Cardiovascular considerations on recreational scuba diving. SEC-Clinical Cardiology Association/SEC-Working Group on Sports Cardiology consensus document.

The practice of recreational scuba diving has increased worldwide, with millions of people taking part each year. The aquatic environment is a hostile setting that requires human physiology to adapt by undergoing a series of changes that stress the body. Therefore, physical fitness and control of cardiovascular risk factors are essential for practicing this sport. Medical assessment is not mandatory before participating in this sport and is only required when recommended by a health questionnaire designed for this purpose. However, due to the significance of cardiovascular disease, cardiology consultations are becoming more frequent. The aim of the present consensus document is to describe the cardiovascular physiological changes that occur during diving, focusing on related cardiovascular diseases, their management, and follow-up recommendations. The assessment and follow-up of individuals who practice diving with previous cardiovascular disease are also discussed. This document, endorsed by the Clinical Cardiology Association of the Spanish Society of Cardiology (SEC) and the SEC Working Group on Sports Cardiology of the Association of Preventive Cardiology, aims to assist both cardiologists in evaluating patients, as well as other specialists responsible for assessing individuals' fitness for diving practice.

Identification of a Shewanella halifaxensis Strain with Algicidal Effects on Red Tide Dinoflagellate Prorocentrum triestinum in Culture.

The dinoflagellate Prorocentrum triestinum forms high biomass blooms that discolor the water (red tides), which may pose a serious threat to marine fauna and aquaculture exploitations. In this study, the algicidal effect of a bacterial strain (0YLH) belonging to the genus Shewanella was identified and evaluated against P. triestinum. The algicidal effects on the dinoflagellate were observed when P. triestinum was exposed to cell-free supernatant (CFS) from stationary-phase cultures of the 0YLH strain. After 24 h exposure, a remarkable reduction in the photosynthetic efficiency of P. triestinum was achieved (55.9%), suggesting the presence of extracellular bioactive compounds produced by the bacteria with algicidal activity. Furthermore, the CFS exhibited stability and maintained its activity across a wide range of temperatures (20-120 °C) and pH values (3-11). These findings highlight the algicidal potential of the bacterium Shewanella halifaxensis 0YLH as a promising tool for the environmentally friendly biological control of P. triestinum blooms.

Aortic Diameters and Calcifications in Former World-Class Cyclists.

PURPOSE: Concerns on whether athletes--particularly older ones--are at an increased risk of pathological aortic dilation exist, and the prevalence of aortic calcifications in these individuals is unknown. We aimed to compare the dimensions, distensibility, and prevalence of calcifications in the thoracic aorta between former male professional cyclists (cases) and sex/age-matched controls. METHODS: We used a retrospective cohort design, where cases were former finishers of at least one Grand Tour (Tour de France, Giro d' Italia or Vuelta a España) and controls were untrained individuals with no previous sports history and free of cardiovascular risk. All participants underwent magnetic resonance and computer tomography assessments for the measurement of aortic dimensions and calcifications, respectively. RESULTS: Cases showed larger ( P < 0.05) dimensions than controls for aortic annulus, sinus, and arch, as well as for ascending and descending aorta. However, none of the participants presented with pathological aortic dilation (all diameters <40 mm). A slightly higher prevalence of calcifications in the ascending aorta was observed in cases (13% vs 0% in controls, P = 0.020). Subanalyses confirmed that cases who were still competing (masters category, n = 8) had larger aortic diameters ( P < 0.05) and a greater presence of calcifications in the ascending/descending aorta (38% vs 0% for both segments, P = 0.032) than those who had become inactive ( n = 15). No between-group differences were found for aortic distensibility. CONCLUSIONS: Former professional cyclists, particularly those who are still competing after retirement, show enlarged aortic diameters (albeit without exceeding upper limits of normality). Former professional cyclists also showed a slightly higher prevalence of calcifications in the ascending aorta than controls, although aortic distensibility was not compromised. The clinical relevance of these findings should be the subject of future studies.

Myocardial Work Index in Professional Football Players: A Novel Method for Assessment of Cardiac Adaptation.

BACKGROUND: The global myocardial work index (GWI), a novel, valid, and non-invasive method based on speckle-tracking echocardiography, could provide value for calculating left ventricular (LV) function and energy consumption in athletes. MATERIALS AND METHODS: We prospectively analyzed a single-center cohort of Spanish First-Division football players who attended a pre-participation screening program from June 2020 to June 2021, compared to a control group. All the individuals underwent an electrocardiogram and echocardiography, including two-dimensional speckle tracking and 4D-echo. The study aimed to evaluate the feasibility of myocardial work in professional football players and its correlations with other echocardiographic parameters. RESULTS: The study population comprised 97 individuals (49 professional players and 48 controls). The mean age was 30.48 ± 7.20 years old. The professional football players had significantly higher values of LVEDV (p < 0.001), LVESV (p < 0.001), LV-mass index (p = 0.011), PWTd (p = 0.023), and EA (p < 0.001) compared with the control group. In addition, the professional players had lower GCW (p = 0.003) and a tendency to show lower GWI values (p < 0.001). These findings could suggest that professional football players have more remodeling and less MW, related to their adaptation to intensive training. Significant differences in GLS (p = 0.01) and GWE (p = 0.04) were observed as a function of the septal thickness of the athletes. Irrespective of the MW variable, the parameters with better correlations across all the populations were SBP, DBP, and GLS. CONCLUSIONS: The GWI is a novel index to assess cardiac performance, with less load dependency than strain measurements. Future GWI analyses are warranted to understand myocardial deformation and other pathological differential diagnoses.

Índice neutrófilo/linfocito en anestesia general con ventilación controlada por volumen versus ventilación controlada por presión: ensayo clínico aleatorizado / Neutrophil/lymphocyte ratio in general anesthesia with volume-controlled ventilation versus pressure-controlled ventilation: a randomized clinical trial

Resumen: Introducción: se ha demostrado que la ventilación mecánica induce la producción de citocinas proinflamatorias. El IN/L es un parámetro sencillo que se utiliza para evaluar el estado inflamatorio. Objetivo: comparar los promedios y porcentajes del índice neutrófilo/linfocito (IN/L) elevado, entre pacientes con anestesia general con ventilación mecánica controlada por volumen (VMCV) y ventilación mecánica controlada por presión (VMCP). Material y métodos: se seleccionaron adultos ≥ 18 años, ASA I-III con cirugía electiva y anestesia general. Ensayo clínico aleatorizado: 25 pacientes con VMCV y 25 con VMCP. A todos los pacientes se les determinó dos biometrías hemáticas: antes y 2 horas después de la cirugía. El IN/L fue medido en forma de razón y dicotómica (< 3 o ≥ 3). Análisis estadístico: se utilizaron las pruebas t de Student, χ2 y McNemar. Resultados: se estudiaron 50 pacientes (27 mujeres y 23 hombres) con un promedio de edad de 47 ± 16 años. El grupo de VMCV tuvo tendencia a presentar valores más bajos de promedios y porcentajes IN/L; sin embargo, no fue estadísticamente significativa (p = 0.06). En la comparación pareada ambos grupos presentaron incremento estadísticamente significativo de los promedios y porcentajes de IN/L. No obstante, el porcentaje de IN/L > 3 en el grupo de VMCP fue de 64%, mientras que en el grupo de VMCV fue de 40%. Conclusiones: la VMCV presenta promedios y porcentajes más bajos del IN/L comparados con VMCP; sin embargo, no fueron estadísticamente significativos.

Abstract: Introduction: it has been shown that mechanical ventilation induces production of proinflammatory cytokines. The Neutrophil-to-lymphocyte ratio (N/L r) is a simple parameter that is used to assess the inflammatory state. Objective: to compare the means and percentages of elevated neutrophil/lymphocyte ratio (N/L r) in patients under general anesthesia with volume-controlled mechanical ventilation (VCMV) and pressure-controlled mechanical ventilation (PCMV). Material and methods: adults ≥ 18 years old, ASA I-III, with elective surgery and general anesthesia. Randomized clinical trial: 25 patients with VCMV and 25 with PCMV. All patients had two blood counts determined: before and 2 hours after surgery. N/L r was measured as a ratio and dichotomous (< 3 or ≥ 3). Statistical analysis: the t-Student, χ2 and McNemar tests were used. Results: 50 patients (27 women and 23 men) with a mean age of 47 ± 16 years (range 18-84 years) were studied. The VCMV group tended to present lower values of means and percentages N/L r, however, it was not statistically significant (p = 0.06). In the paired comparison, both groups presented a statistically significant increase in the means and percentages of N/L r. However, the percentage of N/L r > 3 in the PCMV group was 64%, while in the VCMV group it was 40%. Conclusions: the VCMV presents lower means and percentages of N/L r compared to PCMV, however, they were not statistically significant.

Myocardial Fibrosis and Coronary Calcifications Caused by Endurance Exercise? Insights from Former Professional Cyclists.

PURPOSE: This study aimed to compare the prevalence of myocardial fibrosis and coronary calcification in individuals who have performed very high levels of strenuous endurance exercise (SEE; former male professional cyclists) and sex/age-matched controls. METHODS: We used a retrospective cohort study design, where cases were former finishers of ≥1 Grand Tour (Tour de France, Giro d' Italia or Vuelta a España) and controls were untrained individuals free of cardiovascular risk. All participants underwent cardiac magnetic resonance and cardiac computer tomography in the same center during years 2020-2021 to detect myocardial fibrosis (late gadolinium enhancement) and to quantify coronary calcium, respectively. RESULTS: Twenty-three cases (age, 46 ± 6 yr) and 59 controls (47 ± 7 yr) were studied. Fibrotic patches were evidenced only in the left ventricle, with a higher prevalence in cases (23% vs 2% in controls, P = 0.006). However, fibrotic tissue was nonischemic and of low extension (0.6% ± 0.4% of left ventricle mass), and no significant differences were found between cases and controls for native T1 or T2 values. No between-group differences were found for coronary calcium indicators, including Agatston or density scores. Subanalyses revealed no differences attending to whether cases were still performing regular SEE ( n = 8) or not ( n = 15) after professional retirement. CONCLUSIONS: Although former professional cyclists seemed to show a greater prevalence of myocardial fibrosis, the extension of fibrotic tissue was minimal and no alterations were found in coronary calcification indicators. While keeping in mind the low sample size of the cases' group, our results do not support evidence for major cardiac maladaptations with long-term exposure to SEE, at least in middle-age adults.

Normative Values for Sport-Specific Left Ventricular Dimensions and Exercise-Induced Cardiac Remodeling in Elite Spanish Male and Female Athletes.

BACKGROUND: There is debate about the magnitude of geometrical remodeling [i.e., left ventricle (LV) cavity enlargement vs. wall thickening] in the heart of elite athletes, and no limits of normality have been yet established for different sports. We aimed to determine sex- and sport-specific normative values of LV dimensions in elite white adult athletes. METHODS: This was a single-center, retrospective study of Spanish elite athletes. Athletes were grouped by sport and its relative dynamic/static component (Mitchell's classification). LV dimensions were measured with two-dimensional-guided M-mode echocardiography imaging to compute normative values. We also developed an online and app-based calculator ( https://sites.google.com/lapolart.es/athlete-lv/welcome?authuser=0 ) to provide clinicians with sports- and Mitchell's category-specific Z-scores for different LV dimensions. RESULTS: We studied 3282 athletes (46 different sports, 37.8% women, mean age 23 ± 6 years). The majority (85.4%) showed normal cardiac geometry, particularly women (90.9%). Eccentric hypertrophy was relatively prevalent (13.4%), and concentric remodeling or hypertrophy was a rare finding (each < 0.8% of total). The proportion of normal cardiac geometry and eccentric hypertrophy decreased and increased, respectively, with the dynamic (in both sexes) or static component (in male athletes) of the sport irrespective of the other (static or dynamic) component. The 95th percentile values of LV dimensions did not exceed the following limits in any of the Mitchell categories: septal wall thickness, 12 mm (males) and 10 mm (females); LV posterior wall, 11 mm and 10 mm; and LV end-diastolic diameter, 64 mm and 57 mm. CONCLUSIONS: The majority of elite athletes had normal LV geometry, and although some presented with LV eccentric hypertrophy, concentric remodeling or hypertrophy was very uncommon. The present study provides sport-specific normative values that can serve to identify those athletes for whom a detailed examination might be recommendable (i.e., those exceeding the 95th percentile for their sex and sport).

Holter-determined arrhythmias in young elite athletes with suspected risk: Insights from a 20-year experience.

Purpose: We assessed the occurrence of rhythm alterations in elite athletes with suspected risk using Holter monitoring, and the association of Holter-determined rhythm alterations with echocardiographic findings. Methods: A large cohort of Spanish elite athletes (N = 6,579, 34% female) underwent in-depth cardiological examination (including echocardiographic evaluation, and resting and exercise electrocardiogram [ECG]) between 01/02/1998 and 12/31/2018. Holter monitoring was performed in those reporting cardiovascular symptoms, with suspicion of cardiac structural abnormalities potentially associated with dangerous arrhythmias, or with resting/exercise ECG features prompting a closer examination. We assessed the occurrence of cardiac rhythm alterations, as well as the association between echocardiography-determined conditions and rhythm alterations. Results: Most athletes (N = 5925) did not show any sign/symptom related to arrhythmia (including normal resting and exercise/post-exercise ECG results) whereas 9.9% (N = 654; 28% female; median age, 24 years [interquartile range 19-28]; competition experience [mean ± SD] 10±6 years) met the criteria to undergo Holter monitoring. Among the latter, sinus bradycardia was the most common finding (present in 96% of cases), yet with a relatively low proportion of severe (<30 bpm) bradycardia (12% of endurance athletes during night-time). Premature atrial and ventricular beats were also common (61.9 and 39.4%, respectively) but sinus pauses ≥3 s, high-grade atrioventricular blocks, and atrial fibrillation/flutter were rare (<1%). Polymorphic premature ventricular contractions (PVC, 1.4%) and idioventricular rhythm (0.005%) were also rare. PVC couplets were relatively prevalent (10.7%), but complex ventricular arrhythmias were not frequent (PVC triplets: 1.8%; sustained ventricular tachycardia: 0.0%; and nonsustained ventricular tachycardia: 1.5%). On the other hand, no associations were found between arrhythmias (including their different morphologies) and major cardiac structural alterations (including mitral prolapse). However, an association was found between mild mitral regurgitation and supraventricular (odds ratio 2.61; 95% confidence interval 1.08-6.32) and ventricular (2.80; 1.15-6.78; p = 0.02) arrhythmias, as well as between mild or moderate mitral regurgitation and ventricular arrhythmias (2.49; 1.03-6.01). Conclusions: Irrespective of the sports discipline, "dangerous" ventricular arrhythmias are overall infrequent even among young elite athletes who require Holter monitoring due to the presence of symptoms or abnormal echocardiographic/ECG findings, and do not seem to be associated with underlying serious cardiac structural pathologies.

Left atrial enlargement in competitive athletes and atrial electrophysiology.

INTRODUCTION AND OBJECTIVES: There are scarce data on left atrial (LA) enlargement and electrophysiological features in athletes. METHODS: Multicenter observational study in competitive athletes and controls. LA enlargement was defined as LA volume indexed to body surface area ≥ 34mL/m2. We analyzed its relationship with atrial electrocardiography parameters. RESULTS: We included 356 participants, 308 athletes (mean age: 36.4±11.6 years) and 48 controls (mean age: 49.3±16.1 years). Compared with controls, athletes had a higher mean LA volume index (29.8±8.6 vs 25.6±8.0mL/m2, P=.006) and a higher prevalence of LA enlargement (113 [36.7%] vs 5 [10.4%], P <.001), but there were no relevant differences in P-wave duration (106.3±12.5ms vs 108.2±7.7ms; P=.31), the prevalence of interatrial block (40 [13.0%] vs 4 [8.3%]; P=.36), or morphology-voltage-P-wave duration score (1.8±0.84 vs 1.5±0.8; P=.71). Competitive training was independently associated with LA enlargement (OR, 14.7; 95%CI, 4.7-44.0; P <.001) but not with P-wave duration (OR, 1.02; 95%CI, 0.99-1.04), IAB (OR, 1.4; 95%CI, 0.7-3.1), or with morphology-voltage-P-wave duration score (OR, 1.4; 95%CI, 0.9-2.2). CONCLUSIONS: LA enlargement is common in adult competitive athletes but is not accompanied by a significant modification in electrocardiographic parameters.

Diferencias entre ginecólogos y residentes en habilidades motoras básicas de un módulo de ejercicios de un sistema virtual de simulación / Differences between gynecologists and medical residents in basic motor skills of an exercise module of a virtual simulation system

Resumen OBJETIVO: Evaluar las diferencias en los desenlaces de los ejercicios del módulo de habilidades motoras básicas del simulador Simbionix LAP Mentor entre un grupo de residentes de Ginecología y otro de especialistas en cirugía laparoscópica. MATERIALES Y MÉTODOS: Estudio observacional, prospectivo, longitudinal y comparativo efectuado de diciembre de 2019 a enero de 2020 en el Hospital Español de México. Se seleccionaron médicos residentes de Ginecología y especialistas en la misma rama con experiencia diversa en cirugía laparoscópica. Se evaluaron, con un programa de adiestramiento mediante simulación de alta fidelidad, los ejercicios del módulo de habilidades motoras básicas de un sistema de realidad virtual. Para las variables con distribución normal se aplicó la prueba de t de Student y la de U de Mann-Whitney para las variables que no cumplieron el criterio de normalidad. RESULTADOS: Se incluyeron 31 participantes: el grupo de especialistas (n = 19) y el de residentes (n = 12). Se encontraron diferencias significativas entre residentes y especialistas en el ejercicio 3-coordinación ojo-mano (4.45 seg, IC95%: 0.167-8.73; p < 0.05) y en el ejercicio 5-tracción y engrapado de mangueras con fugas (29.58 seg, IC95%: -42.99 -14.00; p < 0.001), a favor del grupo de especialistas. En los ejercicios 7-corte y ejercicio 8-fulguración no hubo diferencias significativas entre uno y otro grupo. CONCLUSIONES: El simulador de realidad virtual Simbionix LAP Mentor detecta diferencias entre grupos de ginecoobstetras con diferente experiencia en cirugía ginecológica de mínima invasión y residentes de la especialidad.

Abstract OBJECTIVE: To evaluate the differences in the outcomes of the exercises of the basic motor skills module of the Simbionix LAP Mentor simulator between a group of gynecology residents and another group of already graduated specialists. MATERIALS AND METHODS: Observational, prospective, longitudinal and comparative study carried out from December 2019 to January 2020 at the Hospital Español de México. Gynecology residents and specialists in the same branch with diverse experience in laparoscopic surgery were selected. The exercises of the basic motor skills module of a virtual reality system were evaluated with a high-fidelity simulation training program. The Student's t test was applied for variables with normal distribution and the Mann-Whitney U test for variables that did not meet the normality criterion. RESULTS: Thirty-one participants were included: the specialist group (n = 19) and the resident group (n = 12). Significant differences between residents and specialists were found in exercise 3-eye-hand coordination (4.45 sec, 95%CI: 0.167-8.73; p < 0.05) and in exercise 5-pulling and stapling of leaking hoses (29.58 sec, 95%CI: -42.99 -14.00; p < 0.001), in favor of the specialist group. In exercise 7-cutting and exercise 8-fulguration there were no significant differences between one group and the other. CONCLUSIONS: The Simbionix LAP Mentor virtual reality simulator detects differences between groups of obstetrician-gynecologists with different experience in minimally invasive gynecologic surgery and residents of the specialty.

Eficacia y seguridad de la combinación de fexofenadina con montelukast en el tratamiento de la rinitis alérgica / Efficacy and safety of combined therapy of fexofenadine and montelukast for the treatment of allergic rhinitis

El propósito de este trabajo fue revisar la literatura científica que evalúa la eficacia y seguridad de las monoterapias de fexofenadina y montelukast, la terapia combinada (fija o en asociación) de montelukast - fexofenadina, así como de montelukast con otros antihistamínicos de segunda generación en el tratamiento de la rinitis alérgica. Se realizó una estrategia de búsqueda bibliográfica de múltiples etapas, en donde se identificaron estudios basados en ensayos clínicos y estudios no aleatorizados (ensayo controlado no aleatorizado, controlado antes-después, de series de tiempo interrumpidas, con controles históricos, de cohorte, de casos y controles, estudio transversal, y series de casos) en pacientes con rinitis alérgica, en las bases de datos MEDLINE/ PubMed, Scopus, Web of Science, Biblioteca Cochrane, Redalyc y Colección BVS y debido a la cantidad de resultados obtenidos se incluyó la búsqueda en Hinari. Con base en esta revisión se concluye que las combinaciones de antihistamínicos de segunda generación y antagonistas de leucotrienos y, en particular, la combinación fija de fexofenadina ­ montelukast es eficaz, segura y favorece la adherencia al tratamiento, y a largo plazo también ayuda a alcanzar el objetivo terapéutico.

The purpose of this work was to review the scientific literature that evaluates the efficacy and safety of monotherapies of fexofenadine and montelukast, the combined therapy (fixed-dose or separate drug combinations) of montelukast-fexofenadine, as well as the use of montelukast together with other second-generation antihistamines in the treatment of allergic rhinitis. A multistage literature search strategy was designed, including clinical trials and non-randomized studies (non-randomized controlled trial, controlled before-after study, interrupted time series study, historical control study, cohort study, case-control study, crosssectional study, and case series) evaluating patients with allergic rhinitis. The databases MEDLINE/PubMed, Scopus, Web of Science, Cochrane Library, Redalyc, BVS Collection, and, due to the number of results obtained, Hinari were included. Based on this review, the conclusion is that the combinations of secondgeneration antihistamines with leukotriene antagonists and, in particular, the fixed combination of fexofenadine-montelukast are effective, safe and promote treatment adherence. In the long term, they also help achieve therapeutic goals.

Trends in Mortality by HIV/AIDS in Children in Mexico: Towards the Elimination of Mother-To-Child Transmission.

AIM OF THE STUDY: To examine mortality trends in children under 15 years of age due to HIV/AIDS in Mexico and describe their differences by insurance coverage. METHODS: Time series analysis of deaths from 1990-2019 through a Bayesian poisson regression model with linear splines and knots in 1994, 1997, and 2003. RESULTS: Overall, we observed a reduction in the mortality rate due to HIV from 2003 onwards, except in the group of 10-14 years. In the population covered with Social Security, mortality rates decreased in all age groups. However, in the group without Social Security or with Popular Security (subsidized system), mortality rates significantly decreased only for children below 5 years. of age. CONCLUSIONS: Health insurance through the contributory system is associated with faster and larger reductions in HIV related infant mortality. Universal access to health insurance was not sufficient to close the gap in HIV-mortality among children under 15 years of age in Mexico.

Exercise-Induced Cardiac Fatigue in Recreational Ultramarathon Runners at Moderate Altitude: Insights From Myocardial Deformation Analysis.

BACKGROUND: Controversy exists on the actual occurrence of exercise-induced cardiac fatigue (EICF) with ultraendurance exercise, as well as on whether factors such as age or training status might predispose to this condition. The present study aimed to assess the occurrence of EICF among recreational ultramarathon runners, as well as to determine potential predictive factors. METHODS: Nineteen male recreational runners (42 ± 12yrs) participated in a 55-km trial race at moderate altitude (1,800-2,500 m). Participants were evaluated before and after the race using Doppler echocardiography and myocardial deformation analysis. EICF was determined as a reduction >5% of either left ventricular global longitudinal strain (LVGLS) or right ventricular free wall strain (RVFWS). Demographical (age, body mass index), training (training experience, volume and intensity), competition (finishing time, relative intensity) and biochemical variables (blood lactate, creatine kinase [CK] and CK-MB) were assessed as predictors of EICF. RESULTS: A significant reduction in LVGLS (20.1 ± 2.1% at baseline vs. 18.8 ± 2.4% at post-race, p = 0.026), but not in RVFWS (27.4 ± 7.0 vs. 24.6 ± 5.3%, p = 0.187), was observed after the race. EICF was present in 47 and 71% of the participants attending to the decrease in LVGLS and RVFWS, respectively. No associations were found between any of the analyzed variables and EICF except for age, which was associated with the magnitude of decrement of RVFWS (r = 0.58, p = 0.030). CONCLUSIONS: Ultramarathon running at moderate altitude seems to induce EICF in a considerable proportion of recreational athletes.