review will be presented on the basics of Competency-Based Education and how it is applied in Continuum

[Continuum, the continuing education platform based on a competency matrix]. / Continuum, la plataforma de Formación Basada en Competencias.

Competency-Based Education is a learning method that has changed the traditional teaching-based focus to a learning-based one. Students are the centre of the process, in which they must learn to learn, solve problems, and adapt to changes in their environment. The goal is to provide learning based on knowledge, skills (know-how), attitude and behaviour. These sets of knowledge are called competencies. It is essential to have a reference of the required competencies in order to identify the need for them. Their acquisition is approached through teaching modules, in which one or more skills can be acquired. This teaching strategy has been adopted by Continuum, the distance learning platform of the Spanish Paediatric Association, which has developed a competency matrix based on the Global Paediatric Education Consortium training program. In this article, a review will be presented on the basics of Competency-Based Education and how it is applied in Continuum.

El aprendizaje basado en problemas: el reto de la educación activa aplicada a la Pediatría / No disponible

No disponible

Treatment with teriparatide might be associated with cardiometabolic changes in postmenopausal severe osteoporotic women.

Parathormone (PTH) has been suggested to affect the cardiovascular system. Teriparatide (TPT), the hormonally active 1-34 fragment of PTH, provides an anabolic treatment for osteoporosis. The aim of the present study was to evaluate the cardiometabolic effects of 18-month treatment with 20 µg/ die teriparatide subcutaneosly. Fourteen women with postmenopausal severe osteoporosis treated with once-daily sc 20 µg TPT (67.6 ± 2.5 years; BMI 27.7 ± 1.0 kg/m²) and 24 age- and BMI-matched severe osteoporotic women treated with iv yearly 5 mg zoledronate (ZLN) were evaluated at baseline and at 12-18 months of treatment for anthropometric measures, calcium, glucose and lipid metabolic parameters, and assessment of cardiac geometry by conventional echocardiography. TPT was effective in increasing mean lumbar spine bone mineral density with no clinically relevant changes in calcium metabolism parameters. TPT patients experienced an increase of BMI (27.7 ± 1.0 at baseline vs 29.0 ± 1.0 kg/m² at last evaluation, P=0.005) and mean whole body fat percentage (37.0 ± 2.1 vs 40.3 ± 1.9%, P=0.05), associated with increased serum leptin levels (17.3 ± 2.1 vs 22.9 ± 3.0 ng/ml; P=0.049). Glucose and lipid parameters were not affected by TPT as well as by ZLN treatment. Furthermore, TPT was associated with a decrease in systolic blood pressure; a decrease in the fractional shortening (41.2 ± 2.3 vs 36.9 ± 1.2; P=0.05) and an increase in the relative wall thickness (0.39 ± 0.01 vs 0.48 ± 0.01 mm; P=0.002), suggestive for concentric cardiac remodeling, was detected by echocardiographic monitoring. These changes could not be detected in bone active drug-free age- and metabolic-matched controls. In conclusion, long-term TPT therapy might affect cardiometabolic and cardiac geometry parameters in severe osteoporotic women, though changes are not clinically relevant.

Presentación de «Continuum»: el portal de formación continuada de la Asociación Española de Pediatría / Presentation of «Continuum»: The continuing education portal of the Spanish Paediatric Association

No disponible

Tricuspid annular plane systolic excursion and pulmonary arterial systolic pressure relationship in heart failure: an index of right ventricular contractile function and prognosis.

Echo-derived pulmonary arterial systolic pressure (PASP) and right ventricular (RV) tricuspid annular plane systolic excursion (TAPSE; from the end of diastole to end-systole) are of basic relevance in the clinical follow-up of heart failure (HF) patients, carrying two- to threefold increase in cardiac risk when increased and reduced, respectively. We hypothesized that the relationship between TAPSE (longitudinal RV fiber shortening) and PASP (force generated by the RV) provides an index of in vivo RV length-force relationship, with their ratio better disclosing prognosis. Two hundred ninety-three HF patients with reduced (HFrEF, n = 247) or with preserved left ventricular (LV) ejection fraction (HFpEF, n = 46) underwent echo-Doppler studies and N-terminal pro-brain-type natriuretic peptide assessment and were tracked for adverse events. The median follow-up duration was 20.8 mo. TAPSE vs. PASP relationship showed a downward regression line shift in nonsurvivors who were more frequently presenting with higher PASP and lower TAPSE. HFrEF and HFpEF patients exhibited a similar distribution along the regression line. Given the TAPSE, PASP, and TAPSE-to-PASP ratio (TAPSE/PASP) collinearity, separate Cox regression and Kaplan-Meier analyses were performed: one with TAPSE and PASP as individual measures, and the other combining them in ratio form. Hazard ratios for variables retained in the multivariate regression were as follows: TAPSE/PASP

The frequency and severity of cardiac involvement in myotonic dystrophy type 2 (DM2): long-term outcomes.

BACKGROUND: Frequency and severity of cardiac involvement in DM2 are still controversial. The aims of our study were to determine the frequency and progression of cardiac and muscle involvement in a relatively large cohort of patients with DM2 throughout Italy and Germany and to provide long-term outcomes in this disorder. METHODS: 104 DM2 and 117 DM1 patients underwent baseline and follow-up assessments of, ECG, 24h Holter monitoring, 2D echocardiography and electrophysiological study (EPS) when appropriate, and manual muscle strength testing (mean follow-up: 7.4 ± 4.1 for DM2 and 5.7 ± 4 years for DM1). RESULTS: Overall, 10% of DM2 patients vs 31% of DM1 patients had PR ≥ 200 ms and 17% of DM2 patients vs 48% of DM1 patients had QRSD ≥ 100 ms. Six patients with DM2 vs 28 patients with DM1 required PM/ICD implantations. DM2 patients were stronger than DM1 patients at baseline, but muscle strength worsened significantly over time (p<0.0001), just as in DM1, although at a slower annual rate. CONCLUSION: Our data demonstrate that the frequency and severity of cardiac involvement and of muscle weakness are reduced in DM2 compared to DM1 and that progression is slower and less severe. Nonetheless, careful cardiac evaluation is recommended in this patient population to identify patients at risk for potential major cardiac arrhythmias.

IL-18 level in patients undergoing coronary artery bypass grafting surgery or valve replacement: which link with epicardial fat depot?

Interleukin-18 (IL-18) is a member of the interleukin-1 family of cytokines produced constitutively by different cell types and by adipose tissue. Due to the link between obesity, inflammation and cardiovascular diseases, we aimed to measure IL-18 circulating level in patients undergoing open-heart surgery both for elective coronary artery bypass grafting (CABG) or for valve replacement (VR), and we also evaluated whether epicardial adipose tissue (EAT) depot may be a potential source of IL-18. Circulating IL-18 protein was quantified by enzyme-linked immunosorbent assay. IL-18, IL-18 receptor 1 (IL-18 R1) and IL-18 receptor accessory protein (IL-18-RAP) gene expression in EAT depot were evaluated by one colour microarray platform. EAT thickness was measured by echocardiography. In this study we found that all cardiovascular patients (CABG and VR) have increased circulating IL-18 level compared to healthy control subjects (p < 0.0001), but no statistical significant difference was observed between CABG and VR groups (p = 0.35). A great increase in the gene expression of IL-18 (p < 0.05), IL-18 R1 (p < 0.01) and IL-18 RAP (p < 0.001) was observed in EAT samples obtained from CABG vs VR patients. In conclusion, CABG and VR patients had similar increased level of circulating IL-18 protein, but in EAT depots isolated from CABG gene expression of IL-18, IL-18 R1 and IL-18-RAP resulted higher than in VR patients. Future investigation on local IL-18 protein production, its autocrine-paracrine effect and its correlation with plasmatic IL-18 level could give more information on the relationship between IL-18 and coronary artery disease.

Documento de consenso sobre el diagnóstico y tratamiento de la faringoamigdalitis aguda / Consensus document on the diagnosis and treatment of acute tonsillopharyngitis

La faringoamigdalitis aguda (FAA) es una de las enfermedades más comunes en la infancia. La etiología más frecuente es vírica. Entre las causas bacterianas, el principal agente responsable es Streptococcus pyogenes o estreptococo beta hemolítico del grupo A (EbhGA). Las escalas de valoración clínica son una buena ayuda para seleccionar a qué niños se deben practicar las técnicas de detección rápida de antígeno estreptocócico (TDR) y/o el cultivo de muestras faringoamigdalares. Sin su empleo, se tiende al sobrediagnóstico de FAA estreptocócica, con la consiguiente prescripción innecesaria de antibióticos, muchas veces de amplio espectro. Los objetivos del tratamiento son: acelerar la resolución de los síntomas, reducir el tiempo de contagio y prevenir las complicaciones supurativas locales y no supurativas. Idealmente, solo deben tratarse los casos confirmados. En caso de no disponibilidad de la TDR, o en algunos casos, ante un resultado negativo, se recomienda obtener cultivo e iniciar tratamiento a la espera de los resultados, solo si la sospecha clínica es alta. Los antibióticos de elección para el tratamiento de la FAA estreptocócica son penicilina y amoxicilina. Amoxicilina-clavulánico no está indicado de forma empírica en la infección aguda. Los macrólidos tampoco son un tratamiento de primera elección; su uso debe reservarse para pacientes con alergia inmediata a penicilina o como tratamiento erradicador, en los casos indicados. Es urgente y prioritario en nuestro país adecuar la prescripción de antibióticos a la evidencia científica disponible (AU)

Acute tonsillopharyngitis is one of the most common childhood diseases. Viruses are the most frequent origin. Group A Streptococcus (Streptococcus pyogenes) is the main bacterial cause. A culture or a rapid antigen-detection test of a throat-swab specimen should only be done on the basis of clinical scores, in order to avoid over-diagnosis of bacterial origin and unnecessary antibiotic prescription. The objectives of treatment are: the reduction of symptoms, reduce the contagious period, and prevent local suppurative and systemic complications. Ideally, only confirmed cases should receive antibiotics. If there is no possibility to perform a rapid antigen-detection test, or in some cases if the result is negative, it is recommended to perform a culture and, if there is high suspicious index, to prescribe antibiotics. Penicillin is the treatment of choice, although amoxicillin is also accepted as the first option. Amoxicillin/clavulanate is not indicated in any case as empirical treatment. Macrolides are not a first choice antibiotic, and should be reserved for those patients with immediate penicillin allergy reaction or for the treatment of streptococcal carriers. It is of primordial importance to adapt the prescribing of antibiotics to the scientific evidence (AU)

[Consensus document on the diagnosis and treatment of acute tonsillopharyngitis]. / Documento de consenso sobre el diagnóstico y tratamiento de la faringoamigdalitis aguda.

Acute tonsillopharyngitis is one of the most common childhood diseases. Viruses are the most frequent origin. Group A Streptococcus (Streptococcus pyogenes) is the main bacterial cause. A culture or a rapid antigen-detection test of a throat-swab specimen should only be done on the basis of clinical scores, in order to avoid over-diagnosis of bacterial origin and unnecessary antibiotic prescription. The objectives of treatment are: the reduction of symptoms, reduce the contagious period, and prevent local suppurative and systemic complications. Ideally, only confirmed cases should receive antibiotics. If there is no possibility to perform a rapid antigen-detection test, or in some cases if the result is negative, it is recommended to perform a culture and, if there is high suspicious index, to prescribe antibiotics. Penicillin is the treatment of choice, although amoxicillin is also accepted as the first option. Amoxicillin/clavulanate is not indicated in any case as empirical treatment. Macrolides are not a first choice antibiotic, and should be reserved for those patients with immediate penicillin allergy reaction or for the treatment of streptococcal carriers. It is of primordial importance to adapt the prescribing of antibiotics to the scientific evidence.

Psiquiatría infantil: patología prevalente en Atención Primaria, abordaje y tratamiento / Child Psychiatry: prevalent conditions in Primary care, approach and treatment

La Salud Mental Infantojuvenil (SMIJ) comprende el desarrollo de las capacidades sociales y emocionales del niño que le permiten experimentar, regular sus emociones, establecer relaciones próximas y seguras, y aprender. En España, la prevalencia de los trastornos de SMIJ se sitúa en torno al 20%. En el presente documento, partiendo de los trastornos psicopatológicos más frecuentes, se recogen las funciones de los profesionales de la salud que son depositarios de la solicitud de asistencia: pediatras, psiquiatras infantiles y psicólogos, con objeto de mejorar la continuidad asistencial y la coordinación entre niveles. Se describen las indicaciones de derivación y las recomendaciones generales en cuanto al tipo de intervención (AU)

The Child and Adolescent Mental Health (SMIJ) includes the development of social skills and emotional needs that allow them to experience, to regulate their emotions, to establish close and safe relationships, and to learn. In Spain, the prevalence of disorders SMIJ is around 20%. In this document, the roles of the health professionals who are custodians of the request for assistance, based on the most common mental diseases, are collected: pediatricians, child psychiatrists and psychologists aiming to improve the continuity of care and coordination between levels. We describe the indications for referral and general recommendations on the type of intervention (AU)

Trastornos del espectro autista. Detección precoz, herramientas de cribado / Autistic spectrum disorders. Early detection, screening tools

El término trastornos del espectro autista (TEA) agrupa cinco cuadros clínicos según el DSM-IV-TR, ocho si seguimos la Clasificación CIE-10 de la Organización Mundial de la Salud. Todos ellos se caracterizan por dificultades cualitativas de interacción social, con falta de empatía y reciprocidad social, incapacidad para reconocer y responder a gestos y expresiones, dificultades en la comunicación y falta de flexibilidad en razonamientos y comportamientos, con un repertorio restringido, estereotipado y repetitivo de actividades e intereses. Se trata de un trastorno prevalente, que predomina en varones y cuyos síntomas por lo general son evidentes entre los 18 y los 24 meses de edad; pese a ello es habitual que ocurra retraso en el diagnóstico. Desde Atención Primaria se ha de promover una intervención precoz mediante la vigilancia longitudinal del DPM, la realización de cribado sistemático entre los 18-24 meses de edad (M-CHAT) y considerando especialmente las preocupaciones expresadas por los padres como importante signo de alarma. El diagnóstico definitivo será llevado a cabo por un equipo multidisciplinar experto en los TEA que emplearán herramientas diagnósticas más específicas como ADI-R y ADOS. Existe evidencia de que las intervenciones son más efectivas cuando se inician precozmente, entre los 2 y los 4 años de edad. Además de lo anterior se han de atender los problemas médicos asociados, conocer las intervenciones farmacológicas y no farmacológicas para los comportamientos problemáticos y ofrecer formación y apoyo a las familias, las cuales han de conocer la existencia de terapias controvertidas, no sustentadas en evidencias científicas, a fin de que actúen con cautela frente a las mismas (AU)

The term, autistic spectrum disorder (ASD) groups 5 clinical conditions according to the DSM-IV-TR, eight if we follow the ICD-10 Classification of the World Health Organisation. All of them are characterised by qualitative social interaction difficulties, with lack of empathy and social reciprocity, inability to recognise and respond to gestures or expressions, communication difficulties, lack of flexibility in reasoning and behaviour, with a restricted, stereotyped and repetitive activities and interests. It is a prevalent disorder, which predominates in males and the symptoms are generally evident between 18 and 24 months of age, this being a reason for the delay in diagnosis. An early intervention program must be introduced to monitor PSD over the longterm, performing systematic screening between 18-24 months of age ( M-CHAT) and in particular, taking into account the concerns expressed by the parents as an important sign of alarm. The definitive diagnosis will be made by a multidisciplinary team expert in ASD, who will use more specific diagnostic tools like ADI-R and ADOS. There is evidence that interventions are more effective when started early, between 2 and 4 years of age. As well as all this, the associated medical problems have to be attended to. We must know the pharmacological and non-pharmacological interventions for problematic behaviours, and offer training and support ,to the families, who should be aware of controversial treatments, not supported by scientific evidence, so that they may act with caution with those (AU)

Toxoplasma gondii antigenuria in patients with acquired immune deficiency syndrome.

A longitudinal study was performed with sera and urine of patients with acquired immune deficiency syndrome (AIDS), taken before, during and after clinically Toxoplasma infection. The tested patients were followed for an average of two years. The titres of the specific IgG and IgM antibodies were measured by an indirect fluorescent antibody test (IFAT), and the appearance of circulating antigens of T. gondii was determined in 36 urine samples of 13 patients with neurotoxoplasmosis by means of the coagglutination test. The presence of T. gondii antigens in the urine of AIDS patients by this test was correlated with the immunoblot technique, with clinical symptoms and also with pathological findings. Our results indicate that the detection of T. gondii antigens in the urine of AIDS patients can be regarded as a rapid and efficient method for the diagnosis of acute toxoplasmosis.