Sex-related differences of fatty acid-binding protein 4 and leptin levels in atrial fibrillation.

AIMS: Adiposity plays a key role in the pathogenesis of atrial fibrillation (AF). Our aim was to study the sex differences in adipokines levels according to AF burden. METHODS AND RESULTS: Two independent cohorts of patients were studied: (i) consecutive patients with AF undergoing catheter ablation (n = 217) and (ii) a control group (n = 105). (i) Adipokines, oxidative stress, indirect autonomic markers, and leucocytes mRNA levels were analysed; (ii) correlation between biomarkers was explored with heatmaps and Kendall correlation coefficients; and (iii) logistic regression and random forest model were used to determine predictors of AF recurrence after ablation. Our results showed that: (i) fatty acid-binding protein 4 (FABP4) and leptin levels were higher in women than in men in both cohorts (P < 0.01). In women, FABP4 levels were higher on AF cohort (20 ± 14 control, 29 ± 18 paroxysmal AF and 31 ± 17 ng/mL persistent AF; P < 0.01). In men, leptin levels were lower on AF cohort (22 ± 15 control, 13 ± 16 paroxysmal AF and 13 ± 11 ng/mL persistent AF; P < 0.01). (ii) In female with paroxysmal AF, there was a lower acetylcholinesterase and higher carbonic anhydrase levels with respect to men (P < 0.05). (iii) Adipokines have an important role on discriminate AF recurrence after ablation. In persistent AF, FABP4 was the best predictor of recurrence after ablation (1.067, 95% confidence interval 1-1.14; P = 0.046). CONCLUSION: The major finding of the present study is the sex-based differences of FABP4 and leptin levels according to AF burden. These adipokines are associated with oxidative stress, inflammatory and autonomic indirect markers, indicating that they may play a role in AF perpetuation.

Utilidad del calcio arterial coronario para detectar enfermedad arterial coronaria significativa en sujetos asintomáticos / Usefulness of coronary artery calcium for detecting significant coronary artery disease in asymptomatic individuals

Objetivos: Confirmar el valor de la puntuación o score del calcio arterial coronario (CAC) como indicador de enfermedad arterial coronaria (EAC) significativa en población española asintomática, mediante coronariografía no invasiva por tomografía computarizada multidetector (TCMD). Métodos: Estudio retrospectivo de 232 individuos asintomáticos, remitidos para un chequeo de salud cardiovascular que incluyó CAC y TCMD. Resultados: La edad media de los sujetos estudiados fue de 54,6 años (DE: 12,8; 73,3% varones). El valor medio del CAC fue de 117,8 (DE: 277). Los individuos con hipertensión arterial, diabetes mellitus, tabaquismo y con ≥3 factores de riesgo mostraron un CAC significativamente mayor. Un 16,4% de los sujetos se encontraban en el percentil poblacional ≥75 de CAC. La TCMD identificó a 148 individuos (63,8%) con EAC, siendo las lesiones coronarias no significativas en 116 individuos (50%) y significativas (estenosis>50%) en 32 (13,8%). Los sujetos con diabetes, tabaquismo y ≥3 factores de riesgo vascular mostraron una mayor prevalencia de estenosis significativa. Los individuos con estenosis>50% presentaron valores de CAC superiores (352,5 vs. 1; p<0,0001) y los de percentil ≥75 presentaron un alto porcentaje de lesiones (57,9 vs. 5,2%; p<0,0001). Como variables predictoras de EAC significativa destacaron el CAC >300 (OR=10,9; IC95%: 3,35-35,8; p=0,0001), ocupar un percentil ≥75 (OR=5,65; IC95%: 1,78-17,93; p=0,03) y la agrupación de ≥3 factores de riesgo vascular (OR=4,19; IC95%: 1,44-12,14; p=0,008). Conclusión: La cuantificación del CAC es un método eficaz para determinar la extensión y magnitud de la EAC y delimitar la capacidad predictiva de los factores de riesgo tradicionales (AU)

Objectives: To confirm the value of the coronary artery calcium (CAC) score as an indicator of significant coronary artery disease (CAD) in the asymptomatic Spanish population, using noninvasive coronary angiography by multidetector computed tomography (MDCT). Methods: This was a retrospective study of 232 asymptomatic individuals, referred for a cardiovascular health checkup that included CAC and MDCT. Results: Participants’ mean age was 54.6 years (SD±12.8); 73.3% of them were men. The mean CAC value was 117.8 (SD±277). The individuals with arterial hypertension, diabetes mellitus, smoking and 3 or more risk factors had significantly greater CAC scores. Some 16.4% of the participants were in the ≥75 percentile population for CAC. The MDCT identified 148 individuals (63.8%) with CAD; the coronary lesions were not significant in 116 individuals (50%) and were significant (>50% stenosis) in 32 (13.8%). The participants with diabetes, smoking and ≥3 risk vascular factors had a greater prevalence of significant stenosis. The individuals with >50% stenosis had higher CAC values (352.5 vs. 1; P<.0001), and those in the ≥75 percentile had a high percentage of significant lesions (57.9% vs. 5.2%; P<.0001). The predictors of significant CAD were a CAC score >300 (OR=10.9; 95% CI 3.35-35.8; P=.0001), belonging to the ≥75 percentile (OR=5.65; 95% CI 1.78-17.93; P=.03) and having 3 or more vascular risk factors (OR=4.19; 95% CI 1.44-12.14; P=.008). Conclusion: CAC quantification is an effective method for determining the extent and magnitude of CAD and delimiting the predictive capacity of traditional risk factor (AU)

Usefulness of coronary artery calcium for detecting significant coronary artery disease in asymptomatic individuals.

OBJECTIVES: To confirm the value of the coronary artery calcium (CAC) score as an indicator of significant coronary artery disease (CAD) in the asymptomatic Spanish population, using noninvasive coronary angiography by multidetector computed tomography (MDCT). METHODS: This was a retrospective study of 232 asymptomatic individuals, referred for a cardiovascular health checkup that included CAC and MDCT. RESULTS: Participants' mean age was 54.6 years (SD ± 12.8); 73.3% of them were men. The mean CAC value was 117.8 (SD ± 277). The individuals with arterial hypertension, diabetes mellitus, smoking and 3 or more risk factors had significantly greater CAC scores. Some 16.4% of the participants were in the ≥75 percentile population for CAC. The MDCT identified 148 individuals (63.8%) with CAD; the coronary lesions were not significant in 116 individuals (50%) and were significant (>50% stenosis) in 32 (13.8%). The participants with diabetes, smoking and ≥3 risk vascular factors had a greater prevalence of significant stenosis. The individuals with >50% stenosis had higher CAC values (352.5 vs. 1; P<.0001), and those in the ≥75 percentile had a high percentage of significant lesions (57.9% vs. 5.2%; P<.0001). The predictors of significant CAD were a CAC score >300 (OR=10.9; 95% CI 3.35-35.8; P=.0001), belonging to the ≥75 percentile (OR=5.65; 95% CI 1.78-17.93; P=.03) and having 3 or more vascular risk factors (OR=4.19; 95% CI 1.44-12.14; P=.008). CONCLUSION: CAC quantification is an effective method for determining the extent and magnitude of CAD and delimiting the predictive capacity of traditional risk factors.

Evaluación del ventrículo izquierdo por ecocardiografia tridimensional. Comparación con la Cardio-RM / Evaluation of the left ventricle with three-dimensional echocardiography: comparison with cardiac magnetic resonance

Objetivo. La implantación de la ecocardiografia tridimensional (E3D) en el ámbito clínico está experimentando importantes avances. Sin embargo, la calidad de imagen depende de la ventana acústica, y puede ser difícil la identificación de los bordes endocárdicos. El objetivo de este estudio fue comparar la E3D en la determinación de los volúmenes y la fracción de eyección del ventrículo izquierdo en pacientes no seleccionados, usando la resonancia magnética cardiaca (RMC) como patrón de referencia. Material y métodos. A 47 pacientes no seleccionados sometidos a un estudio de RMC, se les practicó también una E3D mediante la técnica de adquisición en tiempo real y análisis con detección semiautomática de los bordes. Resultados. Se excluyeron 4 pacientes (8,5%) por tener una ventana acústica extremadamente deficiente. En el resto (43 pacientes), incluyendo aquellos con una ventana subóptima, se obtuvo una correlación aceptable entre la E3D y la RMC: volumen telediastólico: 0,71; volumen telesistólico: 0,77; fracción de eyección: 0,74. Aunque hubo una infraestimación sistemática del volumen telediastólico, no se observaron diferencias significativas en la determinación de la fracción de eyección. Al excluir los 11 pacientes con ventana subóptima, se observó una infraestimación sistemática de los volúmenes telediastólico y telesistólico, lo que dio lugar paradójicamente a una mejoría de los coeficientes de correlación (0,79, 0,92, 0,84), resultando más exacta la fracción de eyección. Conclusiones. En comparación con la RMC, la E3D infraestima sistemáticamente los volúmenes ventriculares, pero permite la determinación adecuada de la fracción de eyección ventricular izquierda independientemente de la ventana acústica (AU)

Objective. Three-dimensional echocardiography (3DE) is becoming increasingly common in clinical environments. However, the quality of the images depends on the acoustic window, and it can be difficult to identify the endocardial borders. The objective of this study was to evaluate the performance of 3DE in determining the volumes and left ventricular ejection fraction in unselected patients against the gold standard, cardiac magnetic resonance (CMR). Material and methods. In 47 unselected patients who underwent CMR, we performed 3DE using a real-time acquisition technique and semiautomatic border detection. Results. We excluded 4 patients (8.5%) because they had an extremely deficient acoustic window. In the remaining 43 patients, including those with a suboptimal acoustic window, we obtained the following correlations between 3DE and CMR: end-diastolic volume, 0.71; end-systolic volume, 0.77; ejection fraction, 0.74. Although the end-diastolic volume was systematically underestimated, no significant differences were observed in the ejection fraction. When the 11 patients with suboptimal acoustic windows were excluded, we observed a systematic underestimation of the end-diastolic and end-systolic volumes, which paradoxically gave rise to improved correlation coefficients (0.79, 0.92, and 0.84, respectively) and a more accurate ejection fraction. Conclusions. Compared to CMR, 3DE systematically underestimates the ventricular volumes but enables adequate determination of the left ventricular ejection fraction regardless of the quality of the acoustic window (AU)

Optimización en la técnica de medida de la presión arterial pulmonar por ecocardiografía Doppler con el uso de contraste en pacientes con enfermedad pulmonar obstructiva crónica / Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease

Objetivo Evaluar el beneficio del contraste en la ecocardiografía para medir la presión de arteria pulmonar sistólica (PAPs). Diseño Estándar de referencia (ecocardiografía) comparada con contraste. Ambito Gabinete de ecocardiografia. Pacientes Ambulatorio con enfermedad pulmonar obstructiva crónica (EPOC). Intervención La señal de la regurgitación tricuspidea (RT) por Doppler fue evaluada antes y después de administrar contraste intravenoso (Levovist(R)). Se definió una escala de 4 patrones de señal de RT: 0=ausencia de regurgitación; 1=señal protosistólica que no permite la medida de la velocidad pico; 2=señal de intensidad no homogénea pero que permite la medida de la velocidad pico y 3=señal uniforme y pansistólica. El valor de la PAPs fue estimado añadiendo 10mmHg al gradiente transtricuspideo. Resultados La PAPs fue calculada solo en 20 (49%) pacientes antes del contraste. Diecisiete pacientes fueron clasificados en el patrón 2 y 3 en el patrón 3 de la señal de la RT. Tras la administración de contraste 41 (95%) pacientes mostraron señal de RT. Dos fueron clasificados en el patrón 1, 11 con el patrón 2 y 28 con el 3. En los 20 pacientes en los que la PAPs fue estimada antes del contraste se observó aumento de su valor, 44±10mmHg vs. 56±15mmHg (p<0,01). Conclusión El uso de un agente de contraste intravenoso en la ecocardiografía Doppler aumenta el número de pacientes EPOC en los que la PAPs puede ser estimada de manera no invasiva y podría evitar una infraestimación del valor de la PAPs (AU)

Objective To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs). Design Compare standard reference (Doppler-echocardiography) with contrast. Location Echocardiography department. Patients Ambulatory chronic obstructive patient disease (COPD). Intervention Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10mmHg to the transtricuspid gradient, calculated from the TR peak velocity. Results PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10mmHg vs. 56±15mmHg (p<0.01). ConclusionThe use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value (AU)

[Evaluation of the left ventricle with three-dimensional echocardiography: comparison with cardiac magnetic resonance]. / Evaluación del ventrículo izquierdo por ecocardiografia tridimensional. Comparación con la Cardio-RM.

OBJECTIVE: Three-dimensional echocardiography (3DE) is becoming increasingly common in clinical environments. However, the quality of the images depends on the acoustic window, and it can be difficult to identify the endocardial borders. The objective of this study was to evaluate the performance of 3DE in determining the volumes and left ventricular ejection fraction in unselected patients against the gold standard, cardiac magnetic resonance (CMR). MATERIAL AND METHODS: In 47 unselected patients who underwent CMR, we performed 3DE using a real-time acquisition technique and semiautomatic border detection. RESULTS: We excluded 4 patients (8.5%) because they had an extremely deficient acoustic window. In the remaining 43 patients, including those with a suboptimal acoustic window, we obtained the following correlations between 3DE and CMR: end-diastolic volume, 0.71; end-systolic volume, 0.77; ejection fraction, 0.74. Although the end-diastolic volume was systematically underestimated, no significant differences were observed in the ejection fraction. When the 11 patients with suboptimal acoustic windows were excluded, we observed a systematic underestimation of the end-diastolic and end-systolic volumes, which paradoxically gave rise to improved correlation coefficients (0.79, 0.92, and 0.84, respectively) and a more accurate ejection fraction. CONCLUSIONS: Compared to CMR, 3DE systematically underestimates the ventricular volumes but enables adequate determination of the left ventricular ejection fraction regardless of the quality of the acoustic window.

[Improvement in the measurement technique of pulmonary artery pressure by Doppler echocardiography with contrast in chronic obstructive pulmonary disease]. / Optimización en la técnica de medida de la presión arterial pulmonar por ecocardiografía Doppler con el uso de contraste en pacientes con enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To evaluate the benefit of contrast echocardiography in the assessment of systolic pulmonary artery pressure (PAPs). DESIGN: Compare standard reference (Doppler-echocardiography) with contrast. LOCATION: Echocardiography department. PATIENTS: Ambulatory chronic obstructive patient disease (COPD). INTERVENTION: Continuous wave Doppler spectral signal of tricuspid regurgitation (TR) was evaluated before and after intravenous injection of a galactose-based intravenous echo-enhancing agent. A four patterns scale classified the quality of the TR signal: 0=absent regurgitation; 1=protosystolic signal not allowing the recognition of peak velocity; 2=non-homogenous signal intensity, albeit allowing the measurement of maximal velocity; and 3=uniform pansystolic velocity signal. PAPs was estimated adding 10 mm Hg to the transtricuspid gradient, calculated from the TR peak velocity. RESULTS: PAPs was only calculated reliably in 20 (49%) patients before the administration of contrast. Seventeen patients were classified as pattern 2, and three as pattern 3 on the scale of the TR quality signal. After contrast 41 (95%) patients showed a reliable TR signal. Two were classified as pattern 1, 11 as pattern 2 and 28 as pattern 3 on the scale of the TR quality signal. In the 20 patients in whom PAPs was estimated before contrast, a significant increase in PAPs values occurred after contrast, 44±10 mm Hg vs. 56±15 mm Hg (p<0.01). CONCLUSION: The use of an echocardiography contrast agent increases the number of COPD patients in whom PAPs can be estimated non-invasively and may avoid underestimation of the PAP value.

Correlation between myocardial fibrosis and the occurrence of atrial fibrillation in hypertrophic cardiomyopathy: a cardiac magnetic resonance imaging study.

Cardiac magnetic resonance imaging (CMR) in hypertrophic cardiomyopathy (HCM) often shows delayed contrast enhancement (DE) representing regions of focal myocardial fibrosis. Atrial fibrillation (AF) is a commonly reported complication of HCM. We determined the relationship between the presence of left ventricular myocardial fibrosis (LVMF) detected by DE-CMR and the occurrence AF in a series of patients with HCM. 67 patients with HCM (47 males; mean age 50.1+/-18.5 years) were studied by CMR measuring mass of LVMF, left ventricular mass, volume and function, and left atrial (LA) area. AF was present in 17 (25%) patients. LVMF was observed in 57% of patients. AF was significantly more frequent in patients who also showed LVMF, compared with the group without LVMF (42.1% vs. 3.4%, respectively; p<0.0001). LA size was larger in patients showing DE (LA area: 37.4+/-11.1 vs. 25.9+/-6.8 cm(2); respectively, p=0.0001). AF in HCM is related with myocardial fibrosis detected by DE-CMR and dilatation of the LA. This fact adds to the proven adverse prognostic value of myocardial fibrosis in HCM, thus, reinforcing the usefulness of this technique in the assessment of these patients.

Técnicas de imagen no invasivas del árbol coronario / Non-invasive imaging techniques of the coronary tree

El desarrollo tecnológico ha permitido soslayar demanera eficaz las dificultades que entrañaba elestudio no invasivo del árbol coronario, que son supequeño diámetro y su continuo movimiento. Lamejora en la resolución espacial y temporal dela cardio-tomografía computarizada conmultidetectores ha permitido incorporar estatécnica al arsenal diagnóstico de la enfermedadcoronaria con mejores resultados que las pruebasconvencionales. Su limitación principal es lanecesidad de emplear contraste y radiaciónionizante. La cardio-resonancia magnética permite,sin necesidad de contraste ni radiación, visualizarlos orígenes y los segmentos proximalescoronarios, lo que la convierte en la técnica dereferencia en centros experimentados ante lasospecha de una anomalía coronaria, incluso comotécnica de «chequeo» en poblaciones de riesgo dadasu inocuidad

The technological development has made it possibleto effectively evade the difficulties involved in thenon-invasive study of the coronary tree, which is itssmall diameter and continuous movement.Improvement in the spatial and temporal resolutionof the cardiac multidetector computed tomographyhas made it possible to incorporate this techniqueinto the diagnostic armamentarium of coronarydisease, with better results than the conventionaltests. Its principal limitation is the need to usecontrast and ionizing radiation. The cardiacmagnetic resonance makes it possible to visualizethe proximal coronary origins and segments withoutneeding to use contrast or radiation. This makes it areference technique in experienced sites when thereis suspicion of a coronary abnormality, even as a«verification» technique in at risk populations, giving that it is innocuous (AU)

PP2A regulates the pro-apoptotic activity of FOXO1.

FOXO1, a member of the evolutionarily conserved forkhead family of transcription factors, regulates expression of a number of genes that play critical roles in cell cycle and apoptosis. A pivotal regulatory mechanism of FOXO is reversible phosphorylation, catalyzed by kinases and phosphatases. Phosphorylation of FOXO1 is associated with 14-3-3 binding and cytosolic localization, whereas dephosphorylated FOXO1 translocates to the nucleus and is transcriptionally active. Experiments were performed to identify the serine/threonine phosphatase that dephosphorylates FOXO1. PP2A inhibitors, okadaic acid and fostriecin, increased FOXO1 phosphorylation in vitro and in cells. Microcystin-agarose pull-downs suggested that a phosphatase binds to FOXO1, and PP2A catalytic subunit was identified in endogenous FOXO1 immunocomplexes, indicating that PP2A is a FOXO1 phosphatase. Purified PP2A interacted directly with FOXO1 and dephosphorylated FOXO1 in vitro. Silencing of PP2A protected FOXO1 from dephosphorylation and delayed FOXO1 nuclear translocation, confirming the physiologic role of PP2A in the regulation of FOXO1 function. Furthermore, inhibition of PP2A phosphatases rescued FOXO1-mediated cell death by regulating the level of the pro-apoptotic protein BIM. We conclude that PP2A is a physiologic phosphatase of FOXO1.

[Non-invasive imaging techniques of the coronary tree]. / Técnicas de imagen no invasivas del árbol coronario.

The technological development has made it possible to effectively evade the difficulties involved in the non-invasive study of the coronary tree, which is its small diameter and continuous movement. Improvement in the spatial and temporal resolution of the cardiac multidetector computed tomography has made it possible to incorporate this technique into the diagnostic armamentarium of coronary disease, with better results than the conventional tests. Its principal limitation is the need to use contrast and ionizing radiation. The cardiac magnetic resonance makes it possible to visualize the proximal coronary origins and segments without needing to use contrast or radiation. This makes it a reference technique in experienced sites when there is suspicion of a coronary abnormality, even as a <> technique in at risk populations, giving that it is innocuous.

[Transthoracic echocardiography in stroke performed by neurologist: pilot study]. / Ecocardiografía transtorácica realizada por neurólogos en patología vascular: estudio piloto.

INTRODUCTION: The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke. METHODS: We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement. RESULTS: The 27 patients studied had a mean age of 68,7 +/- 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001). CONCLUSION: Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists.

Ecocardiografía transtorácica realizada por neurólogos en patología vascular: estudio piloto / Transthoracic echocardiopraphy in stroke performed by neurologist: pilot study

El objetivo de nuestro estudio es comparar la concordancia entre la ecocardiografía transtorácica (ETT) realizada por neurólogos y cardiólogos en el cribado de fuentes cardioembólicas en pacientes con isquemia cerebral. Métodos. Evaluamos de forma prospectiva y consecutiva 27 pacientes con isquemia cerebral. A todos se les realizó una ETT por un neurólogo que había sido entrenado previamente durante un mes en la técnica, e independientemente, por un cardiólogo cuyos resultados fueron considerados como la referencia estándar. Según el riesgo de cardioembolismo, los hallazgos en la ETT fueron clasificados como normales, de moderado o alto riesgo según los criterios TOAST. La concordancia en el diagnóstico de fuente cardioembólica entre ambos exploradores fue evaluado con el test Kappa de Cohen (K). Una K>0,6 se consideró como buena concordancia. Resultados. De 27 pacientes con isquemia cerebral, la edad media fue de 68,7 ± 10,2 años y 70 % fueron hombres. En 9 pacientes el cardiólogo detectó una fuente cardioembólica, y de ellos, 8 pacientes también por el neurólogo (1 paciente con calcificación del anillo mitral no fue detectado). En 2 pacientes con mala ventana ecocardiográfica, el neurólogo infraestimó la función ventricular. El diagnóstico fue concordante entre ambas exploraciones en un 88,9 % de los pacientes (K: 0,77; p = 0,001). Conclusiones. Comparado con el cardiólogo, un neurólogo entrenado realiza la ETT con una buena fiabilidad. En los casos con mala ventana ecocardiográfica o con hallazgos patológicos, éstos deberían ser confirmados por el cardiólogo (AU)

Introduction. The aim of this study is to assess concordance between transthoracic echocardiography (TTE) performed by neurologists and cardiologists for the screening of cardioembolic sources in patients with ischemic stroke. Methods. We examined prospectively 27 consecutive patients with ischemic stroke. A potential source of embolism in all of the patients was sought by means of a TTE study. This study was performed by one neurologist after one-month full-time training on the technique and independently by one cardiologist whose results were considered as the reference standard. Regarding the risk of cardioembolism, findings from TTE studies were considered as normal, or indicative of either moderate or high risk, according to the TOAST criteria. Agreement between the two observers on the diagnosis of cardioembolic source was analyzed with the Cohen's Kappa Test (K). A K > 0,6 was considered as good agreement. Results. The 27 patients studied had a mean age of 68,7 ± 10,2 years and 70 % were men. A cardioembolic source was detected in 9 patients by the cardiologist and 8 of these were also identified by the neurologist: in 1 patient a mitral annulus calcification was not detected in the examination performed by the neurologist. In 2 patients with poor echocardiographic window, the neurologist underestimated the left ventricular function. Diagnostic agreement between both examinations was 88,9 % (K: 0,77; p = 0,001). Conclusion. Compared with cardiologists, trained neurologists show a fairly high degree of accuracy in the TTE screening of patients with stroke. Those cases with poor echocardiographic window or with abnormal findings should be confirmed by the cardiologists (AU)

Design for a study to determine optimal dosage of ascorbic acid and alpha-tocopherol in humans.

Some clinical trials of vitamins C and E have neglected important design features. Our objective was to demonstrate a detailed design that includes essential elements for an effective study of these vitamins in vivo. While taking 400 IU (international units) of vitamin E, subjects took different dosages of vitamin C during three distinct periods. Dosages were 200 mg in food, 500 mg as supplements twice a day (500 × 2), and 1,000 mg as supplements twice a day (1000 × 2). Ten participants spent 3 weeks at each dosage before plasma was drawn on two consecutive days. Final samples were taken after a week with no supplementation. Selected by investigators at four institutions, endpoints were protein carbonyls, TBARs (thiobarbituric reactive substances), and Heinz body formation in RBCs (red blood cells). TBARs and protein carbonyls did not change significantly with dosage. However, Heinz body formation increased at either higher or lower intakes of vitamin C. Even with daily vitamin E, Heinz bodies were significantly fewer at 500 × 2. Results indicate that even with 400 IU vitamin E daily, it is possible to distinguish the effect of different levels of vitamin C with Heinz bodies. This effect may be due to pro-oxidant action of vitamin C or to prolonged survival of RBCs.

Stroke and pulmonary thromboembolism after a long flight.

In the economy class syndrome (ECS) the patient presents a deep venous thrombosis (DVT) with or without pulmonary thromboembolism (PTE) during or after a long trip as a result of prolonged immobilization. Economy class stroke syndrome is an infrequent ECS variant in which ischemic stroke is associated with a patent foramen ovale (PFO). Few cases have been published in the literature to date. We present a patient who suffered a PTE and an ischemic stroke immediately after a transoceanic flight. A 36-year-old woman with no significant medical or familial history flew economy class from Lima, Peru, to Madrid, Spain. On disembarkation she presented sudden dyspnea and a depressed level of consciousness, global aphasia, and right hemiparesis. A pulmonary scintigraphy showed a PTE and a cranial MRI revealed an ischemic infarct in the left middle cerebral artery territory. We simultaneously performed a transesophageal echocardiography and a transcranial Doppler and observed a massive right-to-left shunt through a PFO. The patient was a heterozygous carrier of the C46T mutation of coagulation factor XII. The appearance of a stroke following a long trip is suggestive of paradoxical embolism through a PFO, mainly if it is associated with a DVT and/or a PTE. The cause of the initial event, the DVT, could be a prothrombotic state.

Astrocytes in multiple sclerosis lack beta-2 adrenergic receptors.

BACKGROUND: In MS, T cells reactive to myelin proteins can cross the blood-brain barrier and release proinflammatory cytokines, such as interferon gamma. These can induce glial cells to express class II major histocompatibility complex (MHC) molecules, which are required to present myelin antigens to the T cells in order to mount a proper autoimmune response. Both microglia and astrocytes can function as antigen-presenting cells. In contrast to microglia, endogenous suppressors, including norepinephrine, regulate astrocytic class II MHC expression. The effects of norepinephrine are mediated through activation of P2 adrenergic receptors. OBJECTIVE: To investigate P, adrenergic receptors in astrocytes in MS. METHODS: Immunocytochemical techniques were applied in postmortem brain tissue from 10 patients with MS, three patients with a cerebral infarction, and six controls, and in spinal cord from three patients with ALS. RESULTS: beta2 adrenergic receptors were visualized on astrocytes in white matter of controls, and they were prominently expressed in reactive astrocytes at the boundary of cerebral infarctions and in the lateral corticospinal tract in ALS. In MS, beta2 adrenergic receptors could neither be visualized on astrocytes in normal-appearing white matter nor in reactive astrocytes in chronic active and inactive plaques, whereas they were normally present on neurons. MHC class II-positive astrocytes were only visualized in chronic active plaques. CONCLUSIONS: Because astrocytic beta2 adrenergic receptors are involved in suppressing inducibility of MHC class II molecules, we suggest that their lack of expression may play an important role in the induction or perpetuation of autoimmune reactions in MS.