Aortic Stenosis With Coronary Artery Disease: SAVR or TAVR-When and How?

The growing number of candidates for transcatheter aortic valve replacement (TAVR) has increased the interest in the concomitant presence of coronary artery disease (CAD) and severe aortic stenosis (AS), prompting the need to define the appropriate revascularization strategy for each case. The reported prevalence of concurrent AS and CAD has varied over the years on the basis of the CAD definition and the population evaluated. Revascularization for treating CAD in patients with severe AS involves additional interventions that could impact outcomes. The addition of coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) has demonstrated favourable effects on long-term prognosis, while the impact of adding percutaneous coronary intervention (PCI) to TAVR may depend on the CAD complexity and the feasibility of achieving complete or reasonably incomplete revascularization. Furthermore, the comparison between SAVR+CABG and TAVR+PCI in low-intermediate surgical risk and low-intermediate complex CAD patients did not reveal differences in all-cause mortality or stroke between the groups. However, there is some evidence showing a lower incidence of major cardiovascular events with the SAVR+CABG strategy for patients with complex CAD. Thus, SAVR+CABG seems to be the best option for patients with low-intermediate surgical risk and complex CAD, and TAVR+PCI for high surgical risk patients seeking complete and/or reasonable incomplete revascularization. After deciding between TAVR+PCI or SAVR+CABG, factors such as timing for PCI, low ejection fraction, coronary reaccess, and valve durability must be considered. Finally, alternative methods for assessing CAD severity are currently under evaluation to ascertain their real value for guiding revascularization in patients with severe AS with CAD.

High-dose vitamin D versus placebo to prevent complications in COVID-19 patients: Multicentre randomized controlled clinical trial.

BACKGROUND: The role of oral vitamin D3 supplementation for hospitalized patients with COVID-19 remains to be determined. The study was aimed to evaluate whether vitamin D3 supplementation could prevent respiratory worsening among hospitalized patients with COVID-19. METHODS AND FINDINGS: We designed a multicentre, randomized, double-blind, sequential, placebo-controlled clinical trial. The study was conducted in 17 second and third level hospitals, located in four provinces of Argentina, from 14 August 2020 to 22 June 2021. We enrolled 218 adult patients, hospitalized in general wards with SARS-CoV-2 confirmed infection, mild-to-moderate COVID-19 and risk factors for disease progression. Participants were randomized to a single oral dose of 500 000 IU of vitamin D3 or matching placebo. Randomization ratio was 1:1, with permuted blocks and stratified for study site, diabetes and age (≤60 vs >60 years). The primary outcome was the change in the respiratory Sepsis related Organ Failure Assessment score between baseline and the highest value recorded up to day 7. Secondary outcomes included the length of hospital stay; intensive care unit admission; and in-hospital mortality. Overall, 115 participants were assigned to vitamin D3 and 105 to placebo (mean [SD] age, 59.1 [10.7] years; 103 [47.2%] women). There were no significant differences in the primary outcome between groups (median [IQR] 0.0 [0.0-1.0] vs 0.0 [0.0-1.0], for vitamin D3 and placebo, respectively; p = 0.925). Median [IQR] length of hospital stay was not significantly different between vitamin D3 group (6.0 [4.0-9.0] days) and placebo group (6.0 [4.0-10.0] days; p = 0.632). There were no significant differences for intensive care unit admissions (7.8% vs 10.7%; RR 0.73; 95% CI 0.32 to 1.70; p = 0.622), or in-hospital mortality (4.3% vs 1.9%; RR 2.24; 95% CI 0.44 to 11.29; p = 0.451). There were no significant differences in serious adverse events (vitamin D3 = 14.8%, placebo = 11.7%). CONCLUSIONS: Among hospitalized patients with mild-to-moderate COVID-19 and risk factors, a single high oral dose of vitamin D3 as compared with placebo, did not prevent the respiratory worsening. TRIAL REGISTRATION: ClincicalTrials.gov Identifier: NCT04411446.

[Feasibility of using artificial intelligence for screening COVID-19 patients in ParaguayViabilidade do uso de inteligência artificial na triagem de pacientes com COVID-19 no Paraguai]. / Factibilidad de la utilización de la inteligencia artificial para el cribado de pacientes con COVID-19 en Paraguay.

Objective: Study the feasibility of using artificial intelligence as a sensitive and specific method for COVID-19 screening in patients with respiratory conditions, using chest CT scan images and a telemedicine platform. Methods: From March 2020 to June 2021, the authors conducted an observational descriptive multicenter feasibility study based on artificial intelligence (AI) for COVID-19 screening using chest images of patients with respiratory conditions who presented at public hospitals. The AI platform was used to diagnose chest CT scan images; this was then compared with molecular diagnosis (RT-PCR) to determine whether they matched and to analyze the feasibility of AI for screening patients with suspected COVID-19. A telemedicine platform was used to send images and diagnostic results. Results: Screening of 3 514 patients with a suspected COVID-19 diagnosis was performed in 14 hospitals around the country. Most patients were aged 27 to 59 years, followed by those over 60. The average age was 48.6 years; 52.8% were male. The most frequent findings were severe pneumonia, bilateral pneumonia with pleural effusion, bilateral pulmonary emphysema, and diffuse ground glass opacity, among others. There was an average of 93% matching and 7% mismatching between images analyzed by AI and RT-PCR. Sensitivity and specificity of the AI system, obtained by comparing AI and RT-PCR screening results, were 93% and 80% respectively. Conclusions: The use of sensitive and specific AI for stratified rapid detection of COVID-19 in patients with respiratory conditions by using chest CT scan images and a telemedicine platform in public hospitals in Paraguay is feasible.

Objetivo: Examinar a viabilidade do uso de inteligência artificial como um método sensível e específico de triagem de COVID-19 em pacientes com afecções respiratórias, empregando imagens obtidas por exame de tomografia do tórax e uma plataforma de telemedicina. Métodos: Entre março de 2020 e junho de 2021, foi realizado um estudo observacional descritivo multicêntrico sobre a viabilidade do uso de inteligência artificial (IA) para a triagem de COVID-19, empregando imagens do tórax de pacientes com afecções respiratórias atendidos em hospitais da rede pública. O diagnóstico das imagens obtidas em tomografia do tórax foi realizado por meio de uma plataforma de IA e, em seguida, cotejado com o diagnóstico molecular (RT-PCR) para determinar a concordância entre os métodos utilizados e analisar a viabilidade deste processo para a triagem de pacientes com suspeita de COVID-19. As imagens e os resultados do exame diagnóstico foram disponibilizados em uma plataforma de telemedicina. Resultados: Foi realizada a triagem de 3 514 pacientes com suspeita de COVID-19 atendidos em 14 hospitais de todo o país. Os pacientes, na sua maioria, tinham entre 27 e 59 anos de idade ou pertenciam à faixa etária acima de 60 anos, com média de idade de 48,6 anos, sendo que 52,8% eram do sexo masculino. Os achados mais comuns foram pneumonia grave, pneumonia bilateral com derrame pleural, enfisema pulmonar bilateral e opacidade difusa em vidro fosco, entre outros. Verificou-se, em média, 93% de concordância e 7% de discordância entre as imagens analisadas com uso de IA e os resultados do exame de RT-PCR, com uma sensibilidade de 93% e especificidade de 80% desse sistema de triagem. Conclusões: Demonstrou-se que o uso de um sistema de IA sensível e específico é viável nos hospitais públicos do Paraguai para a detecção rápida estratificada de COVID-19 em pacientes com afecções respiratórias, empregando imagens de exame de tomografia do tórax e uma plataforma de telemedicina.

Factibilidad de la utilización de la inteligencia artificial para el cribado de pacientes con COVID-19 en Paraguay

[RESUMEN]. Objetivo. Estudiar la factibilidad de utilización de la inteligencia artificial como método sensible y específico para el cribado de COVID-19 en pacientes con afecciones respiratorias empleando imágenes de tórax obtenidas con tomógrafo y una plataforma de telemedicina. Métodos. Entre marzo del 2020 y junio del 2021 se realizó un estudio observacional descriptivo multicéntrico de factibilidad basada en inteligencia artificial (IA) para el cribado de COVID-19 en imágenes de tórax de pacientes con afecciones respiratorias que acudieron a hospitales públicos. El diagnóstico de las imágenes tomográficas de tórax se realizó a través de la plataforma de IA; luego, se comparó con el diagnóstico molecular (RT-PCR) para determinar la concordancia entre ambos y analizar su factibilidad para el cribado de pacientes con sospecha de COVID-19. Las imágenes y los resultados diagnóstico se enviaron a través de una plataforma de telemedicina. Resultados. Se realizó el cribado de 3 514 pacientes con sospecha diagnóstica de COVID-19, en 14 hospitales a nivel nacional. La mayoría de los pacientes tenían entre 27 y 59 años, seguidos por los mayores de 60 años. La edad promedio fue de 48,6 años; el 52,8% eran de sexo masculino. Los hallazgos más frecuentes fueron neumonía grave, neumonía bilateral con derrame pleural, enfisema pulmonar bilateral y opacidad difusa en vidrio esmerilado, entre otros. Se determinó un promedio de 93% de concordancia y 7% de discordancia entre las imágenes analizadas mediante IA y la RT-PCR. La sensibilidad y especificidad del sistema de IA, obtenidas comparando el resultado del cribado obtenido por IA con la RT-PCR, fueron de 93% y 80% respectivamente. Conclusiones. Es viable la utilización de IA sensible y específica para la detección rápida estratificada de COVID-19 en pacientes con afecciones respiratorias utilizando imágenes obtenidas mediante tomografía de tórax y una plataforma de telemedicina en los hospitales públicos de Paraguay.

[ABSTRACT]. Objective. Study the feasibility of using artificial intelligence as a sensitive and specific method for COVID-19 screening in patients with respiratory conditions, using chest CT scan images and a telemedicine platform. Methods. From March 2020 to June 2021, the authors conducted an observational descriptive multicenter feasibility study based on artificial intelligence (AI) for COVID-19 screening using chest images of patients with respiratory conditions who presented at public hospitals. The AI platform was used to diagnose chest CT scan images; this was then compared with molecular diagnosis (RT-PCR) to determine whether they matched and to analyze the feasibility of AI for screening patients with suspected COVID-19. A telemedicine platform was used to send images and diagnostic results. Results. Screening of 3 514 patients with a suspected COVID-19 diagnosis was performed in 14 hospitals around the country. Most patients were aged 27 to 59 years, followed by those over 60. The average age was 48.6 years; 52.8% were male. The most frequent findings were severe pneumonia, bilateral pneumonia with pleural effusion, bilateral pulmonary emphysema, and diffuse ground glass opacity, among others. There was an average of 93% matching and 7% mismatching between images analyzed by AI and RT-PCR. Sensitivity and specificity of the AI system, obtained by comparing AI and RT-PCR screening results, were 93% and 80% respectively. Conclusions. The use of sensitive and specific AI for stratified rapid detection of COVID-19 in patients with respiratory conditions by using chest CT scan images and a telemedicine platform in public hospitals in Paraguay is feasible.

[RESUMO]. Objetivo. Examinar a viabilidade do uso de inteligência artificial como um método sensível e específico de triagem de COVID-19 em pacientes com afecções respiratórias, empregando imagens obtidas por exame de tomografia do tórax e uma plataforma de telemedicina. Métodos. Entre março de 2020 e junho de 2021, foi realizado um estudo observacional descritivo multicêntrico sobre a viabilidade do uso de inteligência artificial (IA) para a triagem de COVID-19, empregando imagens do tórax de pacientes com afecções respiratórias atendidos em hospitais da rede pública. O diagnóstico das imagens obtidas em tomografia do tórax foi realizado por meio de uma plataforma de IA e, em seguida, cotejado com o diagnóstico molecular (RT-PCR) para determinar a concordância entre os métodos utilizados e analisar a viabilidade deste processo para a triagem de pacientes com suspeita de COVID-19. As imagens e os resultados do exame diagnóstico foram disponibilizados em uma plataforma de telemedicina. Resultados. Foi realizada a triagem de 3 514 pacientes com suspeita de COVID-19 atendidos em 14 hospitais de todo o país. Os pacientes, na sua maioria, tinham entre 27 e 59 anos de idade ou pertenciam à faixa etária acima de 60 anos, com média de idade de 48,6 anos, sendo que 52,8% eram do sexo masculino. Os achados mais comuns foram pneumonia grave, pneumonia bilateral com derrame pleural, enfisema pulmonar bilateral e opacidade difusa em vidro fosco, entre outros. Verificou-se, em média, 93% de concordância e 7% de discordância entre as imagens analisadas com uso de IA e os resultados do exame de RT-PCR, com uma sensibilidade de 93% e especificidade de 80% desse sistema de triagem. Conclusões. Demonstrou-se que o uso de um sistema de IA sensível e específico é viável nos hospitais públicos do Paraguai para a detecção rápida estratificada de COVID-19 em pacientes com afecções respiratórias, empregando imagens de exame de tomografia do tórax e uma plataforma de telemedicina.

High frequency of coronary artery ectasia in obstructive sleep apnea.

STUDY OBJECTIVES: Patients with obstructive sleep apnea (OSA) have a greater risk of developing coronary artery disease. However, the frequency of specific coronary artery vascular phenotypes, such as coronary artery ectasia (CAE), which has a frequency of 5% in the general population, has not been studied in patients with OSA. This study aimed to estimate CAE frequency in patients with OSA who underwent coronary angiography. METHODS: A retrospective cross-sectional study was performed. The results of each polysomnography were reviewed, classifying OSA severity according to the apnea-hypopnea index. Each coronary angiography was reviewed. CAE was defined and classified according to the scales described in the literature. Two groups of patients were classified and compared (OSA/CAE group vs OSA/non-CAE group). RESULTS: We identified the frequency of CAE in 185 patients with OSA who underwent coronary angiography. The frequency of CAE was 18.4% in these patients. ST-elevation myocardial infarction as the indication for coronary angiography was significantly greater in the OSA/CAE group than the OSA/non-CAE group (26.5% vs 9.9%; P = .02); 62% of the patients having severe OSA (apnea-hypopnea index ≥ 30 events/h). These patients in the OSA/CAE group had a significantly higher median apnea-hypopnea index than in the OSA/non-CAE group (72.5 events/h vs 53.5 events/h, respectively; P = .039). The CAE severity was not directly related to the OSA severity. CONCLUSIONS: The frequency of CAE in patients with OSA is higher than that reported for the general population. The severity of OSA is related to the presence of CAE but not to its severity. CITATION: del Portillo JH, Hernandez BM, Bazurto MA, Echeverri D, Cabrales J. High frequency of coronary artery ectasia in obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):433-438.

Factibilidad de la utilización de la inteligencia artificial para el cribado de pacientes con COVID-19 en Paraguay / Feasibility of using artificial intelligence for screening COVID-19 patients in Paraguay / Viabilidade do uso de inteligência artificial na triagem de pacientes com COVID-19 no Paraguai

RESUMEN Objetivo. Estudiar la factibilidad de utilización de la inteligencia artificial como método sensible y específico para el cribado de COVID-19 en pacientes con afecciones respiratorias empleando imágenes de tórax obtenidas con tomógrafo y una plataforma de telemedicina. Métodos. Entre marzo del 2020 y junio del 2021 se realizó un estudio observacional descriptivo multicéntrico de factibilidad basada en inteligencia artificial (IA) para el cribado de COVID-19 en imágenes de tórax de pacientes con afecciones respiratorias que acudieron a hospitales públicos. El diagnóstico de las imágenes tomográficas de tórax se realizó a través de la plataforma de IA; luego, se comparó con el diagnóstico molecular (RT-PCR) para determinar la concordancia entre ambos y analizar su factibilidad para el cribado de pacientes con sospecha de COVID-19. Las imágenes y los resultados diagnóstico se enviaron a través de una plataforma de telemedicina. Resultados. Se realizó el cribado de 3 514 pacientes con sospecha diagnóstica de COVID-19, en 14 hospitales a nivel nacional. La mayoría de los pacientes tenían entre 27 y 59 años, seguidos por los mayores de 60 años. La edad promedio fue de 48,6 años; el 52,8% eran de sexo masculino. Los hallazgos más frecuentes fueron neumonía grave, neumonía bilateral con derrame pleural, enfisema pulmonar bilateral y opacidad difusa en vidrio esmerilado, entre otros. Se determinó un promedio de 93% de concordancia y 7% de discordancia entre las imágenes analizadas mediante IA y la RT-PCR. La sensibilidad y especificidad del sistema de IA, obtenidas comparando el resultado del cribado obtenido por IA con la RT-PCR, fueron de 93% y 80% respectivamente. Conclusiones. Es viable la utilización de IA sensible y específica para la detección rápida estratificada de COVID-19 en pacientes con afecciones respiratorias utilizando imágenes obtenidas mediante tomografía de tórax y una plataforma de telemedicina en los hospitales públicos de Paraguay.

ABSTRACT Objective. Study the feasibility of using artificial intelligence as a sensitive and specific method for COVID-19 screening in patients with respiratory conditions, using chest CT scan images and a telemedicine platform. Methods. From March 2020 to June 2021, the authors conducted an observational descriptive multicenter feasibility study based on artificial intelligence (AI) for COVID-19 screening using chest images of patients with respiratory conditions who presented at public hospitals. The AI platform was used to diagnose chest CT scan images; this was then compared with molecular diagnosis (RT-PCR) to determine whether they matched and to analyze the feasibility of AI for screening patients with suspected COVID-19. A telemedicine platform was used to send images and diagnostic results. Results. Screening of 3 514 patients with a suspected COVID-19 diagnosis was performed in 14 hospitals around the country. Most patients were aged 27 to 59 years, followed by those over 60. The average age was 48.6 years; 52.8% were male. The most frequent findings were severe pneumonia, bilateral pneumonia with pleural effusion, bilateral pulmonary emphysema, and diffuse ground glass opacity, among others. There was an average of 93% matching and 7% mismatching between images analyzed by AI and RT-PCR. Sensitivity and specificity of the AI system, obtained by comparing AI and RT-PCR screening results, were 93% and 80% respectively. Conclusions. The use of sensitive and specific AI for stratified rapid detection of COVID-19 in patients with respiratory conditions by using chest CT scan images and a telemedicine platform in public hospitals in Paraguay is feasible.

RESUMO Objetivo. Examinar a viabilidade do uso de inteligência artificial como um método sensível e específico de triagem de COVID-19 em pacientes com afecções respiratórias, empregando imagens obtidas por exame de tomografia do tórax e uma plataforma de telemedicina. Métodos. Entre março de 2020 e junho de 2021, foi realizado um estudo observacional descritivo multicêntrico sobre a viabilidade do uso de inteligência artificial (IA) para a triagem de COVID-19, empregando imagens do tórax de pacientes com afecções respiratórias atendidos em hospitais da rede pública. O diagnóstico das imagens obtidas em tomografia do tórax foi realizado por meio de uma plataforma de IA e, em seguida, cotejado com o diagnóstico molecular (RT-PCR) para determinar a concordância entre os métodos utilizados e analisar a viabilidade deste processo para a triagem de pacientes com suspeita de COVID-19. As imagens e os resultados do exame diagnóstico foram disponibilizados em uma plataforma de telemedicina. Resultados. Foi realizada a triagem de 3 514 pacientes com suspeita de COVID-19 atendidos em 14 hospitais de todo o país. Os pacientes, na sua maioria, tinham entre 27 e 59 anos de idade ou pertenciam à faixa etária acima de 60 anos, com média de idade de 48,6 anos, sendo que 52,8% eram do sexo masculino. Os achados mais comuns foram pneumonia grave, pneumonia bilateral com derrame pleural, enfisema pulmonar bilateral e opacidade difusa em vidro fosco, entre outros. Verificou-se, em média, 93% de concordância e 7% de discordância entre as imagens analisadas com uso de IA e os resultados do exame de RT-PCR, com uma sensibilidade de 93% e especificidade de 80% desse sistema de triagem. Conclusões. Demonstrou-se que o uso de um sistema de IA sensível e específico é viável nos hospitais públicos do Paraguai para a detecção rápida estratificada de COVID-19 em pacientes com afecções respiratórias, empregando imagens de exame de tomografia do tórax e uma plataforma de telemedicina.

Rapid screening for COVID-19 by applying artificial intelligence to chest computed tomography images: A feasibility study.

Aim: The aim of the study was to present the results and impact of the application of artificial intelligence (AI) in the rapid diagnosis of COVID-19 by telemedicine in public health in Paraguay. Methods: This is a descriptive, multi-centered, observational design feasibility study based on an AI tool for the rapid detection of COVID-19 in chest computed tomography (CT) images of patients with respiratory difficulties attending the country's public hospitals. The patients' digital CT images were transmitted to the AI diagnostic platform, and after a few minutes, radiologists and pneumologists specialized in COVID-19 downloaded the images for evaluation, confirmation of diagnosis, and comparison with the genetic diagnosis (reverse transcription polymerase chain reaction (RT-PCR)). It was also determined the percentage of agreement between two similar AI systems applied in parallel to study the viability of using it as an alternative method of screening patients with COVID-19 through telemedicine. Results: Between March and August 2020, 911 rapid diagnostic tests were carried out on patients with respiratory disorders to rule out COVID-19 in 14 hospitals nationwide. The average age of patients was 50.7 years, 62.6% were male and 37.4% female. Most of the diagnosed respiratory conditions corresponded to the age group of 27-59 years (252 studies), the second most frequent corresponded to the group over 60 years, and the third to the group of 19-26 years. The most frequent findings of the radiologists/pneumologists were severe pneumonia, bilateral pneumonia with pleural effusion, bilateral pulmonary emphysema, diffuse ground glass opacity, hemidiaphragmatic paresis, calcified granuloma in the lower right lobe, bilateral pleural effusion, sequelae of tuberculosis, bilateral emphysema, and fibrotic changes, among others. Overall, an average of 86% agreement and 14% diagnostic discordance was determined between the two AI systems. The sensitivity of the AI system was 93% and the specificity 80% compared with RT-PCR. Conclusion: Paraguay has an AI-based telemedicine screening system for the rapid stratified detection of COVID-19 from chest CT images of patients with respiratory conditions. This application strengthens the integrated network of health services, rationalizing the use of specialized human resources, equipment, and inputs for laboratory diagnosis.

Aplicación de tecnologías disruptivas en telemedicina para la cobertura universal de servicios de salud / Application of disruptive technologies in telemedicine for universal coverage of health services

La aplicación de tecnologías disruptivas en telemedicina facilita la accesibilidad a tecnologías diagnósticas de poblaciones remotas sin acceso a especialistas y mejora la cobertura universal de servicios de salud. Este estudio realizado por la Unidad de Telemedicina del Ministerio de Salud Pública y Bienestar Social (MSPBS) en colaboración con el Dpto. de Ingeniería Biomédica e Imágenes del Instituto de Investigaciones en Ciencias (IICS-UNA) sirvió para evaluar la utilidad de aplicaciones de tecnologías disruptivas en telemedicina para la cobertura universal de servicios de salud. Para el efecto se analizaron los resultados obtenidos por la red de telediagnóstico implementado en 67 hospitales del MSPBS. En dicho sentido se analizaron 540.397 diagnósticos remotos realizados entre enero del 2014 y septiembre de 2019. Del total, el 33,174 % (179.274) correspondieron a estudios de tomografía, 64,825 % (350.313) a electrocardiografía (ECG), 1,997 % (10.791) a electroencefalografía (EEG) y 0,004 % (19) a ecografía. La concordancia entre el diagnostico remoto y el diagnóstico "cara a cara" fue del 95 %. Con el diagnostico remoto se logró una reducción del coste que supone un beneficio importante para cada ciudadano del interior del país. Los resultados obtenidos evidencian que la aplicación de tecnologías disruptivas en telemedicina puede contribuir para la cobertura universal de servicios con tecnologías diagnósticas, maximizando el tiempo y productividad del profesional, aumentando el acceso y la equidad, y disminuyendo los costos. Sin embargo antes de su implementación generalizada se deberá contextualizar con el perfil epidemiológico regional. Palabras claves: tecnología disruptiva, aplicación, tecnología diagnóstica, telemedicina, cobertura universal, servicios de salud, innovación tecnológica.

Introduction: The application of disruptive technologies in telemedicine facilitates accessibility to diagnostic technologies of remote populations without access to specialists and improves universal coverage of health services. This study was carried out by the Telemedicine Unit of the Ministry of Public Health and Social Welfare (MSPBS) in collaboration with the Department of Biomedical Engineering and Imaging of the Institute of Research in Sciences (IICS-UNA). Objective: to evaluate the usefulness of disruptive technology applications in telemedicine for universal coverage of health services January 2014 to September 2019. Material and Method: observational and descriptive design study included 540,397 patients. For this purpose, the results obtained by the telediagnostic network implemented in 67 MSPBS hospitals were analyzed. In this regard, 540,397 remote diagnoses carried out between January 2014 and September 2019 were analysed. Results: of the total, 33.174% (179,274) were CT studies, 64.825% (350,313) electrocardiography (ECG), 1.997% (10,791) electroencephalography (EEG) and 0.004% (19) ultrasound. The concordance between remote diagnosis and "face-to-face" diagnosis was 95%. Conclusion: remote diagnosis achieved a cost reduction that is an important benefit for every citizen of the interior of the country. The results show that the application of disruptive technologies in telemedicine can contribute to the universal coverage of services with diagnostic technologies, maximizing the time and productivity of the professional, increasing access and equity, and lowering costs. However, prior to widespread implementation, the regional epidemiological profile should be contextualized. Keywords: Disruptive technology, application, diagnostic technology, telemedicine, universal coverage, health services, technological innovation.

Prevención secundaria antitrombótica intensiva tardía luego de un infarto del miocardio ¿Cuándo, en quiénes y cómo? / Late intensive antithrombotic secondary prevention after myocardial infarction. When, in whom and how?

La probabilidad de nuevos eventos cardiovasculares mayores (ECVM) en pacientes luego de un infarto agudo del miocardio depende de diferentes variables, como el tiempo que haya pasado después del primer evento, el escenario de presentación (síndrome coronario agudo con/sin elevación del ST) y los factores de riesgo asociados. Dichos eventos se han relacionado con la respuesta proinflamatoria persistente1, la actividad plaquetaria y la actividad de la trombina2. La llegada de medicamentos con actividad antitrombótica más potente y específica en puntos clave del proceso trombótico ha permitido evaluar su efecto en el escenario de la prevención secundaria antitrombótica intensiva luego del primer año de un infarto del miocardio3. En este tipo de prevención se han propuesto diferentes estrategias terapéuticas, entre ellas se ha extendiendo la doble terapia antiplaquetaria (DTA) (4, iniciando terapias antiplaquetarias adicionales5, o usando dosis bajas de anticoagulantes directos más aspirina6. Sin embargo, las características similares y, a su vez, heterogéneas en esta población, generan dudas de cuándo, en quiénes y cómo usar este tipo de terapia.

Social Skills and Suicide Risk in Adolescents of an Education Institute of the City of Armenia (Quindio, Colombia) / Habilidades sociales y riesgo suicida en adolescentes de una institución educativa de la ciudad de Armenia (Quindío, Colombia) / Habilidades sociais e risco suicida em adolescentes de uma instituição educativa da cidade de Armênia (Quindío, Colômbia)

Abstract Introduction: The objective of this article is to establish the relationship between the acquisition of social skills and the clinical expression of suicidal ideation and suicide risk in adolescents. Materials and Methods: The research was conducted following a descriptive and correlational design, in a population of 115 adolescents aged between 12 and 18 years old. The Beck's Hopelessness Scale and the Goldstein Social Skills Test were applied. Results: Data showed that there is a significant, inversely proportional correlation between social skills and a lower risk of suicidal symptomatology. Conclusion: Based on the obtained results it was possible to corroborate how family plays a relevant role in the emotional regulation and in the acquisition of social skills in the individual; it was also possible to sustain that, on the basis of a healthy coping mechanism in vital problems resolution, the possibility of developing any suicidal expression reduces.

Resumen Introducción: el objetivo de este artículo es establecer la relación entre la adquisición de habilidades sociales y la manifestación clínica de ideación suicida y riesgo suicida en adolescentes. Materiales y métodos: la investigación se realizó siguiendo un diseño descriptivo y correlacional, en una población de 115 adolescentes entre 12 y 18 años, se aplicó la Escala de Desesperanza de Beck y el Test de Habilidades Sociales de Goldstein. Resultados: los datos arrojaron que existe una correlación significativa, inversamente proporcional entre la adquisición de habilidades sociales y el menor riesgo de sintomatología suicida. Conclusión: por medio de los resultados obtenidos, se ha podido corroborar cómo la familia cumple un papel importante en la regulación emocional y en la adquisición de habilidades sociales en la persona, además de cómo, a partir de la adquisición de un estilo de afrontamiento sano en la resolución de problemas vitales, se aminora la posibilidad de desarrollar alguna manifestación suicida.

Resumo Introdução: o objetivo deste artigo é estabelecer a relação entre a aquisição de habilidades sociais e a manifestação clínica de ideação suicida e risco suicida em adolescentes. Materiais e métodos: a pesquisa se realizou seguindo um desenho descritivo e correlacional, em uma população de 115 adolescentes entre 12 e 18 anos, aplicara-se a Escala de Desesperança de Beck e o Teste de Habilidades Sociais de Golstein. Resultados: os dados revelaram que existe uma correlação significativa, inversamente proporcional entre a aquisição de habilidades sociais e o menor risco de sintomatologia suicida. Conclusão: por meio dos resultados obtidos, se tem conseguido corroborar como a família tem um papel importante na regulação emocional e na aquisição de habilidades sociais na pessoa, para além de como a partir da aquisição de um estilo de afrontamento são na resolução de problemas vitais, diminui-se a possibilidade de desenvolver alguma manifestação suicida.

Prevalencia del Síndrome de Burnout en parte del personal asistencial de una clínica oncológica de la ciudad de Armenia (Quindío, Colombia) / Prevalence of the Burnout Syndrome in part of the nursing staff of an oncology clinic in the city of Armenia (Quindío, Colombia)

Objetivo: revisar los niveles del síndrome de burnout en parte del personal asistencialde una clínica oncológica. Materiales y métodos: la investigación fue de tipo descriptiva, la muestra estuvo compuesta por un total de 19 personas, de las cuales 7 son hombres (36.8%) y 12 personas fueron mujeres (63.2%), todos tienen un cargo dentro de la clínica oncológica, se aplicó el M.B.I. y una ficha de caracterización. Resultados: las subescalas del MBI no indican que existe burnout, ya que la mayoría de las personas han puntuando nivel bajo en las escalas de agotamiento emocional y despersonalización, no así para el de realización personal que puntuó alto. Hay un (69%) de personas que no presentan ninguno de los síntomas, en cambio hay un (31,6%) de personas que si manifiestan o puntúan alto o intermedio en algunas de las subescalas agotamiento emocional o despersonalización o baja en realización personal. Conclusiones: no existe evidencia de que las personas que hacen parte del personal asistencial de una clínica oncológica tengan el síndrome de burnout, tampoco hay diferencias significativas entre los grupos asistenciales..(AU)

Objective: to review levels of burnout syndrome in part of the nursing staff of an oncology clinic. Materials and methods: the research was descriptive, the sample was composed of 19 people, seven were men (36.8%) and twelve were women (63.2%), all have a position within the Oncology clinic, It was applied an MBI and a fact sheet of characterization. Results: the subscales of the MBI does not indicate that there is burnout, since most of the people have scoring low on the scales of emotional exhaustion and depersonalization, not for the personal fulfilment that scored high. It shows that (69%) of people do not have any of the symptoms; instead, (31.6%) of people manifested the condition or scored high or intermediate in some of the subscales of emotional exhaustion and depersonalization or low personal fulfilment. Conclusions: there is no evidence that people who are part of the nursing staff of the Oncology clinic have burnout syndrome, nor there are significant differences between the health care groups..(AU)

Estenosis aórtica severa asintomática ¿Observar mejor que operar? / Asymptomatic severe aortic stenosis ¿Is it better to observe than to operate?

La estenosis aórtica es la valvulopatía primaria más frecuente en el mundo; alcanza una prevalencia estimada en 7,6 millones de personas mayores de 75 años en Europa y Estados Unidos, aunado al aumento en la expectativa de vida de la población mundial que hará que esta tasa continúe en ascenso1. En el momento del diagnóstico de esta valvulopatía, aproximadamente el 50% de los pacientes son asintomáticos y varios pueden tener a fracción de eyección (FE) preservada; a este tipo de pacientes se les ha clasificado en un estadio C1 según la guía de la Asociación americana del corazón/Colegio americano de Cardiología (AHA/ACC, sus siglas en inglés) del año 2014. Su manejo consiste en un seguimiento clínico y ecocardiográfico cada 6 a 12 meses (recomendación dada por expertos y basada en estudios retrospectivos) (2. Sin embargo, se benefician de un reemplazo valvular temprano aquellos que tienen riesgo quirúrgico bajo (puntaje < 4 según la Sociedad de cirujanos del tórax -STS, su sigla en inglés-) y tienen características adicionales de mal pronóstico, tales como síntomas desencadenados por una prueba de esfuerzo, calcificación severa de la válvula con limitación para su apertura, velocidad de flujo transvalvular > 5 m/s, gradiente medio > 60 mm Hg y aumento de la velocidad de flujo valvular de más de 0,3 m/s/año3. Recientemente, la actualización de la guía AHA/ACC de 2017 recomienda el reemplazo valvular aórtico quirúrgico tanto para los pacientes con estenosis aórtica severa sintomáticos (estadio D), como para los asintomáticos (estadio C) que cumplan con alguna indicación quirúrgica, siempre y cuando el riesgo quirúrgico sea bajo o intermedio3. Dicha recomendación podría interpretarse de dos formas: todos los pacientes con estenosis aórtica severa independientemente de los síntomas deberán ser llevados a reemplazo valvular aórtico quirúrgico, o los pacientes asintomáticos deberán tener alguna característica de mal pronóstico para ser llevados a cirugía; esta última interpretación es la que concuerda con el texto de las guías del 2014. Por su parte, la guía de la Sociedad Europea de Cardiología de 20174 propone que la observación en pacientes sin factores de mal pronóstico parece ser segura, mientras que es poco probable que la cirugía temprana traiga beneficio.

Stent liberadores de medicamento en enfermedad coronaria prematura en jóvenes conhipercolesterolemia familiar homocigota y trasplante hepático previo / Drug-eluting stents in premature coronary disease in young people with homozygous familial hypercholesterolemia and prior liver transplantation

Resumen La hipercolesterolemia familiar es una enfermedad genética que se caracteriza por niveles muy elevados de colesterol y lipoproteínas de baja densidad en suero, xantomas tendinosos y aterosclerosis prematura. La forma heterocigota es la más común; alcanza una prevalencia de aproximadamente 1 de cada 300 a 500 personas en el mundo, en tanto que la homocigota, autosómica dominante, es la forma más rara, con una prevalencia de 1 en 1 millón de personas. Esta se caracteriza por hipercolesterolemia severa, que conlleva enfermedad cardiovascular prematura y a menudo no responde al tratamiento tradicional por la falta de receptores para c-LDL funcionales. Los niveles de c-LDL pueden superar seis a diez veces los valores normales, en cuyo caso el trasplante de hígado se ha convertido en el tratamiento de elección para los pacientes que no responden a tratamientos farmacológicos de rutina. Se presentan dos casos con hipercolesterolemia familiar homocigota en jóvenes de 14 y 15 años, con antecedente de trasplante de hígado y enfermedad coronaria severa en vasos principales (descendente anterior y coronaria derecha) a quienes se les hizo implante exitoso de stent liberador de medicamento.

Abstract Familial hypercholesterolemia is a genetic disorder characterised by very high cholesterol and low-density lipoproteins serum levels, tendon xanthomas and premature atherosclerosis. Heterozygous form is the most common, with a prevalence of approximately 1 out of 300 to 500 people worldwide, whereas the homozygous, autosomal dominant, is the rarest form, with a prevalence of 1 out of 1 million people. It is characterised by severe hypercholesterolemia leading to premature cardiovascular disease, and it often does not respond to traditional therapy due to the lack of receptors for functional LDL-c. LDL-c levels can exceed between six and ten times the normal values, in which case liver transplantation has become the treatment of choice for patients who do not respond to routine pharmacological therapies. This study presents two cases of homozygous familial hypercholesterolemia in young patients aged 14 and 15, with prior liver transplantation and severe coronary disease in major vessels (anterior descending artery and right coronary artery) who underwent successful implant of a drug-eluting stent.

Relación entre riesgo suicida, autoestima, desesperanza y estilos de socialización parental en estudiantes de bachillerato / Relations between suicidal risk, self-esteem, despair and parental socialization styles in high school students

Resumen Este trabajo es resultado de una investigación empírico-analítica, realizada con un diseño descriptivo-correlacional y de corte transversal. Su objetivo consistió en describir la relación entre niveles de autoestima, riesgo suicida y estilos de socialización parental, para lo cual se aplicaron: la escala de Autoestima de Rosenberg, la escala de Desesperanza de Beck, Weissman, Lester y Trexler (1974)y la escala de Socialización Parental ESPA-29. El estudio encontró que la autoestima no se correlaciona de forma importante con el riesgo suicida, y que 6 de cada 10 estudiantes presenta algún tipo de riesgo, que se incrementa cuando los padres son indulgentes o negligentes, y ambos perfiles tienden a la coerción verbal e indiferencia. Otros elementos asociados al riesgo suicida fueron: la aceptación e imposición del dominio parental y un elevado control con afecto negativo, coerciones e imposiciones.

Abstract This work is the result of an empirical and analytical research conducted with a descriptive, cor relational and transversal methodology. Its aim was to describe the relations between self-esteem, suicidal risk and parental socialization styles. In order to achieve the objective these tools were used: the Rosenberg Scale for Self-esteem, the Scale of Despair of Beck, Weissman, Lester and Trexler (1974) and the ESPA-29 scale of Parental Socialization Styles. The study found that self esteem is not significantly correlated with suicidal risk; and that 6 out of 10 students presented some risk, that increases when parents are indulgent or negligents; and both profiles present verbal coercion and indifference inclinations. Other elements associated to suicidal risk were: acceptance and imposition of parent control and a high control with negative effects, coercions and impositions.

Isquemia miocárdica: conceptos básicos, diagnóstico e implicaciones clínicas. Tercera parte / Myocardial ischemia: basic concepts, diagnosis and clinical implications. Part three

Resumen El término «cardiopatía isquémica¼ se refiere a la disfunción del ventrículo izquierdo secundaria a infarto del miocardio, miocardio isquémico viable o enfermedad coronaria severa documentada por arteriografía coronaria, la cual tiene un pobre pronóstico, con una supervivencia del 45% a 5 años. El tratamiento de la cardiopatía isquémica involucra la estimación de la viabilidad en el miocardio afectado para determinar si la revascularización puede generar una remodelación positiva que mejore la función del ventrículo izquierdo. Existen cuatro modalidades básicas usadas en la práctica clínica para calcular la viabilidad miocárdica: tomografía de emisión simple de positrones, tomografía por emisión de positrones, ecocardiograma estrés y resonancia magnética cardiaca. Hoy en día hay estudios que demuestran que la terapia médica mejora la función del ventrículo izquierdo en la cardiopatía isquémica, independiente de la presencia o no de viabilidad o de la revascularización miocárdica; por tanto es posible que otros factores como la cantidad de remodelado, los volúmenes del ventrículo izquierdo, la insuficiencia mitral y la fracción de eyección puedan afectar también los desenlaces. Se requiere definir de manera clara los estadios del remodelado ventricular izquierdo en los cuales la presencia de viabilidad es benéfica y las etapas en las que el remodelado es reversible con la revascularización miocárdica. En cuanto a los métodos para determinar la viabilidad, la resonancia magnética parece dar más respuestas al respecto, ya que puede aportar información adicional relacionada con dimensiones del ventrículo izquierdo, fracción de eyección, fibrosis miocárdica y anormalidades valvulares.

Abstract The term myocardial ischemia refers to a left ventricular dysfunction secondary to a myocardial infarction, viable ischemic myocardium or sever coronary disease documented by means of a coronary angiography, which has a poor prognosis, with five-year survival rate of 45%. Management of myocardial ischemia involves estimating viability of the affected myocardium in order to determine whether revascularization can generate a positive remodelling that improves left ventricle functioning. Four different basic modalities are used in clinical practice to assess myocardial viability: single-photon emission computed tomography, positron emission tomography, stress echocardiogram and cardiac magnetic resonance. Nowadays there are studies that have shown medical therapy improves left ventricle function in ischemic heart disease, regardless of the presence or not of the viability or the myocardial revascularization; therefore, it is possible that other factors such as the amount of remodelling, the left ventricle volumes, mitral insufficiency and ejection fraction could also afffect the outcomes. A clear definition of the left ventricle remodelling states where the presence of viability is beneficial and the stages where the remodelling is reversible with myocardial revascularization is required. With regards to methods for assessing viability, magnetic resonance seems to provide more answers, as it can give additional information related to the dimensions of the left ventricle, ejection fraction, myocardial fibrosis and valvular abnormalities.

Isquemia miocárdica: conceptos básicos, diagnóstico e implicaciones clínicas. Segunda parte / Myocardial ischemia: basic concepts, diagnosis and clinical implications. Part two

Resumen La isquemia miocárdica puede ser irreversible o reversible dependiendo de diferentes factores moleculares y fisiológicos. En la isquemia miocárdica irreversible se presentan tres tipos de muerte celular a nivel miocárdico: la necrosis, la apoptosis y la autofagia; mientras en la isquemia reversible la restauración de la función de los miocitos está determinada por factores como el restablecimiento temprano del flujo sanguíneo coronario y fenómenos de pre y posacondicionamiento isquémico. Conceptos como el miocardio aturdido (disfunción mecánica temporal luego de una lesión isquémica pero con flujo sanguíneo normal en ausencia de cualquier lesión irreversible) y el miocardio hibernante (región miocárdica viable, sin contractilidad) son formas quiescentes de la función cardiaca y explican un poco la capacidad del miocardio de restablecer su funcionamiento normal luego de un episodio de isquemia.

Abstract Myocardial ischemia can be irreversible or reversible depending on multiple molecular and physiological factors. In irreversible myocardial ischemia there are three types of cell death on a myocardial level: necrosis, apoptosis and autophagy; whereas in reversible ischemia the restoration of the myocytes is determined by factors such as early recovery of coronary blood flow and pre- and postischemic conditioning phenomena. Concepts such as stunned myocardium (temporary mechanical dysfunction following an ischemic episode but with normal blood flow and without irreversible damage) and hibernating myocardium (viable myocardial region without contractility) are quiescent forms of the cardiac function and explain the ability of the myocardium to resume its normal functioning after an ischemic episode.

Isquemia miocárdica: conceptos básicos, diagnóstico e implicaciones clínicas. Primera parte / Myocardial ischaemia: basic concepts, diagnosis and clinical implications

Resumen La isquemia miocárdica es el conjunto de una serie de fenómenos fisiológicos que se manifiesta por condiciones clínicas como isquemia silente, angina estable y síndromes corona-rios agudos. Diversos mecanismos de la regulación del flujo sanguíneo, la demanda miocárdica, la liberación de adenosina y la función del endotelio en las arterias coronarias son claves para mantener la irrigación miocárdica y han sido la base fisiológica para el desarrollo de pruebas de detección de isquemia como lo es el flujo de reserva fraccional, que hoy día hace parte de las recomendaciones de las guías.

Abstract Myocardial ischaemia as a whole is a series of physiological phenomena manifested by clinical conditions such as silent ischaemia, stable angina and acute coronary syndromes. Various blood flow regulation mechanisms, myocardial demand, adenosine release and endot-helial function in the coronary arteries are vital for maintaining myocardial irrigation, and have been the physiological basis for tests like fractional flow reserve, developed to detect ischaemia, that today forms part of the guideline recommendations.