Iatrogenic Complications During the Diagnostic Work-Up of an Inflammatory Cardiomyopathy

Abstract A 72-year-old woman was admitted for acute heart failure. The echocardiography revealed moderate depression of the left ventricular ejection fraction. Coronary disease was excluded by coronarography. Cardiac magnetic resonance showed predominantly left ventricular septal hypertrophy and severe depression of the left ventricular systolic function. There was also a bright, multifocal and patchy late gadolinium enhancement with subendocardial, mesocardial and subepicardial involvement, suggestive of sarcoidosis. Biochemical study, thoracic computed tomography and positron emission tomography were inconclusive for extra-cardiac sarcoidosis. Therefore, an endomyocardial biopsy was performed. The procedure was complicated by the development of complete atrioventricular block, requiring implantation of a cardiac resynchronization pacing device. A few days after device implantation, the patient developed fever. The echocardiography revealed extensive vegetations, and thus the diagnosis of a device-associated infective endocarditis was made. Even though antibiotic therapy was promptly started, the patient ended up dying. Biopsy results revealed lymphocytic myocarditis. This case is paradigmatic because it shows how the etiologic diagnosis of dilated cardiomyopathy can be challenging. Non-invasive diagnostic exams may not provide a definite diagnosis, requiring an endomyocardial biopsy. However, the benefits versus risks of such procedure must always be carefully weighted.

Application of Risks Scores in Acute Coronary Syndromes. How Does ProACS Hold Up Against Other Risks Scores? / Aplicação de Escores de Risco em Síndromes Coronárias Agudas: Como o ProACS se Comporta Diante de Outros Escores de Risco?

Abstract Background: Multiple risk scores (RS) are approved in the prediction of worse prognosis in acute coronary syndromes (ACS). Recently, the Portuguese Journal of Cardiology has proposed the ProACS RS. Objective: Application of several validated RS, as well as ProACS in patients, admitted for ACS. Evaluation of each RS's performance in predicting in-hospital mortality and the occurrence of all-cause mortality or non-fatal ACS at one-year follow-up and compare them to the ProACS RS. Methods: A retrospective study of ACS was performed. The following RS were applied: GRACE, ACTION Registry-GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS and ProACS. ROC Curves were created to determine the predictive power for each RS and then were directly compared to ProACS. Results: The ProACS, ACTION Registry-GWTG and GRACE showed a c-statistics of 0.908, 0.904 and 0.890 for predicting in-hospital mortality, respectively, performing better in ST-segment elevation myocardial infarction patients. The other RS performed satisfactorily, with c-statistics over 0.750, apart from the CHA2DS2-VASc-HS and C-ACS which underperformed. All RS underperformed in predicting worse long-term prognosis revealing c-statistics under 0.700. Conclusion: ProACS is an easily obtained risk score for early stratification of in-hospital mortality. When evaluating all RS, the ProACS, ACTION Registry-GWTG and GRACE RS showed the best performance, demonstrating high capability of predicting a worse prognosis. ProACS was able to demonstrate statistically significant superiority when compared to almost all RS. Thus, the ProACS has showed that it is able to combine simplicity in the calculation of the score with good performance in predicting a worse prognosis.

Resumo Fundamento: Existem muitos escores de risco (ERs) aprovados na predição de um pior prognóstico em síndromes coronárias agudas (SCAs). Recentemente, a Revista Portuguesa de Cardiologia propôs o ER ProACS. Objetivo: Aplicar vários ERs validados, bem como o ProACS em pacientes internados por SCA. Avaliar o desempenho de cada ER em predizer mortalidade hospitalar e a ocorrência de mortalidade por todas as causas ou SCA não fatal em um ano de acompanhamento e compará-los com o ProACS. Métodos: Estudo retrospectivo de SCA. Os seguintes ERs foram aplicados: GRACE, ACTION Registry-GWTG, PURSUIT, TIMI, EMMACE, SRI, CHA2DS2-VASc-HS, C-ACS e ProACS. Curvas ROC foram criadas para determinar o poder preditivo de cada ER e diretamente comparadas com a do ProACS. Resultados: Os escores ProACS, ACTION Registry-GWTG e GRACE mostraram estatística-C de 0,908, 0,904 e 0,890, respectivamente, em predizer mortalidade hospitalar, mostrando melhor desempenho em pacientes com infarto do miocárdio com elevação do segmento ST. Os demais ERs mostraram desempenho satisfatório, com estatística-C acima de 0,750, com exceção de CHA2DS2-VASc-HS e C-ACS, que mostraram baixa performance. Todos os ERs apresentaram baixo desempenho em predizer um pior prognóstico em longo prazo, com estatística-C abaixo de 0,700. Conclusão: O ProACS é um escore de risco facilmente obtido para estratificação precoce de mortalidade intra-hospitalar. Ao avaliar todos os ERs, ProACS, ACTION Registry-GWTG e GRACE mostraram o melhor desempenho, com alta capacidade de predizer um pior prognóstico. O ProACS mostrou superioridade estatisticamente significativa em comparação aos outros ERs. Portanto, o ProACS mostrou-se capaz de combinar simplicidade no cálculo do escore com bom desempenho em predizer um pior prognóstico.

A biceps muscle Latissimus dorsi in a dog / Una segunda cabeza del músculo Latissimus dorsi en un perro

This article reports the finding of a twin unreported muscle begin. In one dog, both, left and right muscle latissimus dorsi were biceps. The thin second head of m. latissimus dorsi that we founded, could be an intermediate step of comparative anatomy changes from reptilian to mammal. Man breast surgery and cardiomyoplasty, use dog latissimus dorsi as experimental, to know this information can be useful to these situations.

Este artículo describe el hallazgo del origen de un músculo gemelo no reportado. En un perro, los dos músculos latissimus dorsi, izquierdo y derecho, eran biceps. La segunda cabeza delgada del M. latissimus dorsi observada, podría ser un paso intermedio de los cambios de la anatomía comparada de reptil a mamífero. Conocer esta información puede ser útil para la cirugía de tórax y cardiomioplastía en el humano, donde el músculo latissimus dorsi del perro, es utilizado en forma experimental.

Anatomy of corpus callosum in prenatally malnourished rats

The effect of prenatal malnutrition on the anatomy of the corpus callosum was assessed in adult rats (45-52 days old). In the prenatally malnourished animals we observed a significant reduction of the corpus callosum total area, partial areas, and perimeter, as compared with normal animals. In addition, the splenium of corpus callosum (posterior fifth) showed a significant decrease of fiber diameters in the myelinated fibers without changing density. There was also a significant decrease in diameter and a significant increase in density of unmyelinated fibers. Measurements of perimeter's fractal dimensions from sagittal sections of the brain and corpus callosum did not show significant differences between malnourished and control animals. These findings indicate that cortico-cortical connections are vulnerable to the prenatal malnutrition, and suggest this may affect interhemispheric conduction velocity, particulary in visual connections (splenium).

Fractal Dimension of Dog Kidney Proximal Convoluted Tubuli Sections by Mean Box-Counting Algorithm / Dimensión Fractal de Secciones de los Túbulos Contorneados Proximales del Riñón Mediante un Algoritmo de Recuento de Cajas

The possibility of characterizing the proximal convoluted tubuli of the dog kidney by means of a unique and objective value, is an attractive idea in order to automate its recognition in anatomy and patology. For this, we obtained a fractal dimension of the proximal convoluted tubuli in the dog kidney by mean box-counting method. The fractal value we obtained is a flat dimension, and it is different than the line fractal dimension of the dog kidney arterial pattern, which was previously calculated by us (Gil et al., 2006). Thus, from optical microscopy images, we are able to obtain a single quantitative measure to discriminate these dog kidney components. This measures can use to automate its recognition. Fractal geometry provides many advantages when examining the complex microscopical images of natural objects.

La posibilidad de caracterizar los túbulos contorneados proximales del riñón de perro, mediante un valor único y objetivo, es una idea interesante para automatizar su reconocimiento en anatomía y en patología. Para ello, hemos obtenido la dimensión fractal de los túbulos contorneados proximales del riñón de perro, mediante la técnica de recuento de cajas. El valor fractal obtenido es una dimensión de superficie, diferente de la dimensión fractal lineal que calculamos previamente (Gil et al., 2006). De esta forma, desde imágenes microscópicas, nos es posible obtener una medida simple y cuantitativa para diferenciar estos compontes del riñón de perro. Esta medida puede usarse para automatizar su reconocimiento.

Tangential Algorithm for Calculation of the Fractal Dimension of Kidney Tubuli Sections / Algoritmo de Tangencialización para el Cálculo de la Dimensión Fractal de Túbulos Renales Seccionados

We have developed a new algorithm to calculate the fractal dimension of dog kidney proximal convoluted tubule section. This algorithm is intermediate between box-counting and perimeter-stepping algorithms. The result of this new algorithm and correlations found between fractal dimensions and other Euclidian values of these tubuli, suggest that this algorithm is adequate to calculate fractal dimensions by points.

Hemos desarrollado un nuevo algoritmo para calcular la dimensión fractal de las secciones de los túbulos contorneados proximales del riñón de perro. Este algoritmo es promedio de los que emplean el recuento de cajas y la medida del perímetro. El resultado de las medidas con este nuevo algoritmo y las correlaciones encontradas entre sus valores de dimensión fractal y otros valores euclidianos de dichos túbulos, sugieren la adecuación de método para calcular la dimensión fractal referida a puntos.

Síndrome de Gardner / Gardner's syndrome

Se presenta el caso de una paciente de 48 años de edad en la cual la asociación de poliposis múltiple, osteomas craneanos, gran quiste dentígeno de maxilar inferior, con quistes epidérmicos y fibromas cutáneos conduce al diagnóstico de Sindrome de Gardner. Se efectúa una revisión bibliográfica, nosológica y clinicopatogénica de esta genodermatosis y se destaca la trascendencia del dermatólogo en la pesquisa temprana de esta rara afección