El infarto oculto: las claves para el diagnóstico precoz de infarto posterior / True posterior infarction diagnosis: report of three cases

Acute Coronary Syndrome with ST segment elevation requires rapid reperfusion, which is why the timely identification of these conditions, based on the patient's symptoms and the correct interpretation of the EKG, is essential for therapeutic decisions. We report three patients with True Posterior Infarction and their difficult EKG diagnosis. The classic 12-lead EKG method is often not capable of supporting the diagnosis, so we recommend the use of posterior leads and mirror images observing inverted V1-V2-V3 leads on the classic EKG.

Consequences of COVID-19 pandemic on myocardial infarction reperfusion therapy and prognosis / Consecuencias de la pandemia COVID-19 en la reperfusión y pronóstico del infarto de miocardio

ABSTRACT Background The coronavirus disease (COVID-19) pandemic affected the prompt diagnosis and treatment of Acute myocardial infarction (AMI). Aim: To characterize the clinical profile of patients with AMI during the COVID-19 pandemic, comparing them with a historical cohort. Material and Methods: A case-control study of 96 patients with AMI transferred to a high-volume percutaneous coronary intervention (PCI) hospital between March and July 2020, and a historical cohort of 269 patients transferred during the same period in 2019. Results: When comparing patients transferred during the pandemic with those of the historical cohort, the former were younger (63 ± 12 vs 68 ± 12 years, p 12 hours from the onset of symptoms (44 vs 0%, p < 0.01), a higher median door-to-device time (4 vs 3 hours, p < 0.01), a higher use of primary percutaneous coronary intervention (97 vs 71%, p < 0.01), and higher frequencies of cardiogenic shock (20 vs 4%, p < 0.01) and mechanical complications (10% vs 2%, p < 0.01). Patients during COVID pandemic had a higher thirty-day overall (20 vs 1.4%, p < 0.01) and cardiovascular mortality (13 vs 1%, p < 0.01). During the outbreak, 40% of patients had positive COVID-19 status, which was a predictor for thirty-day overall mortality (Risk ratio 2.90; 95% confidence intervals 1.14-7.36). Conclusions: During the pandemic patients with AMI exhibited delays in consultations and treatment, higher morbidity, and increased mortality. COVID-19 positivity was associated to worse thirty-day overall survival.

Antecedentes: La pandemia COVID-19 afectó el tratamiento oportuno del infarto agudo de miocardio (IAM). Objetivo: Caracterizar el perfil clínico de pacientes con IAM durante la pandemia COVID-19 y compararlos con una cohorte histórica. Pacientes y Métodos: Estudio caso-control de 96 pacientes con IAM transferidos a un hospital de alto volumen de intervención coronaria percutánea (ICP) entre marzo julio de 2020 y una cohorte histórica de 269 pacientes transferidos en el mismo período de 2019 (n = 269). Resultados: Al comparar los pacientes transferidos durante pandemia y la cohorte histórica, los primeros eran más jóvenes (63 ± 12 y 68 ± 12 años respectivamente, p 12 h desde iniciados síntomas de IAM con elevación ST (44,4 y 0% respectivamente, p < 0,01), una mediana de tiempo puerta-guía mayor (4 y 3 horas respectivamente, p < 0,01), un mayor uso de ICP primaria (97 y 71% respectivamente, p < 0,01), mayor frecuencia de shock cardiogénico (19,8 y 4,1% respectivamente, p < 0.01) y complicaciones mecánicas (10,4 y 1,7% respectivamente, p < 0,01). A treinta días, los primeros tuvieron mayor mortalidad general (19,8 y 1,4% respectivamente p < 0.01) y cardiovascular (12,5 y 1,4% respectivamente, p < 0,01). Durante la pandemia, 40% de los pacientes presentó positividad para COVID-19, siendo un factor predictivo de mortalidad general (razón de riesgo 2,90; intervalos de confianza 95% 1,14-7,36). Conclusiones: Durante la pandemia, hubo retrasos en tiempos de consulta y tratamiento y mayor morbimortalidad del IAM. La positividad de COVID-19 se asoció a peor sobrevida general a treinta días.

Characterization of the sensitization profile of bee venom allergic patients ­ Association with the severity of reaction? / Caracterização do perfil de sensibilização molecular de doentes alérgicos à picada de abelha - Associação com a gravidade da reação?

Introduction: Bee venom (BV) allergy, a common cause of anaphylaxis in adults, is often associated with severe reactions. The use of component-resolved diagnostics (CRD) increases diagnostic accuracy. Objectives: To characterize the sensitization profile of BV allergic patients and a possible correlation with the severity of reaction. Materials and methods: We selected patients with a clinical history of BV allergy, positive skin tests, and specific IgE (sIgE) for BV. The allergenic profile was analyzed by both CRD and Western blot using a well-defined and properly characterized BV extract. Results: Forty-four patients were included, 30 (68.2%) were men. Mean age was 48.9 (SD 17.9) years. Eleven (25%) had large local reactions (LLRs) and 33 (75%) had systemic sting reactions (SSRs). One patient with negative sIgE for BV had positive sIgE for Api m 1, Api m 5, and Api m 10. The sensitization frequency for BV, Api m 1, Api m 2, Api m 3, Api m 5, and Api m 10 was 97.7%, 75%, 47.7%, 20.5%, 40.9%, and 61.4%, respectively. Five patients (11.4%) were sensitized to all BV components. CRD association showed that 5 patients (11.4%) were sensitized only to Api m 1, 8 (18.2%) to Api m 1/Api m 3/Api m 10, and 16 (36.6%) to Api m 1/ Api m 10. Twenty-eight patients (84.8%) with SSRs were sensitized to Api m 1, and concomitant sensitization to Api m 1/Api m 10 was detected in 20 (60.6%). There was a significant difference in Api m 1 between patients with LLRs and SSRs (p = 0.0104). Similar profiles were identified by Western blot analysis, with relevance for the detection of Api m 6 in 28 (64%) and Api m 4 in 16 (36%) patients. Conclusion: The analysis of the sensitization profile using CRD and the association of several of these components can increase diagnostic accuracy in BV allergy. Our data showed that concomitant sensitization to Api m 1 and Api m 10, detected by both CRD and electrophoretic profile, may be associated with SSRs. We emphasize the identification of sensitization to Api m 6 in > 50% of patients, which may be considered a major allergen, and to Api m 4, which may be related to reactions during BV immunotherapy.

Introdução: A alergia ao veneno de abelha (VA) é uma causa frequente de anafilaxia em adultos e está muitas vezes associada a reações graves. O diagnóstico por componentes moleculares (CRD) contribui para uma melhor caracterização desta alergia. Objetivos: Caracterização do perfil de sensibilização molecular de doentes alérgicos ao veneno de abelha e possível correlação com a gravidade da reação. Material e métodos: Selecionaram-se doentes com história de alergia a VA, testes cutâneos e IgE específica (sIgE) positivos para VA. Avaliou-se o perfil alergênico por CRD e por Western Blot, utilizando extrato de VA bem caracterizado. Resultados: 44 doentes, 30 (68,2%) sexo masculino. Média de idades 48,9 ± 17,9 anos, 11 (25%) com reacções locais exuberantes e 33 (75%) com reações sistêmicas à picada (SSR). Um doente tinha sIgE negativa para VA, mas Api m 1, Api m 5 e Api m 10 positivas. A frequência de sensibilização para VA, Api m 1, Api m 2, Api m 3, Api m 5 e Api m 10 foi 97,7%; 75%; 47,7%; 20,5%; 40,9% e 61,4%, respectivamente. Cinco (11,4%) doentes estavam sensibilizados a todos os componentes. Por associação de CRD, detectaram-se 5 (11,4%) doentes sensibilizados apenas a Api m 1, 8 (18,2%) a Api m 1/Api m 3/Api m 10, e 16 (36,6%) a Api m 1/Api m 10. Vinte e oito (84,8%) doentes com SSR tinham Api m 1 positiva e 20 (60,6%) tinham Api m 1/Api m 10 simultaneamente positivas. Observou-se uma diferença estatisticamente significativa para a Api m 1 entre doentes com reações locais exuberantes e sistêmicas (p = 0,0104). Os perfis detectados por Western Blot foram semelhantes, de referir, à detecção de Api m 6 em 28 (64%) e Api m 4 em 16 (36%) dos doentes. Conclusão: A análise do perfil de sensibilização através de CRD e a sua associação aumentam a precisão do diagnóstico de alergia a VA. Sensibilização simultânea a Api m 1 e Api m 10 identificados tanto por CRD como por perfil eletroforético, pode estar associada à ocorrência de SSR. Destaca-se a sensibilização a Api m 6 em > 50% dos doentes, podendo ser considerado um alergênio major, e a Api m 4, possivelmente associado a reações durante a imunoterapia com VA.

Peripheral venoarterial extracorporeal membrane oxygenation for periprocedural Cardiogenic shock during interventional cardiology

ABSTRACT Background: Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. Aim: To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. Material and Methods: Review of clinical records of seven patients treated between January 2014 and October 2018. Results: pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. Conclusions: pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.

Antecedentes: El shock cardiogénico (SC) es infrecuente en el laboratorio de cateterismo cardíaco (LCC) entre pacientes que son sometidos a coronariografía. El SC peri-procedimiento es más frecuente en pacientes de alto riesgo y en procedimientos técnicamente complejos. Objetivos: Describir los resultados clínicos de pacientes que fueron conectados a oxigenación con membrana extracorpórea veno-arterial periférica (ECMO-VAp) por SC peri-procedimiento de cardiología intervencional. Material y Métodos: Revisión de fichas clínicas de siete pacientes tratados en nuestro centro desde enero de 2014 a octubre de 2018. Resultados: ECMO-VAp fue utilizado dentro de las primeras 6 horas del procedimiento. Todos los pacientes tenían enfermedad coronaria y uno de ellos tenía además estenosis aórtica severa. Un paciente ingresó al LCC en paro cardíaco. Una intervención coronaria percutánea (ICP) fue realizada en todos los pacientes; 4 se realizaron procedimientos de emergencia y 5 pacientes tuvieron complicaciones de la ICP. A un paciente se le realizó un reemplazo valvular aórtico percutáneo y desarrolló una insuficiencia valvular aórtica aguda severa. Se instaló un balón de contrapulsación en el LCC en 5 pacientes. Seis pacientes tuvieron un paro cardiorrespiratorio. El valor del score de SAVE fue de -4,3 y el lactato basal 55 mg/dL. La duración media del ECMO-VAp fue 5 ± 4 días. La sobrevida al alta y a los 12 meses fue 85,7%. Como complicaciones del sitio de acceso vascular se observaron 1 hematoma y un episodio de sangrado que requirió reparación quirúrgica. Conclusiones: ECMO-VAp debería ser considerado en pacientes con SC peri-procedimiento como un puente a recuperación; su utilización estuvo asociada con mejoría de resultados clínicos en esta serie.

Infarto agudo de miocardio sin enfermedad coronaria ateroesclerótica obstructiva: utilidad de las imágenes intravasculares y resonancia cardíaca en su diagnóstico

Background: Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is common. Cardiac magnetic resonance (CMR) and intravascular imaging (IVI) may be useful for establishing its etiology. Aim: To describe a population with MINOCA and its multi-image assessment using IVI or CMR. Material and Methods: Review of medical records, imaging and functional studies of patients with MINOCA treated in three different clinical centers between 2015 and 2019. Results: Twenty-eight patients with MINOCA and IVI were included. Seventy eight percent were women, 46% had hypertension, 32% smoked and 32% had dyslipidemia. At wall motion assessment, 46% presented apical ballooning pattern. In 36% of patients IVI identified lesions that explained the cause of MINOCA, namely plaque disruption (PD) in 18%, spontaneous coronary dissection in 11% and a thrombus without PD in 7%. Forty-six percent of patients had uncomplicated atherosclerotic plaques, and 36% had no pathological findings. CMR was performed in 50% of patients, identifying in all a diagnostic pattern. In nine cases it was compatible with stress cardiomyopathy, three cases had a myocarditis and two cases had transmural infarctions. PD and transmural late gadolinium enhancement were observed in 23% of patients with apical ballooning. Patients with a pattern of myocarditis did not have acute pathological findings at IVI. After a mean follow-up of 16.4±11.4 months, 3 patients with PD died. Conclusions: Among patients with MINOCA, there was a predominance of female gender with low cardiovascular risk factor load. The multi-image assessment allowed greater precision for etiological diagnosis of MINOCA. Apical ballooning was not pathognomonic for stress cardiomyopathy. PD was associated with mortality.

Hipoxemia recurrente y formen oval permeable. Unidad diagnóstica fácilmente inadvertida. Caso clínico / Recurrent hypoxemia secondary to a patent foramen ovale. Report of one case

Patent foramen ovale (PFO) is a prevalent congenital septal atrial defect usually without pathological significance. In certain pathogenic situations, PFO can trigger episodes of recurrent hypoxemia, a specific condition known as platipnea-orthodeoxia syndrome (POS). We report a 73 years old female presenting with dyspnea and low arterial oxygen saturation. On admission the patient had a hemoglobin saturation of 81% and an arterial oxygen partial pressure of 50 mmHg. After breathing 100% a 17% arterial-venous shunt was found (normal: less than 12%). A transesophageal echocardiogram and a cardiac catheterization showed the presence of a PFO. A percutaneous closure was performed.

Experiencia inicial del implante percutáneo de válvula aórtica en el Instituto Nacional del Tórax: Experience in 26 patients / Transcatheter aortic valve implantation

Background: Aortic valve stenosis (AS) is the most common valvular disease. Its surgical indication is undisputed in symptomatic severe AS, however, 30% of patients are at high surgical risk or inoperable. Transcatheter Valve Implantation (TAVI) is an alternative for this group of patients. Aim: To describe the clinical outcomes of TAVI in a group of patients treated at the Instituto Nacional del Tórax, Santiago, Chile. Patients and Methods: Prospective study including all patients referred for TAVI due to their high surgical risk or being inoperable. All-cause mortality, secondary stroke, permanent pacemaker implantation, vascular complications, prosthetic and periprosthetic regurgitation, Karnosfky test and Functional Capacity (FC) were assessed as endpoints. Results: We evaluated 26 patients with a mean age of 82 years (74% women) in whom 27 procedures were done. The mean Society of Thoracic Surgeons score was 8.8%. Overall mortality at 30 days, one and two years was 11.1, 18.5 and 29.6% respectively. Karnofsky score increased significantly from 62.3% at baseline to 83.9; 88.6 and 88.8% at six months, one and two years, respectively. Prior to the procedure, FC was 3.1 ± 0.6, decreasing significantly to 1.2; 1.3 and 1 at six months, one and two years of follow up. Conclusions: TAVI is an effective alternative treatment for patients with severe symptomatic AS and high surgical risk.

Factores psicosociales asociados con el inicio tardío de tratamiento antirretroviral en pacientes mexicanos con VIH / Psychosocial factors associated with late HAART initiation in Mexican patients with HIV

Objetivo. Explorar la asociación entre variables psicosociales y el inicio tardío de tratamiento antirretroviral en una muestra de pacientes mexicanos con diagnóstico de VIH. Material y métodos. Estudio transversal en la clínica de VIH del Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, donde se aplicaron cuestionarios estructurados a 150 pacientes que iniciaron terapia antirretroviral altamente activa (TARAA) entre enero de 2010 y agosto de 2011. Se consideró inicio tardío (IT) de TARAA cuando los pacientes iniciaron el tratamiento con CD4 <200 células/mm³. Resultados. Mediante el análisis multivariado, se encontró que el principal factor psicosocial asociado con IT fue la percepción de autoestigma relacionada con el VIH/sida. Además, la realización de la prueba del VIH se asoció con la indicación médica y no con la iniciativa del paciente; a su vez, tener uno o más contactos médicos previos se relacionó con un mayor riesgo de presentar IT. Conclusiones. Los resultados sugieren la necesidad de intervenciones psicosociales dirigidas a disminuir la autoimagen negativa y actitudes y comportamientos estigmatizantes en grupos de riesgo.

Objective. To explore the association between psychosocial factors and late highly active antiretroviral therapy (HAART) initiation in a sample of Mexican patients with HIV. Materials and methods. We conducted a cross-sectional study at the HIV Clinic of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), and applied structured questionnaires to 150 patients who initiated HAART between January 2010 and August 2011. Late HAART initiation (LHI) was considered when patients started HAART with CD4 counts of <200+ cells/mm³. Results. By multivariate analysis, the strongest psychosocial risk factor for LHI observed was self-stigma towards HIV/AIDS. In addition, being tested by medical prescription, not by own initiative, as well as having one or more previous medical contacts, were associated with greater risk for LH. Conclusions. Our findings suggest the need to develop psychosocial interventions to decrease negative self-image and stigmatizing attitudes and behaviors in risk groups for HIV in Mexico.

Prácticas de Crianza Asociadas a la Reducción de los Problemas de Conducta Infantil: Una Aportación a la Salud Pública / Child Raising Practices Associated to the Reduction of Problematic Child Behavior: A Public Health Approach

El entrenamiento conductual a padres resulta en cambios conductuales que están asociados con la reducción de la conducta problemática de los niños. El objetivo del trabajo fue identificar los componentes de un programa de entrenamiento conductual a padres para cambiar la conducta parental y la de sus hijos. Participaron 84 padres mexicanos de niños con problemas de conducta con edades de entre dos y 12 años. Los padres participaron en un programa de crianza positiva, que consistió en un juego de roles y que los entrenó a responder de forma positiva ante las diferentes conductas del niño con el fin de disminuir su conducta problemática. La conducta de los niños se evaluó mediante cuestionarios de auto-reporte que respondieron los padres. Los resultados mostraron que después del entrenamiento se observó que los padres modificaron su conducta, lo cual redundó en que reportaran que la conducta de sus hijos también se modificó. Los componentes más efectivos del programa fueron la corrección del comportamiento, el elogio, las instrucciones claras, el establecimiento de reglas, la solución de problemas, la interacción social y la reducción en el uso del castigo.

Parent behavioral training results in behavioral changes that are associated with the reduction of a child's problematic behaviors. The purpose of the present study was to identify the most effective components of a parent behavioral training program on both, the observed parents' behavior and their report on the reduction of their child's problematic behavior. Participants were 84 Mexican parents of two to twelve years old children with behavioral problems. Parents attended a positive child raising program based in role playing that trained them to respond in a positive manner to their children's behaviors with the ultimate goal of reducing problematic behaviors. The children's behaviors were assessed using self-report questionnaires answered by the parents. After the behavioral training, a significant change in the parents' behavior was observed. Parents also reported a significant reduction of their child's problematic behavior. The most effective components of the intervention program were behavior correction, praise, giving clear instructions, rule establishment, problem solving, social interaction, and the reduction in punishment.

Situs inversus totalis / Situs inversus totalis

Situs inversus totalis (SIT) es una enfermedad rara, en la cual existe transposición de los órganos torácicos y abdominales. Se presenta el caso de una paciente de 65 años de edad, que acude a emergencias por dolor epigástrico de 20 horas de evolución que luego de unas horas migra a fosa iliaca izquierda asociado a hiporexia. En primera instancia, se sospecha del diagnóstico de diverticulitis, luego de los exámenes imagenológicos respectivos es descartada por encontrarse hallazgos correspondientes con situs inversus totalis y se plantea apendicitis del lado izquierdo. Por tal motivo, la realización de una adecuada historia clínica y examen físico apoyado en pruebas imagenológicas resultan importantes para tener en cuenta a la apendicitis como parte del diagnóstico diferencial, con el fin de evitar errores en su diagnóstico per se y tratamiento...

Situs inversus totalis (SIT) is a rare disease in which there is transposition of thoracic and abdominal organs. The symptoms of appendicitis in SIT are often confused with other intraperitoneal processes such as diverticulitis. We report the case of a 65-year-old, attended by emergency epigastric pain of 20 hours of the onset after a few hours left iliac fosse migrates associated with hyporexia. Diverticulitis is diagnosed in the first instance, and after the respective imaging tests is discarded for being relevant findings with situs inversus totalis and left poses appendicitis. Therefore, the realization of an adequate medical history and physical examination supported by imaging tests are important to keep in mind, appendicitis as part of the differential diagnosis, in order to avoid errors in diagnosis and treatment...

Evaluación de conocimientos sobre habilidades de manejo conductual infantil en profesionales de la salud / Children Behavior Management Skills: Assessment of Knowledge in Health Professionals

El objetivo del estudio fue evaluar conocimientos sobre habilidades para manejar problemas de conducta infantil. Los conocimientos se evaluaron a través de situaciones hipotéticas de crianza, entrevistando a 294 profesionales de diversos estados del país, empleando un diseño pre-experimental pre-post. Se empleó un instrumento con 13 situaciones hipotéticas de problemas de conducta infantil en casa, donde se calificaba las respuestas de los participantes sobre las habilidades a emplear por los adultos. Los resultados mostraron que a partir de una capacitación breve hubo un aumento significativo en los conocimientos sobre las habilidades de manejo conductual para las 13 situaciones. Se concluye que el cuestionario de situaciones hipotéticas de crianza fue útil para evaluar el conocimiento sobre habilidades de crianza. Además, los profesionales lograron reportar estrategias para el aumento de conductas pro-sociales, la corrección de conducta inadecuada, el establecimiento de reglas en el hogar y la solución de problemas en familia. Investigación adicional mostrará el proceso de adquisición de las habilidades a través de técnicas de observación directa de estas situaciones hipotéticas de crianza.

The purpose of this study was to assess knowledge acquisition of children behavior management skills by professionals. Knowledge of skills use was assessed by a hypothetical breeding situations questionnaire interviewing nationwide to 294 health professionals using a pre experimental pre test post test design. Professionals responded to 13 hypothetical child rearing home situations indicating in each what management skill were to be used by adults. Results show that after a brief training, professional's knowledge of child behavior management skills use increase significantly over the 13 child rearing situations. It is concluded that the hypothetical breeding situations questionnaire was helpful to assess knowledge acquisition. Also professionals were able to report strategies for the strengthening of prosocial behavior, the correction of inappropriate behavior, the establishing of home rules, and family problem solving. Further research will show the process of skill acquisition through direct observation techniques of the hypothetical breeding situations used here.

Primer caso de preservación de fertilidad en Guatemala / First case of preservation of fertility in Guatemala

La sobrevida a largo plazo de las pacientes con patología oncológica se ha incrementado en las últimas décadas, gracias a la detección temprana y a los avances en la terapia oncológica. Esta condición cada vez es mayor en mujeres que se encuentran en edad fértil, y que aún no han considerado su deseo gestacional. Se sabe muy bien que la terapia oncológica es tóxica para las gónadas, efecto que dependerá del medicamento, dosis, empleo de radioterapia y de edad de administración del tratamiento...