Cardiac Imaging in Systemic Diseases: What the Clinician should Know.

IMPORTANCE: Systemic diseases that affect the cardiovascular system constitute a diagnostic and therapeutic challenge for all specialists involved; imaging tools along with clinical suspicion play an essential role in their evaluation. These entities share neurological, immunological, renal, hematologic, oncologic, infectious and endocrine processes, all of which may have associated cardiac involvement. OBSERVATIONS: Recent advances in cardiac ultrasound, Computed Tomography (CT), cardiac Magnetic Resonance (CMR) and nuclear scintigraphy have impacted the management of these conditions when involving the heart since they provide valuable anatomical and functional information while avoiding the use of invasive techniques. For this review, bibliographic sources were gathered from diverse databases, including PubMed, Cochrane, EBSCO and Google Scholar, concentrating on English language publications dealing with the clinical use of these tools. CONCLUSION: Clinical suspicion should always guide the use of imaging since in many instances, these techniques only play a supportive role rather than representing a diagnostic gold standard. Early diagnosis is critical due to the fact that cardiac manifestations are commonly a late phenomenon.

Effect of cilostazol on platelet reactivity among patients with peripheral artery disease on clopidogrel therapy.

BACKGROUND: Antiplatelet therapy with clopidogrel is recommended to reduce cardiovascular events in patients with peripheral artery disease (PAD); however, clopidogrel efficacy has not been adequately studied in this patient population. Therefore, we aimed to determine the effects of cilostazol therapy on platelet reactivity among PAD patients on clopidogrel. METHODS: We performed a cross-sectional pilot study of 46 Puerto Rican patients diagnosed with PAD. The cohort was divided based on use of clopidogrel and cilostazol (n=24) or clopidogrel alone (n=22). Platelet function was measured ex vivo using the VerifyNow P2Y12 assay. Genomic DNA was extracted from peripheral blood samples using the QIAamp DNA Blood Midi Kit, which was subjected to candidate variant genotyping (CYP2C19, ABCB1, PON1 and P2RY12) using TaqMan quantitative polymerase chain reaction assays. All analyses were performed using SAS version 9.4 (SAS Institute). RESULTS: Among all enrolled patients, 18 (39%) had high on-treatment platelet reactivity (HTPR). The mean platelet reactivity was 207±53 (range, 78-325) with higher P2Y12 reaction units in the non-cilostazol group, 224±45 vs. 191±55 on the cilostazol group (p=0.03). No significant differences were observed in the clinical or genetic variables between the two groups. A multiple regression analysis determined that history of diabetes mellitus (p=0.03), use of cilostazol (p=0.03) and hematocrit (p=0.02) were independent predictors of platelet reactivity. CONCLUSIONS: In Puerto Rican PAD patients on clopidogrel therapy, history of diabetes mellitus, use of cilostazol and hematocrit are independent predictors of platelet reactivity. Adjunctive cilostazol therapy may enhance clopidogrel efficacy among PAD patients with HTPR.

Activo distribution and paraphernalia among "street children" / Distribución del activo y la parafernalia entre "niños de la calle"

Abstract Introduction The use of solvent inhalants has been documented in Mexico since the 1970s. Nevertheless, very little is known about the distribution and use dynamics among "street children". Few have ventured to study this issue because of the difficulties involved in working with marginalized, relatively inaccessible populations. Objective To analyze the distribution and consumption dynamics of activo, as it is known among street children in downtown Mexico City, and to document the paraphernalia and argot associated with these practices. Method This is a qualitative, descriptive, and interpretative study guided by the "Meeting Place" approach used by Hughes (1977), which has been adapted to Mexican population by Ortiz (1979). We also used ethnographic observation techniques and a social and immersion mapping of street spaces that allowed us to contact and relate to both informants and users. Results We identified activo distributors and storage areas; user groups were made up of men and women in a 7-3 ratio; physical and psycho-social characteristics of sellers and users, and some street argot and paraphernalia that allowed us to understand the dynamics of distribution and consumption. Discussion and conclusion The activo market is both captive and hidden; it is detrimental to the physical and mental health of street children, and is fostered by social exclusion and the lack of legislation.

Resumen Introducción El consumo de solventes inhalables se ha documentado en México desde la década de 1970; sin embargo, poco se sabe sobre la dinámica de distribución y consumo entre los "niños de la calle". Este tema se ha estudiado poco por las dificultades inherentes al trabajo con poblaciones marginales y de difícil acceso. Objetivo Analizar la dinámica de distribución y consumo del "activo" entre los "niños de la calle" de la zona centro de la Ciudad de México, así como documentar la parafernalia y el argot asociados a estas prácticas. Método Es un estudio de tipo cualitativo, de carácter descriptivo-interpretativo, guiado por el enfoque llamado "Lugares de Reunión" empleado por Hughes (1977) y adaptado a población mexicana por Ortiz (1979). También se emplearon técnicas etnográficas de observación, mapeo social e inmersión en los espacios de calle, que sirvieron para contactar y establecer un vínculo con los informantes y consumidores. Resultados Se identifican distribuidores y zonas de almacenamiento del activo; grupos de consumidores formados por hombres y mujeres en una proporción de 7 a 3; signos físicos y características psicosociales de vendedores y usuarios, así como el argot y parafernalia; lo que permite comprender la dinámica de distribución y consumo. Discusión y conclusión El mercado del activo es cautivo y oculto, deteriora la salud física y mental de los "niños de la calle" y es promovido además por la exclusión social y la falta de legislación.

El consumo de solventes inhalables en la festividad de San Judas Tadeo / Solvent inhalants use in the San Judas Tadeo feast

INTRODUCCIÓN: A San Judas Tadeo se le considera en México el patrón de las causas difíciles y desesperadas. Entre las creencias populares, se piensa que los "niños en situación de calle" se acogen a él para que les proteja y ayude a dejar de consumir drogas. OBJETIVO: Conocer el espacio social del uso de solventes inhalables en el marco del culto a San Judas Tadeo, a partir las prácticas y experiencias vividas con los niños en situación de calle de la zona del Centro Histórico de la Ciudad de México. MÉTODO: Se aplicó la metodología conocida como "Lugares de Reunión" propuesta por Hughes y adaptada por Ortiz, en un periodo de trabajo que abarcó del año 2011 a inicios del 2014. Se utilizó la observación no participante y la participante, así como la entrevista no estructurada a informantes no calificados, a calificados y a clave. RESULTADOS: Se documentaron 22 celebraciones del día de San Judas incluyendo dos fiestas anuales. Se entrevistaron a más de 300 usuarios de solventes inhalables y los resultados mostraron, entre otras cosas, que la edad promedio es de 25 años, que se desempeñan en subocupaciones informales y a la mendicidad en la vía pública. Todos consumen activo, pero con diferencias en la intensidad, con periodos alternantes de consumos altos y bajos y consideran que es prácticamente imposible dejar de consumirlo. DISCUSIÓN Y CONCLUSIÓN: El vínculo entre el consumo de inhalables y el culto a San Judas Tadeo en los niños en situación de calle, es ficticio.

INTRODUCTION: San Judas Tadeo is the patron saint of the difficult and desperate causes. Among popular beliefs, it is supposed that street kids pray to him and that he helps them quit the use of drugs. OBJECTIVE: Understanding the phenomenon of the misuse of solvents in the context of the san Judas Tadeo festivity among street children living in the Historical Center zone of Mexico City. METHOD: The "Meeting places" methodology developed by Hughes and adapted by Ortiz was applied from 2011 to 2014. Non-participant and participant observations, as well as unstructured and structured interviews to key informants were conducted. RESULTS: Twenty-two festivities of san Judas Tadeo were documented, and more than 300 solvent users were interviewed. The average age was 25 years. They were unemployed and begged for money. All of them were activo users which they administered with monas. They usually did it in binge patterns: use - non use, high - low use. DISCUSSION AND CONCLUSION: The link between the consumption of inhalants and the cult of St. Jude in children living in the streets is fictitious.

Calidad de imagen y dosis de radiación de la angiografía coronaria por tomografía computada multidetector con técnica de adquisición axial con gatillado prospectivo / Imaging quality and effective radiation dose of prospective ECG-gated axial multidetector row computed tomography coronary angiography Objective

Objetivo. Determinar la calidad de imagen y la dosis de radiación efectiva (DRE) de la angiografía coronaria por tomografía computada con adquisición con gatillado prospectivo (ACTC-P) en comparación con la técnica de adquisición con gatillado retrospectivo (ACTC-R). Materiales y Métodos. Cuarenta y cinco estudios de ACTC-P fueron analizados en forma retrospectiva para la valoración de la calidad de imagen y DRE, y se compararon con 90 estudios de ACTC-R realizados sin (n = 45) y con (n = 45) modulación de la corriente del tubo de rayos X seleccionados de la base de datos acorde a características demográficas similares. La DRE se comparó entre los tres grupos. La calidad de imagen fue analizada en forma independiente por dos observadores y comparada con el grupo de ACTC-R modulada. Se determinó también la variabilidad interobservador. Resultados. No hubo diferencias significativas en la calidad de imagen entre los dos grupos. La variabilidad interobservador fue k=0,92 (IC 95%: 0,87 a 0,96). La DRE (media ± DS) de la ACTC-P fue 2,88 ± 0,37 mSv comparado con 10,50 ± 1,15 mSv (p < 0,0001) de la ACTC-R sin modulación de la corriente del tubo de rayos X y 7,92 ± 0,99 mSv (p < 0,0001) de la ACTC-R con modulación. Conclusiones. Nuestra experiencia utilizando la ACTC-P demostró que es una técnica de adquisición de imágenes adecuada para pacientes con ritmo cardíaco regular y una frecuencia cardíaca estable, lograndouna sustancial reducción en la DRE y una calidad de imagen comparable a las obtenidas con ACTC-R.

To determine the imaging quality and effective radiation dose (ERD) of prospective ECG-gated multidetector row computed tomography coronary angiography (PMDCT-CA) compared to retrospective ECG-gating (RMDCT-CA). Materials and Methods. Forty-five PMDCT-CA scans were retrospectively reviewed for assessing imaging quality and ERD, and compared to 90 RMDCT-CA scans performed with (n= 45) and without (n= 45) tube current modulation, selected from our database on the basis of similar demographical characteristics. ERD was compared between all three groups. Imaging quality was assessed by two independent observers and compared to the imaging quality of the group of RMDCT-CA scans performed with tube current modulation. The interobserver variability was also determined. Results. There were no significant differences in imaging quality between the two groups. Interobserver variability was k=0.92 (95 % CI: 0.87-0.96). The ERD (mean ± SD) using PMDCT-CA was 2.88 ± 0.37 mSv compared to 10.50 ± 1.15 mSv (p<0.0001) using RMDCT-CA performed without tube current modulation and 7.92 ± 0.99 mSv (p<0.0001) using RMDCT-CA with tube current modulation. Conclusions. In our experience, PMDCT-CA proved to be an adequate imaging acquisition technique for selected patients with regular heart rhythm and a stable heart rate, with a substantial reduction in ERD and an image quality comparable to that of RMDCT-CA.

Accuracy of low-dose prospectively gated axial coronary CT angiography for the assessment of coronary artery stenosis in patients with stable heart rate.

BACKGROUND: Desirable methods for cardiac CT angiography would both reduce radiation exposure from cardiac CT angiography and preserve accuracy. OBJECTIVES: We assessed image quality, radiation dose, and diagnostic accuracy of a low-dose, prospectively gated axial cardiac CT angiography protocol for the evaluation of patients with suspected coronary artery disease (CAD). METHODS: Fifty consecutive patients referred for diagnostic invasive coronary angiography (ICA) and with a stable heart rate < 60 beats/min after beta-blocker administration were prospectively enrolled in a single center study. Subjects underwent CT angiography with a 64-row multidetector CT scanner with a prospectively gated axial imaging protocol. If the examination was determined to be nondiagnostic, then a retrospectively gated helical scan was performed. Two reviewers independently assessed image quality and the presence of significant coronary artery stenosis (>50%). RESULTS: Prospectively gated CT angiography was successfully performed in 46 of 50 patients. Of 794 coronary segments, 777 were determined to be of diagnostic image quality. The overall patient-based sensitivity (95% CI), specificity, positive predictive value, negative predictive value, and accuracy for the diagnosis of significant coronary stenosis were 100% (87%-100%), 75% (53%-90%), 81% (64%-93%), 100% (81%-100%), and 88% (81%-95%), respectively. The mean effective radiation dose for CT angiography and ICA were 3.4 +/- 0.4 mSv and 6.9 +/- 0.8 mSv, respectively. CONCLUSIONS: Cardiac CT angiography performed in a prospectively gated axial mode with 64-row multidetector CT provides an accurate, low-dose alternative for the detection of CAD.

Feasibility of 64-slice gadolinium-enhanced cardiac CT for the evaluation of obstructive coronary artery disease.

OBJECTIVE: To assess the feasibility of gadolinium-enhanced 64-slice cardiac CT (CCT) for the diagnosis of obstructive coronary artery disease. DESIGN: Comparative prospective study. SETTING: Outpatient Imaging Diagnostic Centre, Diagnóstico Maipú, Buenos Aires, Argentina. PATIENTS: Twenty patients with suspected coronary artery disease. INTERVENTIONS: Gadolinium-enhanced 64-slice CCT was performed before invasive coronary angiography (ICA). MAIN OUTCOME MEASURES: The feasibility of gadolinium-enhanced 64-slice CCT for detection of obstructive coronary artery disease (>50% diameter reduction) was evaluated, using ICA as the 'gold standard'. Mean lumen attenuation, non-calcified and calcified plaques densities were correlated between gadolinium-enhanced CCT studies and iodine-enhanced CCT studies of a control group. Renal function was strictly monitored. RESULTS: Gadolinium-enhanced CCT demonstrated adequate visualisation of 283/289 coronary segments that were evaluable by ICA, 31 of which had >50% luminal stenosis. In per-segment analysis, gadolinium-enhanced CCT showed a sensitivity of 90.3%, specificity of 96.8%, positive predictive value of 77.8% and negative predictive value of 98.8%. The agreement of coronary stenosis between multidetector CT (MDCT) and ICA was 94.1% (272/289). The mean lumen attenuation, non-calcified and calcified plaques densities in gadolinium-enhanced CCT studies were 140.1 Hounsfield units (HU), 51.1 HU and 523.6 HU, whereas in iodine-enhanced CCT studies the values were 354.1 HU, 101.0 HU and 778.5 HU, respectively (p < 0.001). CONCLUSION: Gadolinium-enhanced CCT is a feasible alternative for patients with severe contraindications to iodinated contrast agents referred for MDCT coronary angiography.

Angiografía coronaria por tomografía computarizada multidetector con gatillado electrocardiográfico prospectivo: análisis de la calidad de imagen y de la dosis de radiación / Prospective Electrocardiogram-Gated Multidetector Row Computed Tomography Coronary Angiography: analysis of Quality Image and Radiation Dose

Introducción La angiografía coronaria por tomografía computarizada multidetector (ACTCM) se ha convertido en una herramienta diagnóstica útil para la cuantificación directa de la estenosis coronaria, la identificación de anomalías coronarias y la evaluación de bypass. Pese a que su valor clínico en ocasiones se ve cuestionado debido a la dosis de radiación efectiva (DRE) que recibe cada paciente, ésta no es mayor que la de otros estudios. No obstante, es motivo de permanente preocupación la búsqueda de diferentes estrategias para reducir la DRE sin detrimento de la calidad de imagen y de la certeza diagnóstica. Objetivos Determinar la calidad de imagen y la dosis de radiación efectiva (DRE) de los estudios de angiografía coronaria por tomografía computarizada multidetector realizados con gatillado electrocardiográfico prospectivo (ACTCM-P) (emisión de radiación sincronizada con la fase diastólica) en comparación con la técnica de adquisición con gatillado retrospectivo (ACTCMR) (emisión durante todo el ciclo cardíaco) y, en forma preliminar, su certeza diagnóstica en relación con la cinecoronariografía digital invasiva (CCG). Material y métodos Cincuenta pacientes consecutivos con sospecha de enfermedad coronaria y ritmo sinusal fueron estudiados con ACTCM-P y comparados con un grupo control al que se le realizó una ACTCM-R. La calidad de imagen fue analizada por dos observadores. Se determinaron la concordancia interobservador y la DRE. En 30 pacientes se evaluó la certeza diagnóstica de la ACTCM-P para la detección de estenosis > 50% en comparación con la CCG. Resultados No hubo diferencias significativas en la calidad de imagen entre los dos grupos. La concordancia interobservador fue: k = 0,92. La DRE media de la ACTCM-P fue de 3,5 mSv en comparación con 12,9 y 9,7 mSv de la ACTCM-R sin modulación del tubo de rayos X y con ella, respectivamente. En el análisis por paciente incluyendo todos los segmentos, la sensibilidad, la especificidad y el valor predictivo positivo y negativo de la ACTCM-P para la detección de estenosis fueron del 94,74%, 81,82%, 90% y 90%, respectivamente. Conclusión Nuestra experiencia inicial demostró que la ACTCM-P brinda una reducción sustancial de la DRE con una calidad de imagen comparable a la de la ACTCM-R en una población seleccionada.

Background Multidetector row computed tomography coronary angiography (MDCT-CA) has become a useful diagnostic tool for the direct quantification of coronary stenosis, for identifying coronary anomalies and for the assessment of coronary artery bypass grafts. Despite its clinical value has been questioned due to the effective radiation dose (ERD) received by each patient, radiation exposure is similar to other studies. However, different strategies are permanently tested in order to reduce the ERD maintaining adequate and diagnostic image quality. Objectives To determine the image quality and effective radiation dose (ERD) of prospective electrocardiogram-gated multidetector row computed tomography coronary angiography (PMDCTCA) (the x-ray beam is turned on for only a short portion of diastole) compared to retrospective ECG gating (RMDCTCA) (the x-ray beam is turned on throughout the cardiac cycle) and a preliminary approach of its diagnostic accuracy compared to digital invasive coronary angiography (CA). Material and Methods Fifty consecutive patients with suspected coronary artery disease and sinus rhythm were evaluated with PMDCT-CA and compared to a control group who underwent RMDCTCA. Image quality was analyzed by two reviewers. Interobserver concordance and ERD were determined. The diagnostic accuracy of PMDCT-CA compared to CA to detect coronary artery stenosis > 50% was assessed in 30 patients. Results There were no significant differences in the image quality between both groups. Agreement between the reviewers for segment image quality scores was k = 0.92. Mean ERD was 3.5 mSv for PMDCT-CA compared to 9.7 and 12.9 mSv for RMDCT-CA with and without tube current modulation, respectively. Individual analysis including all segments showed that the sensitivity, specificity, positive predictive value and negative predictive value of PMDCT-CA for the detection of coronary stenosis were 94.74%, 81.82%, 90% and 90%, respectively. Conclusion Our initial experience demonstrated that PMDCT-CA has similar subjective image quality scores with a substantial reduction of ERD when compared to RMDCT-CA in a selected population.

Certeza diagnóstica de la tomografía computarizada multicorte para la detección de la vasculopatía del injerto cardiaco: comparación con angiografía coronaria invasiva y ecografía intravascular / Accuracy of multidetector row computed tomography for the detection of transplant vasculopathy: comparison with invasive coronary angiography and intravascular ultrasound

Objetivo: Evaluar la certeza diagnóstica de la tomografía computarizada multicorte (TCM) en pacientes trasplantados cardiacos para la detección de estenosis coronaria y vasculopatía del injerto cardiaco (VDI) en comparación con la angiografía coronaria (AC) y la ecografía intravascular (EIV), respectivamente. Material y métodos: Diecinueve pacientes trasplantados cardiacos fueron estudiados con angiografía coronaria por TCM entre 7 a 14 días después del cateterismo (AD y EIV). Los estudios se llevaron a cabo con un tomógrafo multicorte de 16 filas. Dos observadores evaluaron en forma ciega los estudios de TCM para la detección de estenosis coronaria >50% y VDI. Resultados: Para la detección de estenosis coronaria >50%, la sensibilidad fue: 80-88% y la especificidad: 98- 99%; para la detección de VDI, 91-96% y 88-98%, respectivamente. Conclusión: En esta serie preliminar, nuestros resultados mostraron que la TCM fue una técnica adecuada para evaluar pacientes trasplantados cardiacos y podría ser una alternativa a la AD y EIV para el seguimiento y control no invasivo de estos pacientes.

Objective: To evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) for detection of luminal stenosis and cardiac allograft vasculopathy in comparison with coronary angiography (CA) and intravascular ultrasound (IVUS) respectively. Material and methods: Nineteen cardiac transplant patients scheduled for follow-up CA were included. MDCT coronary angiography was performed using a 16-row CT scanner within 7-14 days after CA and IVUS. Studies were analyzed by independent readers; two observers evaluated the CT datasets for the presence of coronary artery stenosis >50% and allograft vasculopathy. Results: The sensitivity for detecting >50% luminal stenosis was 80-88% and specificity, 98-99% and for detection of cardiac allograft vasculopathy, the sensitivity was 91-96% and specificity, 88-91%. Conclusion: In this preliminary series, our results indicate that MDCT coronary angiography was capable of detecting both significant coronary stenosis as well as diffuse intimal proliferation. This non-invasive procedure could be an alternative to CA and IVUS in the surveillance of heart transplant patients.

Feasibility of gadolinium-diethylene triamine pentaacetic acid enhanced multidetector computed tomography for the evaluation of coronary artery disease.

BACKGROUND: Multidetector computed tomography (MDCT) has been proposed as a noninvasive method for the diagnosis of obstructive coronary artery disease (CAD). In patients with high risk of iodinated contrast adverse effects such as acute allergic-type reactions, the use of gadolinium could be an alternative. OBJECTIVE: We sought to evaluate the feasibility of gadolinium-enhanced MDCT for the diagnosis of obstructive CAD. METHODS: Twenty patients (mean age, 61 years; range, 50-73 years) referred for X-ray coronary angiography were studied by both gadolinium and iodine-enhanced 16-row MDCT coronary angiography. The degree of enhancement and the accuracy for detection of obstructive CAD (>50% diameter reduction) were evaluated with X-ray coronary angiography as the standard. Renal nephrotoxicity was strictly monitored. RESULTS: Gadolinium- and iodine-enhanced MDCT showed adequate visualization of the coronary arteries in 310 of the 312 coronary artery segments that were available by X-ray angiography, respectively. The average density of the coronary arteries in both iodine and gadolinium CT scans was 253.65 Hounsfield unit (HU) and 135.20 HU, respectively. In a per-coronary segment analysis, gadolinium- and iodine-enhanced MDCT showed sensitivities of 89% vs 84%, specificities of 96% vs 95%, and negative predictive values of 97% vs 96%, respectively. In a per-patient analysis, both gadolinium- and iodine-enhanced MDCT showed sensitivities of 92.85% vs specificities of 83.33%. Intermethod agreement between gadolinium- and iodine-enhanced MDCT (kappa) was 0.95 (P < 0.0001). CONCLUSION: Our preliminary results indicate lower attenuation with gadolinium but similar diagnostic accuracy for the detection of obstructive CAD when compared with iodine-enhanced MDCT. Therefore, gadolinium is a feasible alternative contrast agent for patients with iodine contrast allergy referred for MDCT coronary angiography.

Incidencia de nausea y dolor transoperatorio bajo diferentes tecnicas de anestesia regional en cesarea / Incidence of nausea and transoperative pain in several regional anesthesia techniques for cesarea

El presente trabajo es un estudio de cohorte prospectivo, realizado en el Hospital Ramón González Valencia de Bucaramanga, con una muestra de 260 pacientes que fueron llevadas a cesárea bajo anestesia regional, entre junio del 99 y enero del 2002. El objetivo del estudio fue comparar la incidencia de Náusea, Vómito, Prurito, Hipotensión y Dolor a la limpieza del peritoneo, durante el transoperatorio en grupos de pacientes organizados de acuerdo con la técnica anestésica utilizada. Se encontraron diferencias importantes y significativas en la incidencia de Dolor a la limpieza del peritoneo cuando se comparan técnicas subaracnoideas con técnicas peridurales, y disminución de la incidencia de náusea transoperatoria con el uso de fentanyl intratecal