Detection of Early Diffuse Myocardial Fibrosis and Inflammation in Chagas Cardiomyopathy with T1 Mapping and Extracellular Volume.

Purpose: To evaluate myocardial T1 mapping and extracellular volume (ECV) parameters in different stages of Chagas cardiomyopathy and determine whether they are predictive of disease severity and prognosis. Materials and Methods: Prospectively enrolled participants (July 2013 to September 2016) underwent cine and late gadolinium enhancement (LGE) cardiac MRI and T1 mapping with a precontrast (native) or postcontrast modified Look-Locker sequence. The native T1 and ECV values were measured among subgroups that were based on disease severity (indeterminate, Chagas cardiomyopathy with preserved ejection fraction [CCpEF], Chagas cardiomyopathy with midrange ejection fraction [CCmrEF], and Chagas cardiomyopathy with reduced ejection fraction [CCrEF]). Cox proportional hazards regression and the Akaike information criterion were used to determine predictors of major cardiovascular events (cardioverter defibrillator implant, heart transplant, or death). Results: In 107 participants (90 participants with Chagas disease [mean age ± SD, 55 years ± 11; 49 men] and 17 age- and sex-matched control participants), the left ventricular (LV) ejection fraction and the extent of focal and diffuse or interstitial fibrosis were correlated with disease severity. Participants with CCmrEF and participants with CCrEF showed significantly higher global native T1 and ECV values than participants in the indeterminate, CCpEF, and control groups (T1: 1072 msec ± 34 and 1073 msec ± 63 vs 1010 msec ± 41, 1005 msec ± 69, and 999 msec ± 46; ECV: 35.5% ± 3.6 and 35.0% ± 5.4 vs 25.3% ± 3.5, 28.2% ± 4.9, and 25.2% ± 2.2; both P < .001). Remote (LGE-negative areas) native T1 and ECV values were also higher (T1: 1056 msec ± 32 and 1071 msec ± 55 vs 1008 msec ± 41, 989 msec ± 96, and 999 msec ± 46; ECV: 30.2% ± 4.7 and 30.8% ± 7.4 vs 25.1% ± 3.5, 25.1% ± 3.7, and 25.0% ± 2.2; both P < .001). Abnormal remote ECV values (>30%) occurred in 12% of participants in the indeterminate group, which increased with disease severity. Nineteen combined outcomes were observed (median follow-up time: 43 months), and a remote native T1 value greater than 1100 msec was independently predictive of combined outcomes (hazard ratio, 12 [95% CI: 4.1, 34.2]; P < .001). Conclusion: Myocardial native T1 and ECV values were correlated with Chagas disease severity and may serve as markers of myocardial involvement in Chagas cardiomyopathy that precede LGE and LV dysfunction.Keywords: MRI, Cardiac, Heart, Imaging Sequences, Chagas Cardiomyopathy Supplemental material is available for this article. © RSNA, 2023.

Bioactivity of Ceftazidime and Fluconazole Included in Polymethyl Methacrylate Bone Cement for Use in Arthroplasty.

BACKGROUND: The microorganisms that most frequently cause prosthetic joint infection are methicillin-resistant Staphylococcus aureus and gram-negative aerobic bacillus. Studies have documented the efficacy of mixing antibiotics with polymethyl methacrylate, but that of antifungal drugs has not received much attention. The objective of this in vitro study was to characterize the elution profile and bioactivity of ceftazidime and fluconazole when incorporated into bone cement in proportions intended for prophylaxis and treatment of bone infections. METHODS: Antibiotic-loaded bone cement cylinders in a proportion of 1:40 and 4:40 (ratio of grams of antibiotic to grams of cement) were assayed. Drug delivery was investigated in a flow-through dissolution apparatus (SotaxCE7). To assess bioactivity, antibiotic concentrations were simulated in the joint space of 1000 patients. Antibacterial properties were evaluated by counting colony forming units and the inhibition-halo test. RESULTS: The ratio of released ceftazidime and fluconazole was 453% and 648%, respectively, higher when used for treatment proportions than prophylaxis proportions. A bioactivity simulation exercise showed that the efficacy of ceftazidime/fluconazole determined as the amount of drug is released at the active site in the first 3 days after surgery would depend on the sensitivity of the microorganism and would increase substantially after drain removal. The microbiology study showed that biofilm formation by Pseudomonas aeruginosa could be a problem when ceftazidime was used in treatment or prophylaxis proportions. CONCLUSION: Our in vitro findings suggest that ceftazidime and fluconazole can be added into polymethyl methacrylate for the prevention/treatment of infections associated to joint surgery. Their efficacy depends on the sensitivity of the microorganism causing the infection.

In vitro evaluation of extemporaneously compounded immediate-release capsules with premixed excipients, based on the biopharmaceutics classification system (BCS) of the drugs.

Hard-capsule compounding plays an essential role in drug delivery for pharmaceutical application. Versatile and easy to use, capsules represent a popular dosage form for patients. Nevertheless, bioavailability of the drugs compounded in hard capsules is not always optimized and choosing the appropriate excipients is a key factor to improve the dissolution kinetics of active pharmaceutical ingredients. The Biopharmaceutical Classification System, which categorizes drugs regarding their solubility and permeability, is a unique tool which can be used to select the most compatible excipients for a particular drug when compounding immediate-release capsules. The aim of this study was to evaluate the efficiency of premixed excipient blends called CapsuBlend Excipients, based on the Biopharmaceutical Classification System concept, for drug dissolution rate and absorption enhancement. Drug assay and dissolution profiles were studied for three batches of metronidazole 250-mg, theophylline 100-mg, and levocarnitine 250-mg capsules, each respectively representing a highly soluble, poorly soluble, and hygroscopic drug. Methods followed the specifications set forth in the United States Pharmacopeia. Assay results demonstrated that each batch of metronidazole 250 mg, theophylline 100 mg, and levocarnitine 250 mg contained not less than 90.0% of and not more than 110.0% of the labeled amount of drug, which is in accordance with the United States Pharmacopeia requirements. Moreover, dissolution profile results for the aforementioned capsules depicted dissolution values meeting the Pharmacopeial criteria of acceptance. These results reinforce the fact that the Biopharmaceutical Classification System concept represents a valuable guideline for formulation chemists or pharmacists to assist them for capsule compounding. To ensure a high level of efficiency of compounded capsules, premixed excipient blends, carefully developed by taking into consideration the solubility and permeability of a drug, represent a significant formulation advantage to improve the dissolution of active pharmaceutical ingredients.

Leiomioma facial. A propósito de un caso / No disponible

Los leiomiomas son tumores benignos raros que se originan desde el músculo erector de los folículos pilosos, en el escroto, en la zona genital y en los vasos sanguíneos. Se desarrollan en las zonas donde existe tejido muscular liso. Por ello, tienden a ser bastante frecuentes en los tractos gastrointestinal y genitourinario, algo menos frecuentes en la piel y raros en el tejido blando profundo. En general, los leiomiomas del tejido blando causan poca morbilidad y por ello existen pocos trabajos en la literatura concernientes a su presentación, diagnóstico y tratamiento. Presentamos el caso de un leiomioma de localización atípica (facial) que remite con tratamiento oral con doxazosina. Sólo hay descritos en la bibliografía cuatro casos a nivel mundial con este tratamiento

Leiomyomas are uncommon benign tumors that arisefrom the erector pili muscle of hair follicles, in the scrotum, in the genital zone and in the blood glasses. They develop in zones where there is smooth muscle tissue. Thus, they tend to be quite frequent in the gastrointestinal and genitourinary tracts, and somewhat less frequent in the skin and rare in the deep soft tissue. In general, soft tissue leiomyomas cause little morbidity and thus few works have been published in the literature regarding its presentation, diagnosis and treatment. We present the case of an atypical presentation site of leiomyoma, that is facial, that abated with oral treatment with doxazosine. Only four cases worldwide with this treatment have been described

Fiebre en Atención Primaria / No disponible

La fiebre es un motivo frecuente en las consultas de Atención Primaria que plantea un amplio diagnóstico diferencial, la mayoría de las veces debida a procesos víricos o bacterianos autolimitados y de corta duración, pero también puede ser la expresión de procesos más graves que pueden poner en peligro la vida del paciente. Un estudio protocolizado y racional desde la consulta puede ahorrar pruebas complementarias costosas, innecesarias e incluso ingresos hospitalarios. La mayoría de los protocolos consultados recomiendan la secuencia de estudios que exponemos en el protocolo recogido en la figura 1

Fever is a frequent reason for consultation in Primary Health Care that entails a wide range of differential diagnoses, most of the times due to self-limited viral or bacterial conditions of short duration. However, it may also be the expression of more serious life-threatening conditions. A protocolize and rational study made from the consultation may avoid expensive and unnecessary complementary studies and even hospital admissions. Most of the protocols consulted recommend a sequence of studies

[Organic pollutant residues of different origins in Navarra]. / Residuos de contaminantes orgánicos de diferentes orígenes en Navarra.

An analysis was made of residues of polychlorobyphenyls and trihalomethanes through GC-ECD and of herbicides through HPLC-PAD in samples proceeding from Navarra. Polychlorobyphenyls were detected (0.30 +/- 0.05 and 0.11 +/- 0.05 microg/l) in two of the 106 water samples analysed. Sixty-six food samples were analysed, and polychlorobyphenyls were only found in 8 samples of trout (dissimilar to dioxins: 21-194 microg/kg of fat; similar to dioxins: 41-139 microg/kg of fat). Of 107 fat samples analysed, polychlorobyphenyls dissimilar to dioxins were detected in two (27 +/- 5 and 30 +/- 5 microg/kg). Out of a total of 94 feed samples analysed, polychlorobyphenyls were detected in all the samples (12) of feed for aquaculture and their raw materials; the concentration of polychlorobyphenyls dissimilar to dioxins varied by an interval of 8-247 microg/kg of fat; polychlorobyphenyls similar to dioxins, between 18 and 107 microg/kg of fat. Contamination by polychlorobyphenyls of the fish from aquaculture could be due to the feed used in these exploitations. The average of trihalomethanes in the waters of the southern zone of Navarra (44 +/- 4 microg/l) was higher than those of the middle zone (16 +/- 1 microg/l) and the mountain zone (12 +/- 1 microg/l). The concentration of 99% of the samples fulfilled the norms on halomethanes. A relation was observed between muddiness and the concentration of trihalomethanes. Herbicide (cianazine) was only detected in one of the 135 samples of water analysed, with a concentration of (0.4 +/- 0.2 microg/l) which exceeded the established limit. The use of confirmation techniques (GC-MS, HPLC-MS/MS) would make it possible to validate these results and to expand the number of compounds analysed.

Myocardial contrast echocardiography in coronary artery disease.

Myocardial contrast echocardiography (MCE) allows the assessment of myocardial perfusion by imaging the coronary microcirculation. The development of new contrast agents and new diagnostic tools far assessing myocardial perfusion by means of MCE has led to a new field of applications far patients suffering from ischemic heart disease. Several studies have shown that MCE is a feasible and accurate method to evaluate patients with: a) acute coronary syndromes: MCE is useful before the epicardial reperfusion to delineate the area at risk and to assess the collateral-derived myocardial blood flow, and after the epicardial reperfusion to detect the non-reflow phenomenon; b) chronic coronary syndromes: MCE allows the detection of significant coronary stenosis by means of stress methods and methods without any stress; c) myocardial viability and hibernating myocardium: MCE helps to predict functional recovery of akinetic segments. In these settings, MCE is not only useful as a diagnostic tool but also provides prognostic information. MCE is a technique in constant development. Among the latest advances we note the development of transesophageal probes with second-harmonic image that allows assessment of myocardial perfusion in a more accurate way. This technique should introduce MCE into new clinical fields, especially the evaluation of myocardial perfusion during cardiac operations. Another recent development is in parametric imaging techniques. These consist in obtaining time curves for all the pixels in the image instead of working only with a few separate regions of interest. A parameter scan is computed far any pixel showing their value as a color overlay in the parametric image. Summarizing, we can say that MCE is crossing from the experimental laboratory to the daily clinical practice far the evaluation of ischemic heart disease. MCE provides an interesting tool that offers the potential of a complete evaluation of patients with chronic coronary artery disease. This includes both diagnostic and prognostic evaluation.

Isovolumic contraction time by pulsed-wave Doppler tissue imaging in aortic stenosis.

BACKGROUND: Doppler Tissue Imaging (DTI) has been evaluated in ischaemic heart disease and some cardiomyopathies. In patients with aortic stenosis (AS), left ventricular contraction is slowered. This study aimed to evaluate the possible role of the measurement of isovolumic contraction time (ICT) by DTI in the evaluation of AS severity. METHODS: The study population constitutes 30 patients: 15 with AS (nine severe and six non-severe) and 15 control subjects. All of them had normal systolic function, sinus rhythm, and absence of ischaemic heart disease of conduction abnormalities. ICT was defined as the time from the onset of the QRS complex to the beginning of the DTI systolic wave. The correlation between ICT and aortic area obtained by continuity equation, as well as the diagnostic value of ICT in the identification of severe AS were studied. RESULTS: ICT was significantly increased in patients with severe AS (98+/-27 versus 65+/-21 ms, p=0.024). There was a significant correlation between ICT and aortic area (r=-0.56; p=0.035). The receiver operator characteristic curve of ICT in the identification of severe AS yielded an area under the curve of 0.852 (95% confidence interval: 0.665-1.0). The two best cut-points were >73 ms (88% sensitivity, 77% specificity) and >85 ms (78% sensitivity, 83% specificity). A value of >41 ms had a 100% sensitivity, but only a 17% specificity, and >91 ms showed a 100% specificity, but only a 44% sensitivity. CONCLUSIONS: ICT measured by pulsed-wave DTI is increased in patients with aortic stenosis.

Usefulness of contrast agents in the diagnosis of left ventricular pseudoaneurysm after acute myocardial infarction.

BACKGROUND AND OBJECTIVE: The diagnosis of left ventricular pseudoaneurysm after acute myocardial infarction is usually based on echocardiography. However, this technique may have limitations in some patients, especially in cases with suboptimal acoustic window. The objective of this study was to evaluate the usefulness of contrast echocardiography in the diagnosis of left ventricular pseudoaneurysm after myocardial infarction. METHODS AND RESULTS: The study population comprises six patients in whom a two-dimensional echocardiography showed an image consistent with left ventricular pseudoaneurysm. Levovist (Schering) 4gr was administered i.v. to more clearly visualize the blood flow from the left ventricle to the left ventricular pseudoaneurysm cavity in all patients. Infarct location was anterior in five patients, and posterolateral in one. No patient had received thrombolysis or primary angioplasty during the acute phase. The transthoracic echocardiographic study showed an echo-free space adjacent to left ventricle in all patients. In four cases, the diagnosis of left ventricular pseudoaneurysm was made before contrast administration. In the remaining two patients, the definite diagnosis was made only after Levovist administration. CONCLUSION: In the diagnosis of postinfarction left ventricular pseudoaneurysm, the administration of contrast agents may be of help in the correct visualization of the blood flow from the left ventricle to the left ventricular pseudoaneurysm cavity, and may allow a definite diagnosis to be obtained in some patients.

[Isolated ventricular diverticulum in asymptomatic male]. / Divertículo ventricular aislado en varón asintomático.

Ventricular diverticulum are small outpouchings, in the cardiac wall, which are mostly described as a part of malformation syndromes. This finding is infrequent in asymptomatic patients with no pathology in the thoraco abdominal line. The case we present shows a diverticulum in the cardiac apex in a male patient with no cardiological clinic manifestations and with an abnormal electrocardiogram. At present, magnetic resonance is the best diagnostic test, for this kind of malformation, and is also the most reliable in the follow-up of these patients.

[Effect of the use of echoenhancers on interobserver variability in dobutamine stress echocardiography]. / Influencia de la administración de ecopotenciadores sobre la variabilidad interobservador en la ecocardiografía de estrés con dobutamina.

INTRODUCTION: Dobutamine stress echocardiography is an accurate technique for the noninvasive diagnosis of coronary artery disease. However, interobserver variability is an important limitation of stress echocardiography. Image quality and echocardiographer experience have been described to influence interobserver agreement. AIM: The aim of this study was to determine whether use of contrast agents during dobutamine stress echocardiography improves the agreement between an experienced and a unexperienced observer, and if learning period would be influenced by the use of contrast. METHODS: Two blind observers interpreted all the studies: one experienced echocardiographer (A) and one unexperienced observer (B) in this technique. The contrast agent Levovist/Levograf 2.5 g was administered by two bolus (at rest and at peak stress). In all cases, second harmonic imaging and stress digitalisation packs were used. The kappa test was used to determine interobserver agreement. RESULTS: Fifty-two unselected consecutive studies in 51 patients were analyzed. Twenty-two studies were performed with contrast. The agreement between the experienced and the unexperienced observer was Kappa 0.58 and 0.52, with and without the use of contrast, with no statistically significant difference being archived. CONCLUSIONS: The routine use of contrast provides better although not significant, interobserver agreement. However, this improvement is not sufficient to substitute specific training.

[Usefulness of contrast echocardiography with harmonic imaging in a patient with hypertrophic cardiomyopathy and midventricular obstruction]. / Utilidad de la ecocardiografía de contraste con segundo armónico en un paciente con miocardiopatía hipertrófica y obstrucción mesoventricular.

Echocardiography is routinely used for the evaluation of cardiac function. Definition of the endocardial border is essential for the assessment of global and regional left ventricular contractility. This is sometimes difficult due to an inadequate acoustic window. New echocardiographic techniques may be useful to accurate and noninvasively diagnose certain conditions which may otherwise remain undiagnosed with traditional techniques. We present a case of a patient diagnosed with segmental wall motion abnormalities (lateral and apical hypokinesis) by conventional echocardiography. The use of harmonic imaging with contrast changed the initial diagnosis and the patient was diagnosed with severe hypertrophic cardiomyopathy with midventricular obstruction, without segmental wall motion abnormalities.

[Transient paradoxical embolism. Importance of early ultrasonography diagnosis]. / Embolia paradójica en tránsito. Importancia del diagnóstico ecocardiográfico precoz.

The paradoxical embolism or the crossing of an embolism through a permeable foramen ovale is considered to be a rare mechanism of cerebral embolism although its real frequency is unknown. Reports demonstrating the embolism during its crossing through cardiac cavities are scarce. Two cases of moving paradoxical embolism are presented. In the first, an infarction of the superior branch of the left middle cerebral artery was produced during the course of deep vein thrombosis and pulmonary thromboembolism with transesophageal echocardiography demonstrating the crossing of the embolism through the foramen ovale. Surgery performed 12 days later did not discover the auricular thrombus. In the second case, a mass was discovered in the right auricle with a permeable foramen ovale during the course of a left middle cerebral artery infarction and a large auricular thrombus was demonstrated in surgery. The diagnostic usefulness of early transsesophageal echocardiography in the diagnosis of moving paradoxal embolism is discussed.

Cardiopulmonary and haemodynamic changes during total hip arthroplasty.

We report a prospective study of 30 patients who underwent total hip arthroplasty for osteoarthrosis in order to investigate the haemodynamic and respiratory changes which occur during operation. Cement was used in 17 cases and the implants were not cemented in 13. Pulmonary and cardiac function, blood levels of methylmethacrylate monomer, intramedullary pressure and transoesophageal echocardiography were recorded. Two well differentiated echogenic patterns appeared consistently during the operation. The intramedullary pressure became raised as the cement was inserted. The following changes occurred within seconds and continued for some minutes: elevation of mean arterial pressure and mean pulmonary artery pressure; decrease of arterial oxygen tension and of mixed venous PO2, and greater tissue consumption of oxygen. Although we recorded raised concentration of methylmethacrylate monomer in venous blood after the cement was inserted, there is no evidence that the monomer is responsible for the haemodynamic changes which take place.

[Conventional and color Doppler echocardiography in mitral balloon valvotomy]. / Ecocardiografía-Doppler convencional y color en la valvotomía mitral con balón.

With the aim of assessing the value of conventional echocardiography and Doppler and colour Doppler during and in the follow-up of percutaneous mitral valvotomy we have studied prospectively 100 consecutive patients with 1 (90%), 6 (69%) and 12 (53%) months follow-up. Age was 50 years and 80% were women. The single balloon technique was used in 68%, mitral valve area increased from 0.9 +/- 0.2 to 1.8 +/- 0.3 cm2 and decrease in pulmonary artery pressure was 10 +/- 0.05 mmHg. We found that: 1) percutaneous mitral valvotomy produced and acute and transient decrease in left ventricular ejection fraction (pre 69 +/- 9%, post 61 +/- 10% p less than 0.001; 1 month 70 +/- 10; 2) a severe mitral regurgitation appeared in 4% of patients and 17% of patients had a moderate degree of regurgitation after valvotomy; 3) after valvular dilation an increase in the width of the aliasing greater than 29% predicted a successful procedure (final area greater than 1.5 cm2) with a sensibility 80% and specificity 94%, and 4) colour Doppler detected an atrial septal defect immediately after valvular dilation in 77% of patients, and permitted non invasive follow-up of the left to right shunt. At one year a left to right shunt at the atrial level persisted roughly in 1/3 of patients. We conclude that colour Doppler Echocardiography during percutaneous mitral valvotomy is useful for a rapid assessment of the increase in valve area, the detection and quantification of mitral regurgitation induced by valvular dilation and the follow-up in these patients.