Síndrome cardiorrenal: aspectos clínicos y ecocardiográficos / Cardiorenal syndrome: Clinical and echocardiographic aspects

Resumen El síndrome cardiorrenal (SCR) es un trastorno en el que intervienen el corazón y los riñones, interactuando y produciendo una disfunción entre ellos en forma aguda o crónica. Existen diferentes fenotipos clínicos bien identificados como «desórdenes del corazón y riñón en los que la disfunción aguda o crónica en un órgano induce la disfunción aguda o crónica del otro¼. La alta incidencia de morbimortalidad cardiovascular presente en los pacientes con enfermedad renal crónica terminal (ERCT), en especial la insuficiencia cardiaca (IC), origina inicialmente una lesión miocárdica que conlleva remodelamiento ventricular, lo cual induce a la activación de mecanismos compensadores, entre los cuales el riñón es pieza fundamental, ya que regula la homeostasis hidroelectrolítica y así el volumen circulante, siendo esto en la etapa dialítica más evidente. Los cambios funcionales y anatómicos cardiovasculares que se producen en estos pacientes son muy prevalentes e incluyen las interacciones hemodinámicas del corazón y los riñones en la insuficiencia cardiaca, y el impacto de la enfermedad aterosclerótica en ambos sistemas de órganos. También describimos estrategias diagnósticas y terapéuticas aplicables al síndrome cardiorrenal, que determinan la importancia de la ecocardiografía como modelo de diagnóstico útil. Finalmente, se analizan las posibilidades de tratamiento y la remisión de las alteraciones funcionales cardiacas con el trasplante renal en los pacientes con ERCT.

Abstract Cardiorenal syndrome (CRS) is a disorder in which the heart and kidneys are involved, interacting and producing a dysfunction between them in an acute or chronic way. There are different clinical phenotypes well identified as "heart and kidney disorders in which acute or chronic dysfunction in one organ induces acute or chronic dysfunction in the other". The high incidence of cardiovascular morbimortality in patients with chronic terminal kidney disease (CKD), especially heart failure (HF), initially causes a myocardial lesion that leads to ventricular remodeling, which induces the activation of compensatory mechanisms, among which the kidney is a fundamental part since it regulates the hydroelectrolytic homeostasis and thus the circulating volume, being this in the dialytic stage more evident. The functional and anatomical changes at cardiovascular level that occur in these patients are very prevalent, and include hemodynamic interactions of the heart and kidneys in heart failure and the impact of atherosclerotic disease in both organ systems. We also describe diagnostic and therapeutic strategies applicable to cardiorenal syndrome, which determine the importance of echocardiography as a useful diagnostic model. Finally, we analyze the possibilities of treatment and remission of cardiac functional alterations with renal transplantation in patients with T-CKD.

Efecto de la hipertensión arterial en la función cognitiva de pacientes de 45 a 65 años. Hospital Luis Vernaza, Guayaquil, Ecuador / Impact of arterial hypertension on the cognitive function of patients between 45 and 65 years. Luis Vernaza Hospital, Guayaquil, Ecuador

Resumen Introducción: El deterioro cognitivo leve es una alteración de la función cognitiva que no afecta de manera negativa a las actividades diarias de la persona. Factores de riesgo modificables como la hipertensión arterial podrían intervenir en el aceleramiento de este proceso y afectar a personas menores de 65 años. Una detección temprana del deterioro cognitivo leve por medio del Montreal Cognitive Assesment (MoCA) en personas con hipertensión arterial ayudaría a idear medidas para su control eficaz. Materiales y métodos: Se diseñó un estudio de tipo observacional transversal. La población se integra con pacientes hipertensos de 45 a 65 años de Guayaquil. De una base de datos de 570 pacientes, se realizó un llamado a sujetos que cumplieran los criterios de inclusión y exclusión, para la evaluación de la función cognitiva por medio del MoCA. Resultados: El 93.3% de los participantes sometidos a la prueba MoCA presentó un puntaje menor de 26. El promedio del puntaje total fue de 18.9 y el 51.6% de los participantes reveló deterioro cognitivo leve. Se obtuvo una correlación negativa del 40% (-0.40) con una p = 0.0015 entre años con hipertensión arterial y el resultado total de la prueba MoCA. Conclusiones: Por medio del MoCA se pudo cuantificar la magnitud del deterioro cognitivo en estos pacientes. Se identificó que la mayoría de los participantes examinados presentaba un puntaje promedio menor del intervalo normal. Las cifras obtenidas de los valores de correlación de Pearson muestran una actividad tendencial y relación de la hipertensión arterial con el deterioro de la función cognitiva.

Abstract Introduction: Mild cognitive impairment is an alteration of cognitive function that does not negatively affect the daily activities of the person. Modifiable risk factors such as hypertension could be involved in the acceleration of this process affecting people under 65 years of age. Early detection of mild cognitive impairment through the Montreal Cognitive Assessment (MoCA) in people with high blood pressure, would help to formulate strategies for its effective control. Materials and methods: A cross-sectional observational study was designed. The population is hypertensive patients between 45 and 65 years old in Guayaquil. From a database of 570 patients, a call was made to patients who met the inclusion and exclusion criteria, for the evaluation of cognitive function through MoCA. Results: 93.3% of the participants who underwent the MoCA test had a score lower than 26. The average of the total score was 18.9, with 51.6% of the participants suffering from mild cognitive impairment. A negative correlation of 40% (-0.40) was obtained with a p = 0.0015 between years with arterial hypertension and the total result of the MoCA test. Conclusions: Through MoCA, the magnitude of cognitive deterioration in these patients could be quantified. It was detected that the majority of the examined participants had a lower average score of the normal range. The figures obtained from the Pearson correlation values show trend activity, relating arterial hypertension and deterioration of cognitive function.

Un novedoso agente en el tratamiento de la insuficiencia cardiaca con función sistólica deprimida / A novel agent in the treatment of heart failure with depressed systolic function

Resumen Introducción: Se revisará la evolución del tratamiento farmacológico de la insuficiencia cardiaca (IC) en los últimos 25 an˜os, desde el concepto de tratamiento con vasodilatadores, pasando por el bloqueo o inhibición del sistema renina-angiotensina-aldosterona y la inhibición betaadrenérgica y su importante contribución en la disminución de la morbimortalidad por IC, el papel de los péptidos natriuréticos y, finalmente, se conocerá uno de los estudios más importantes en el área cardiológica y específicamente en el manejo de la IC, en el cual se demuestra un enfoque modulador de los sistemas neuro humorales que se activan en estos pacientes. Objetivos: La IC constituye la etapa final de la mayoría de las enfermedades cardiovasculares, con una alta tasa de hospitalización y de morbimortalidad cardiovascular, siendo, por lo tanto, de interés constante la necesidad de encontrar un agente terapéutico innovador que disminuya significativamente estas complicaciones y también que mejore la calidad de vida de los que la presentan. Metodología: Se realizará una descripción del PARADIGM-HF Clinical Trial, que utilizó un compuesto sacubitrilo/valsartán para el manejo de la IC con un mecanismo modulador diferente del concepto de bloqueador de sistemas deletéreos que se activan cuando un paciente presenta síntomas y signos de IC. Conclusiones: La muerte por causas cardiovasculares u hospitalización por IC (el punto final primario) se produjo en 914 pacientes (21.8%) en el grupo sacubitrilo/valsartán y 1,117 pacientes (26.5%) en el grupo de enalapril (razón de riesgo en el grupo sacubitrilo/valsartán, 0.80; intervalo de confianza (IC) del 95%: 0.73 a 0.87; p < 0.001 (exacta p = 4.0 × 10 - 7)). De los pacientes que recibieron sacubitrilo/valsartán, 537 (12.8%) fueron hospitalizados por IC, en comparación con los 658 pacientes (15.6%) que recibieron enalapril (razón de riesgo, 0.79; IC del 95%, 0.71 a 0.89; p < 0.001). Un total de 711 pacientes (17.0%) en el grupo sacubitrilo/valsartán y 835 pacientes (19.8%) en el grupo de enalapril murió (razón de riesgo de muerte por cualquier causa, 0.84; IC del 95%, 0.76 a la 0.93; p < 0.001).

Abstract Introduction: A review is presented on the evolution of the pharmacological treatment of heart failure (HF) in the last 25 years, from the concept of treatment with vasodilators to the blocking or inhibition of the renin angiotensin aldosterone system. Beta-adrenergic inhibition and its important contribution in the reduction of morbidity and mortality due to HF will be discussed along with the role of the natriuretic peptides. One of the most important studies in the cardiology area, and specifically in the management of HF, is presented, in which an approach is demonstrated of the modulator of the neurohumoral systems that are activated in these patients. Objectives: HF is the final stage of most cardiovascular diseases, and has a high rate of hospital admission, as well as cardiovascular morbidity and mortality. Therefore, there is constant interest in the need to find an innovative therapeutic agent that significantly reduces these complications and that improves the quality of life of those who suffer from it. Methods: A description will be presented of the PARADIGM-HF Clinical Trial using a sacubitril/valsartán compound for the management of HF with a modulating mechanism different from the concept of a deleterious system blocker that is activated when a patient has symptoms and signs of heart failure. Conclusions: Death due to cardiovascular causes, or hospital admission due to heart failure (the primary endpoint) occurred in 914 patients (21.8%) in the Sacubitril / valsartán group, and 1117 patients (26.5%) in the enalapril group (risk ratio in the sacubitril / valsartán group, 0.80, with a 95% confidence interval [CI]: 0.73 to 0.87, P<0.001 ;exact P= 4.0 × 10 --7;). Of the patients receiving sacubitril / valsartán, 537 (12.8%) were hospitalised due to heart failure, compared with 658 patients (15.6%) receiving enalapril (hazard ratio 0.79, 95% CI: 0.71 to 0.89, P<.001). A total of 711 patients (17.0%) in the sacubitril / valsartán group, and 835 patients (19.8%) in the enalapril group, died (all-cause death rate, 0.84, 95% CI: 0.76 to 0.93, P<.001)

A detailed description of an economical setup for electroporation of chick embryos in ovo

One of the challenges of the postgenomic era is characterizing the function and regulation of specific genes. For various reasons, the early chick embryo can easily be adopted as an in vivo assay of gene function and regulation. The embryos are robust, accessible, easily manipulated, and maintained in the laboratory. Genomic resources centered on vertebrate organisms increase daily. As a consequence of optimization of gene transfer protocols by electroporation, the chick embryo will probably become increasingly popular for reverse genetic analysis. The challenge of establishing chick embryonic electroporation might seem insurmountable to those who are unfamiliar with experimental embryological methods. To minimize the cost, time, and effort required to establish a chick electroporation assay method, we describe and illustrate in great detail the procedures involved in building a low-cost electroporation setup and the basic steps of electroporation.

Immunohistochemical characterization of the chick marginal retina

The retina is a highly differentiated tissue with a complex layered structure that has been extensively characterized. However, most of the previous studies focused on the histology of the central retina while little is known about the cellular composition, organization and function of the marginal retina. Recent research has identified a subpopulation of multipotential progenitor cells in the marginal regions of the retina, closest to the ciliary body ("ciliary marginal zone"). These cells are capable of differentiation in response to an appropriate stimulus. Thus, it is possible that the structure and composition of the marginal retina are distinct from those of the central retina to accommodate the potential addition of newly formed neurons. To characterize the cellular profile of the chick marginal retina, we labeled it immunohistochemically for markers whose staining pattern is well established in the central retina: calbindin, calretinin, protein kinase C, and choline acetyltransferase. Calbindin was present at very low levels in the marginal retina putative photoreceptor layer. Calretinin-positive horizontal cells were also sparse close to the ciliary marginal zone. The bipolar cells in the marginal outer plexiform layer were positive for anti-protein kinase C antibodies, but the density of labeling was also decreased in relation to the central retina. In contrast, the marginal starburst cholinergic amacrine cell pattern was very similar to the central retina. From these data we conclude that the structure of the marginal retina is significantly different from that of the central retina. In particular, the expression of late retina markers in the marginal retina decreased in comparison to the central retina.

Pattern of Wnt ligand expression during chick eye development

The dorsoventral axis of the eye is determined prior to optic cup invagination. A variety of signaling pathways have been implicated in the maintenance of the optic dorsoventral axis, including, but not limited to, bone morphogenetic protein 4, Sonic Hedgehog and retinoic acid. Here, we investigated the possible contribution of Wnt ligands to the establishment or maintenance of the optic axis by analyzing their expression pattern during early chick optic development. We performed in situ hybridization of Wnt-1, Wnt-3a, Wnt-4, and Wnt-5a during the optic vesicle, early optic cup and established optic cup stages and focused our analysis on the optic region. Our data showed that Wnt-5a, but none of the others, is expressed in the dorsal region of the eye starting from the Hamburger and Hamilton stage 14 (HH14). These results are supported by cryosections of the labeled optic region, which further reveal that Wnt-5a is expressed only in the dorsal retinal pigmented epithelium. Thus, we propose that Wnt-5a is a marker for dorsal retinal pigmented epithelium in chick embryos from HH14 to HH19.

Highlights on the World Bank Loan Schistosomiasis Control Program in China (1991-1998): a special focus on Hunan Province.

A region-wide sampling survey was conducted in 1995 in order to evaluate the current epidemiological status of schistosomiasis japonica in Hunan Province, China. A total of 45,590 humans and 3,726 domestic animals, from 52 villages, were examined parasitologically and/or serologically for current Schistosoma japonicum infections. In uncontrolled endemic areas (43 villages) the overall human prevalence of S. japonicum was 7.81% across the different geographical subtypes. The geometric mean intensity of infection was 17.71 eggs per gram (epg) among infected individuals and only 1.25 epg in the general population. The bovine prevalence, as determined by the hatching test, was 9.63% in the uncontrolled endemic villages. Only one sero-positive (by indirect hemagglutination assay) child was found among 1,072 children tested aged 10-14 years in the 9 endemic villages under effective control. No infection was confirmed by the Kato-Katz thick smear stool examination. When the results of this survey were compared to those seen at baseline (1989) an overall reduction of 45.65% was seen in the human prevalence but no significant change was apparent in the lake-beach ecotype. Additionally, there was more than a 60% reduction in the prevalence among bovines over the same sampling period. The results demonstrate that the World Bank Loan Schistosomiasis Program was successful in achieving its most basic objectives for this province - to reduce human and bovine infections by 40%.

Summer camps for diabetic children in Beijing of China.

The first summer camp for diabetic children was held in 1984 in Beijing. Since then we have held summer camp every year, the last summer camp was the fifth camp in 1988. The purpose of summer camps for diabetic children are to train the patients and increase the skills of diabetics self-control practice. The recreation activities are also important for their good communication and psychological adaptation. The campers of camps were 28-35 diabetic children, totally 154 participants consisting of 73 boys and 81 girls. Most of the children were 10-14 years old. The staffs include pediatricians, nurses and others. The ratio of campers with staffs were 2.7-3.2. The session of the camps were always of five days length. The characters of activities in camps were all the arrangements must be for diabetic children, included planning diet, insuring the urine sugar exam, insulin injection before each meal, and give some lectures for training the managed skills of diabetes, meanwhile the recreation programs and exercise were also a consisting portion of activations. The summer camps were beneficial for diabetic children. They learned many useful techniques of diabetes and their capacity of life adaptation were increased, and the self-confidence enhanced their future daily life.