Circulating Interleukin-22 in Patients with Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention.

Acute coronary syndrome (ACS) represents an important clinical manifestation of coronary artery disease (CAD) and is characterized by a particularly poor prognosis. Myocardial reperfusion through primary percutaneous coronary intervention (PPCI) is imperative in the event of acute ST elevation myocardial infarction (STEMI). Interleukin-22 (IL-22) regulates immune and inflammatory responses. This interleukin has been described in the scenario of the CAD, but there are no data in patients with STEMI undergoing PPCI. Objectives: The goals of this study were to investigate the differences in circulating IL-22 levels between patients with STEMI undergoing PPCI and healthy controls and to determine whether these differences were associated with the culprit coronary artery, door-to-balloon time (DBT), final angiographic result, CAD classification, and presence of diabetes mellitus (DM). Methods: A total of 280 participants were recruited, comprising 210 STEMI cases and 70 healthy controls. Participants underwent clinical and angiographic evaluations, and serum IL-22 levels were measured using an enzyme-linked immunosorbent assay (ELISA). Data analysis was performed using the Mann-Whitney and Fisher tests, with p < 0.05 indicating significance. Results: Serum IL-22 levels were lower in cases (149.63, 84.99-294.56) than in the controls (482.67, 344.33-641.00); p < 0.001. Lower IL-22 levels were associated with the right coronary artery (RCA) (144.57, 70.84-242.43; 146.00, 63.60-279.67; 191.71, 121.80-388.97); p = 0.033. IL-22 was lower with shorter DBT (≤60 min, 106.00, 49.60-171.71; >60 min, 153.00, 88.86-313.60); p = 0.043. Conclusions: IL-22 levels were significantly lower in patients with STEMI than in healthy controls.

Potentially avoidable hospitalizations and associated factors among older people in French Guiana using the French National Health Data System.

Knowing the prevalence of potentially avoidable hospitalizations (PAHs) and the factors associated with them is essential if preventive action is to be taken. Studies on PAHs mainly concern adults, and very few have been carried out in South America. To the best of our knowledge, there has been no study on PAHs in French Guiana, particularly among older adults. This case-control study aimed to estimate the prevalence of PAHs in the Guianese population aged over 65 and to analyze their associated factors. We used the 2017-2019 data from the French National Health Service database (Système National des Données de Santé). The patients were age- and sex-matched 1 : 3 with controls without any PAH in 2019. Factors associated with PAHs were investigated through two conditional logistic regression models [one including the Charlson comorbidity index (CCI) and one including each comorbidity of the CCI], with calculation of the adjusted odds ratio (aOR) and 95% confidence interval (CI). The PAH incidence was 17.4 per 1000 inhabitants. PAHs represented 6.6% of all hospitalizations (45.6% related to congestive heart failure or hypertension). A higher CCI was associated with PAHs [aOR 2.2 (95% CI: 1.6, 3.0) and aOR 4.8 (95% CI: 2.4, 9.9) for 1-2 and ≥3 comorbidities, respectively, versus 0], as was immigrant health insurance status [aOR 2.3 (95% CI: 1.3, 4.2)]. Connective tissue disease, chronic pulmonary disease, congestive heart failure, diabetes, and peripheral vascular disease were comorbidities associated with an increased risk of PAHs. While the prevention of PAHs among immigrants is probably beyond the reach of the Guianese authorities, primary care and a public health policy geared toward prevention should be put in place for the French Guianese population suffering from cardiovascular disease in order to reduce PAHs.

Scorpion-Induced Acute Coronary Syndrome: A Stinging Complication.

The Tityus trinitatis, a black scorpion species endemic to the fauna of Trinidad, has been implicated in envenomation with devastating clinical sequelae such as acute pancreatitis and major adverse cardiovascular events. We present the first in-Caribbean case of a 59-year-old Caribbean South Asian male with human immunodeficiency virus who presented with a non-ST-segment-elevation acute coronary syndrome after being stung, which was managed with comprehensive, guideline-directed medical therapy. The clinician should be cognizant of scorpion-induced acute coronary syndrome (ACS) as a potential sequela of envenomation and its clinical management.

The South African Flag Sign: An Electrocardiographic Flag for All Coronary Territories?

The South African flag sign (SAFS) is an acute, dynamic electrocardiographic (ECG) finding typically associated with first diagonal (D1) artery occlusion. We report the case of a 47-year-old woman who exhibited this pattern but subsequently revealed the dreaded "widow-maker" lesion (100% occluded proximal left anterior descending [LAD] artery) and severe multivessel disease (90% stenosis of the posterior left ventricular [PLV] artery and 80% stenosis of the left circumflex artery [LCx]).

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator is not reliable in predicting complications and length of stay after primary total hip arthroplasty at an institution implementing clinical pathways.

INTRODUCTION: The authors aimed to: (1) determine how length of stay (LOS) and complication rates changed over the past 10 years, in comparison to values estimated by the ACS-NSQIP surgical risk calculator, at a single private institution open to external surgeons; and (2) determine preoperative patient factors associated with complications. METHODS: We retrospectively assessed 1018 consecutive patients who underwent primary elective THA over 10 years. We excluded 87 with tumours and 52 with incomplete records. Clinical data of the remaining 879 were used to determine real LOS and rate of 9 adverse events over time, as well as to estimate these values using the risk calculator. Its predictive reliability was represented on receiver operating characteristic curves. Multivariable analyses were performed to determine associations of complications with age, sex, ASA score, diabetes, hypertension, heart disease, smoking and BMI. RESULTS: Over the 10-year period, real LOS and real complication rates decreased considerably, while LOS and complication rates estimated by the surgical risk calculator had little or no change. The difference between real and estimated LOS decreased over time. The overall estimated and real rates of any complication were respectively 3.3% and 2.8%. The risk calculator had fair reliability for predicting any complications (AUC 0.72). Overall estimated LOS was shorter than the real LOS in 764 (86.9%) patients. Multivariable analysis revealed risks of any complication to be greater in patients aged ⩾75 (OR = 4.36, p = 0.002), and with hypertension (OR = 3.13, p = 0.016). CONCLUSIONS: Since the implementation of clinical pathways at our institution, real LOS and complication rates decreased considerably, while LOS and complication rates estimated by the surgical risk calculator had little or no change. The difference between real and estimated LOS decreased over time, which could lead some clinicians to reconsider their discharge criteria, knowing that advanced age and hypertension increased risks of encountering complications.

Long-term mortality after acute coronary syndromes among patients with normal, mildly reduced, or reduced ejection fraction.

AIMS: Left ventricular ejection fraction (LVEF) ≤ 40% is a well-established risk factor for mortality after acute coronary syndromes (ACS). However, the long-term prognostic impact of mildly reduced ejection fraction (EF) (LVEF 41-49%) after ACS remains less clear. METHODS AND RESULTS: This was a retrospective study enrolling patients admitted with ACS included in a single-centre databank. LVEF was assessed by echocardiography during index hospitalization. Patients were divided in the following categories according to LVEF: normal (LVEF ≥ 50%), mildly reduced (LVEF 41-49%), and reduced (LVEF ≤ 40%). The endpoint of interest was all-cause death after hospital discharge. A multivariable Cox model was used to adjust for confounders. A total of 3200 patients were included (1952 with normal EF, 375 with mildly reduced EF, and 873 with reduced EF). The estimated cumulative incidence rates of mortality at 10 years for patients with normal, mildly reduced, and reduced EF were 24.8%, 33.5%, and 41.3%, respectively. After adjustments, the presence of reduced EF was associated with higher mortality compared with normal EF [adjusted hazard ratio (HR) 1.64; 95% confidence interval (CI) 1.36-1.96; P < 0.001], as was mildly reduced EF compared with normal EF (adjusted HR 1.33; 95% CI 1.05-1.68; P = 0.019). The presence of reduced EF was not associated with a statistically significantly higher mortality compared with mildly reduced EF (adjusted HR 1.23; 95% CI 0.96-1.57; P = 0.095). CONCLUSIONS: In patients with ACS, mildly reduced EF measured in the acute phase was associated with higher long-term mortality compared with patients with normal EF. These data emphasize the importance of anti-remodelling therapies for ACS patients who have LVEF in the mildly reduced range.

A Closer Look at the HEART Score.

The history, electrocardiogram, age, risk factors, and troponin (HEART) score is currently a widely used tool for acute chest pain risk stratification. Relatively soon after its inception in 2008, a number of validation studies on the HEART score showed it to be superior to Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores and at least as accurate to other existing scores for predicting short-term major adverse cardiovascular events (MACEs). However, partly due to its focus on simplicity, the HEART score has some limitations. In this article we review how the HEART score has evolved and taken on various modifications to circumvent some of its limitations. We also highlight the strength of the HEART score in comparison with other risk stratification tools and the current guidelines.

Clinical and economic impact of coronary artery bypass graft and percutaneous coronary intervention in young individuals with acute coronary syndromes and multivessel disease: A real-world comparison in a middle-income country.

Background: In recent decades, the world watched a dramatic increase in the incidence of acute coronary syndromes (ACS) among young individuals (≤55 years-old) and a relative decrease in the elderly. The management of ACS in young patients with multivessel disease still needs to be elucidated, as these individuals maintain a long life expectancy. Research Question: To compare clinical outcomes and care costs in individuals with premature ACS and multivessel disease undergoing coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). Methods and Results: Participants included all individuals ≤55 years-old admitted with ACS to public hospitals in Brasília (Brazil) between 2013 and 2015 and who underwent cardiac catheterization with SYNTAX score ≥23 or Duke category 6. Outcomes were adjudicated with death certificates and data from medical records. The primary outcome was the occurrence of major adverse cardiovascular events (MACE), defined as death due to cardiovascular causes, recurrent hospitalizations due to cardiovascular ischemic events, and incident heart failure New York Heart Association III-IV. As secondary outcome we assessed indirect and direct costs by evaluating the cost of lost productivity (in international dollars (Int$) per year) due to illness and death, outpatient costs and costs with new hospitalizations. Multivariate and principal components (PC) adjusted analyzes were performed. Results: Among 1,088 subjects (111 CABG and 977 PCI) followed for 6.2 years (IQR: 1.1), 304 primary events were observed. MACE was observed in 20.7% of the CABG group and 28.8% of the PCI group (p = 0.037). In multivariate analyses, PCI was associated with a hazard ratio (HR) = 1.227 (95% CI: 1.004-1.499; p = 0.0457) for MACE, and in PC-adjusted HR = 1.268 (95% CI: 1.048-1.548; p = 0.0271) compared with CABG. Despite direct costs were equivalent, the cost due to the loss of labor productivity was higher in the PCI group (Int$ 4,511 (IQR: 18,062)/year vs Int$ 3,578 (IQR: 13,198)/year; p = 0.049], compared with CABG. Conclusions: Among young individuals with ACS and multivessel disease, surgical strategy was associated with a lower occurrence of MACE and lower indirect costs in the long-term.

Ultra-Low Oxygen and Preconditioning Storage Regulate Ethylene Synthesis to Prevent Corky Disorders in 'Fuji' Apple.

Corky disorders in apples represent a significant problem for long-term storage where controlled atmosphere (CA) is mainly used. Ultra-low oxygen (ULO) is an alternative to CA, which consists of low partial pressure of O2 to maintain a low metabolism in the apple fruit, achieving an effective decrease in the ethylene production and physiological disorders. The aim of this research was to study the effectiveness of a short hypoxia period on the development of cork physiological disorders during the storage of apple. 'Fuji' apples were prestored under ULO (0.5 kPa O2) for two periods of time (15 and 30 days) and at two temperatures (0 or 5°C). Corky physiological disorders increased at 5°C prestorage temperature; however, ULO treatments for 15 or 30 days at 0 or 5°C achieved a significant reduction in corky disorders near to 1%, compared with control treatments. In addition, a considerable reduction in ethylene production for up to 30 days was observed in ULO-treated fruit at 0 and 5°C. ULO for 30 days at 0 and 5°C increased the internal production of ethanol and acetaldehyde, causing a lower sensory quality due to the presence of fermentative flavors in fruit stored at 5°C. ULO of 15 days of conditioning decreased the relative expression of ethylene biosynthesis genes MdACS1 and MdACO1, resulting in lower ethylene production.

Application and validation of a surgical risk calculator in a liver surgery cohort of patients in Veracruz, Mexico.

OBJECTIVE: Multiple models have tried to predict the morbidity and mortality of liver resections (HR). This study aims to determine the efficacy and validity of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator in a cohort of patients undergoing HR in Veracruz, Mexico. MATERIAL AND METHODS: Retrospective analysis of patients undergoing HR between 2005 and 2019. To estimate the performance of the calculator, the observed results were compared with the average risk predicted by the calculator, using ROC curve, Brier score and Z test. RESULTS: 67 patients were evaluated, mean age 51.9 years of age, 50.7% female. The majority of resections (56.7%) were for malignancy and 62.1% were partial hepatectomies (up to 3 liver segments). The morbidity was 25.4% and the mortality 4.5%. There was a good prediction in the complications (serious complication: C = 0.725 statistic, Brier score 0.26, p = 0.006 and any statistical complication C = 0.731, Brier score 0.33, p = 0.005) and mortality (C = 0.922 statistic, Brier score 0.005, p = 0.014). CONCLUSIONS: The application of the ACS-NSQIP calculator in patients undergoing HR has good discrimination power and good predictive ability. Prediction of postoperative risks achieves a preoperative planning of the appropriate procedure.

OBJETIVO: Múltiples modelos han intentado predecir la morbilidad y mortalidad de las resecciones hepáticas (RH). Este estudio tiene por objetivo determinar la eficacia y validez de la calculadora de riesgo quirúrgico del American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) en una cohorte de pacientes sometidos a RH en Veracruz, México. MATERIAL Y MÉTODOS: Análisis retrospectivo de pacientes sometidos a RH entre 2005 y 2019. Se compararon los resultados observados con la media del riesgo previsto por la calculadora, mediante Curva ROC, score de Brier y prueba Z. RESULTADOS: Se evaluaron 67 pacientes, con 51.9 años de edad media, un 50.7% de sexo femenino. La mayoría de las resecciones (56.7%) fueron por patología maligna y el 62.1% fueron hepatectomías parciales. La morbilidad fue del 25.4% y la mortalidad del 4.5%. Hubo una predicción buena en las complicaciones (complicación seria, estadística: C: 0.725, score Brier: 0.26, p = 0.006 y cualquier complicación, estadística: C: 0.731, score Brier: 0.33, p = 0.005) y la mortalidad (estadística C: 0.922, score Brier: 0.005, p = 0.014). CONCLUSIONES: La aplicación de la calculadora ACS-NSQIP en pacientes sometidos a RH tiene buen poder de discriminación y buena habilidad predictiva. Predecir riesgos postoperatorios logra una adecuada planeación preoperatoria del procedimiento.

Endovascular therapeutic hypothermia adjunctive to percutaneous coronary intervention in acute myocardial infarction: realistic simulation as a game changer.

BACKGROUND: Endovascular therapeutic hypothermia (ETH) reduces the damage by ischemia/reperfusion cell syndrome in cardiac arrest and has been studied as an adjuvant therapy to percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). New available advanced technology allows cooling much faster, but there is paucity of resources for training to avoid delays in door-to-balloon time (DTB) due to ETH and subsequently coronary reperfusion, which would derail the procedure. The aim of the study was to describe the process for the development of a simulation, training & educational protocol for the multidisciplinary team to perform optimized ETH as an adjunctive therapy for STEMI. METHODS AND RESULTS: We developed an optimized simulation protocol using modern mannequins in different realistic scenarios for the treatment of patients undergoing ETH adjunctive to PCI for STEMIs starting from the emergency room, through the CathLab, and to the intensive care unit (ICU) using the Proteus® Endovascular System (Zoll Circulation Inc™, San Jose, CA, USA). The primary endpoint was door-to-balloon (DTB) time. We successfully trained 361 multidisciplinary professionals in realistic simulation using modern mannequins and sham situations in divisions of the hospital where real patients would be treated. The focus of simulation and training was logistical optimization and educational debriefing with strategies to reduce waste of time in patient's transportation from different departments, and avoiding excessive rewarming during transfer. Afterwards, the EHT protocol was successfully validated in a trial randomizing 50 patients for 18 minutes cooling before coronary recanalization at the target temperature of 32 ± 1.0 ∘C or PCI-only. A total of 35 patients underwent ETH (85.7% [30/35] in 90 ± 15 minutes), without delays in the mean door-to-balloon time for primary PCI when compared to 15 control group patients (92.1 minutes versus 87 minutes, respectively; p = 0.509). CONCLUSIONS: Realistic simulation, intensive training and educational debriefing for the multidisciplinary team propitiated feasible endovascular therapeutic hypothermia as an adjuvant therapy to primary PCI in STEMI. CLINICALTRIALS: gov: NCT02664194.

Correlação entre suporte social percebido e conflito trabalho-família em agentes comunitários de saúde / Correlation between perceived social support and work-family conflict in community health agents / Correlación entre apoyo social percibido y conflicto trabajo-familia en ACS

Este estudo tem como objetivo avaliar se existe correlação entre conflito trabalho-família e suporte social percebido em Agentes Comunitários de Saúde (ACS). Ademais, este é um estudo transversal e correlacional com delineamento quantitativo, em que foram ocupadas a Escala Multidimensional de Conflito Trabalho-Família (EMCT-F) e a Escala de Percepção de Suporte Social (2-Way SSS). Os participantes da pesquisa foram 139 ACS atuantes em quatro municípios do interior do Rio Grande do Sul. Para a análise dos dados, foram utilizadas a Estatística Descritiva, Estatística Paramétrica e Correlação de Pearson. Os resultados entre as correlações das escalas foram estatisticamente significativos (p<0,05) nos fatores dar suporte emocional e conflito família-trabalho, e receber suporte instrumental e conflito família trabalho. Assim, o estudo permitiu compreender melhor a relação entre as variáveis destacadas, sendo que esse entendimento poderá subsidiar intervenções baseadas na Psicologia Positiva para os ACS.(AU)

This study aimed to assess whether there is a correlation between work-family conflict and perceived social support in Community Health Agents (CHA). Moreover, this is a cross-sectional and correlational study with quantitative design, in which the Multidimensional Work-Family Conflict Scale (MWFCS) and the 2-Way Social Support Scale (2-Way SSS) were used. The participants in this study were 139 CHA workers in four municipalities in the interior of Rio Grande do Sul. Descriptive Statistics, Parametric Statistics, and Pearson Correlation were used to analyze the data. The results between the correlations of the scales were statistically significant (p<0.05) in the factors give emotional support and work family conflict, and receive instrumental support and work family conflict. Therefore, the study allowed us to better understand the relationship between the variables highlighted, and this understanding may support interventions based on Positive Psychology for the CHA.(AU)

El presente estudio tuvo como objetivo evaluar si existe correlación entre conflicto trabajo-familia y apoyo social percibido en trabajadores Agentes Comunitarios de Salud. Además, este es un estudio transversal y correlacional con delineamiento cuantitativo, en que fueron empleadas la Escala Multidimensional de Conflicto Trabajo-Familia (EMCT-F) y la Escala de Percepción de Suporte Social (2-Way SSS). Los participantes de este estudio fueron 139 trabajadores que actúan como agentes comunitarios de salud (ACS) en cuatro municipios del interior de Rio Grande do Sul. Para el análisis de los datos fueron empleadas la Estadística Descriptiva, Estadística Paramétrica y Correlación de Pearson. Los resultados entre las correlaciones de las escalas fueron estadísticamente significativos (p<0,05) en los factores dar apoyo emocional y conflicto familia trabajo y recibir apoyo instrumental y conflicto familia trabajo. Por tanto, el estudio permitió comprender mejor la relación entre las variables destacadas, siendo que ese entendimiento podrá subsidiar intervenciones basadas en la Psicología Positiva para los ACS.(AU)

Shortening in the Tp-e/QTc ratio after angioplasty in patients with acute coronary syndrome. / Acortamiento en la relación Tp-f/QTc tras angioplastia en pacientes con síndrome isquémico coronario agudo.

Objetivo: La dispersión transmural de la repolarización ventricular (DTMRV) es un factor de riesgo para muerte en pacientes con síndrome isquémico coronario agudo (SICA). Con el objetivo de conocer el efecto de la realización de angioplastia sobre la DTMRV, se estudió la relación Tp-f/QTc en pacientes con SICA sometidos a angioplastia. Método: Se diseñó un estudio observacional, retrospectivo y descriptivo. Se incluyeron 150 pacientes (N = 150) con diagnóstico de SICA. Se valoró la relación Tp-f/QTc inicial y se evaluó su acortamiento posangioplastia. Como objetivo secundario, se comparó la asociación de dichos cambios en la relación Tp-f/QTc con la mortalidad cardiovascular y los eventos adversos cardiovasculares. Resultados: El promedio en la relación Tp-f/QTc inicial fue de 0.2529, mientras que posangioplastia fue de 0.2397. Por medio de prueba de rangos de Wilcoxon se evidenció un descenso significativo en la relación Tp-f/QTc posterior a la angioplastia, con un valor Z de -2.051 y una p < 0.04. En el análisis secundario se encontró que una Tp-f/QTc ≥ 0.29 posangioplastia es factor de riesgo para presentación de los siguientes eventos adversos: muerte intrahospitalaria (7.4 vs 0%; p < 0.003), nuevo SICA en seguimiento a 1 año (25.9 vs. 18.5%; p < 0.006) y reintervención en seguimiento a 1 año (29.6 vs. 15.0%; p < 0.002). Conclusiones: Existe un acortamiento significativo en la relación Tp-f/QTc posangioplastia en pacientes con SICA. Esta medida de la DTMRV puede servir como un predictor de muerte intrahospitalaria, eventos cardiovasculares y reintervención a 1 año en pacientes con SICA tratados con angioplastia. Objective: Transmural Dispersion of Repolarization (TDR) is a Risk factor for Death in patients with Acute Coronary ­Syndrome (ACS). In order to know the effect of angioplasty on TDR, the Tp-e/QTc ratio was studied in patients with ACS undergoing angioplasty. Method: An observational, retrospective and descriptive study was designed. 150 patients (N = 150) with diagnosis of ACS were included. The initial Tp-e/QTc ratio was assessed and then its post-angioplasty shortening was evaluated. As a secondary objective, we compared the association of these Tp-e/QTc ratio changes with cardiovascular mortality and cardiovascular adverse events. Results: The average in the initial Tp-e/QTc ratio was 0.2529, while post-angioplasty was 0.2397. Through a Wilcoxon rage test, a significant decrease in the Tp-e/QTc ratio after angioplasty was observed, with a Z value of −2.051 and p < 0.04. In the secondary analysis, it was found that a Tp-e/QTc ≥ 0.29 post-angioplasty is a risk factor for presenting the following adverse events: in-hospital death (7.4 vs. 0%; p < 0.003), new ACS in 1-year follow-up (25.9 vs. 18.5%; p < 0.006), and reintervention in 1-year follow up (29.6 vs. 15%; p < 0.002). Conclusions: There is a significant shortening in the Tp-e/QTc ratio post-angioplasty in patients with ACS. This measure of TDR can serve as a predictor of in-hospital death, cardiovascular events and 1-year reintervention in patients with ACS treated initially by angioplasty.

Acortamiento en la relación Tp-f/QTc tras angioplastia en pacientes con síndrome isquémico coronario agudo / Shortening in the Tp-e/QTc ratio after angioplasty in patients with acute coronary syndrome

Resumen Objetivo: La dispersión transmural de la repolarización ventricular (DTMRV) es un factor de riesgo para muerte en pacientes con síndrome isquémico coronario agudo (SICA). Con el objetivo de conocer el efecto de la realización de angioplastia sobre la DTMRV, se estudió la relación Tp-f/QTc en pacientes con SICA sometidos a angioplastia. Método: Se diseñó un estudio observacional, retrospectivo y descriptivo. Se incluyeron 150 pacientes (N = 150) con diagnóstico de SICA. Se valoró la relación Tp-f/QTc inicial y se evaluó su acortamiento posangioplastia. Como objetivo secundario, se comparó la asociación de dichos cambios en la relación Tp-f/QTc con la mortalidad cardiovascular y los eventos adversos cardiovasculares. Resultados: El promedio en la relación Tp-f/QTc inicial fue de 0.2529, mientras que posangioplastia fue de 0.2397. Por medio de prueba de rangos de Wilcoxon se evidenció un descenso significativo en la relación Tp-f/QTc posterior a la angioplastia, con un valor Z de −2.051 y una p < 0.04. En el análisis secundario se encontró que una Tp-f/QTc ≥ 0.29 posangioplastia es factor de riesgo para presentación de los siguientes eventos adversos: muerte intrahospitalaria (7.4 vs 0%; p < 0.003), nuevo SICA en seguimiento a 1 año (25.9 vs. 18.5%; p < 0.006) y reintervención en seguimiento a 1 año (29.6 vs. 15.0%; p < 0.002). Conclusiones: Existe un acortamiento significativo en la relación Tp-f/QTc posangioplastia en pacientes con SICA. Esta medida de la DTMRV puede servir como un predictor de muerte intrahospitalaria, eventos cardiovasculares y reintervención a 1 año en pacientes con SICA tratados con angioplastia.

Abstract Objective: Transmural Dispersion of Repolarization (TDR) is a Risk factor for Death in patients with Acute Coronary Syndrome (ACS). In order to know the effect of angioplasty on TDR, the Tp-e/QTc ratio was studied in patients with ACS undergoing angioplasty. Method: An observational, retrospective and descriptive study was designed. 150 patients (N = 150) with diagnosis of ACS were included. The initial Tp-e/QTc ratio was assessed and then its post-angioplasty shortening was evaluated. As a secondary objective, we compared the association of these Tp-e/QTc ratio changes with cardiovascular mortality and cardiovascular adverse events. Results: The average in the initial Tp-e/QTc ratio was 0.2529, while post-angioplasty was 0.2397. Through a Wilcoxon rage test, a significant decrease in the Tp-e/QTc ratio after angioplasty was observed, with a Z value of −2.051 and p < 0.04. In the secondary analysis, it was found that a Tp-e/QTc ≥ 0.29 post-angioplasty is a risk factor for presenting the following adverse events: in-hospital death (7.4 vs. 0%; p < 0.003), new ACS in 1-year follow-up (25.9 vs. 18.5%; p < 0.006), and reintervention in 1-year follow up (29.6 vs. 15%; p < 0.002). Conclusions: There is a significant shortening in the Tp-e/QTc ratio post-angioplasty in patients with ACS. This measure of TDR can serve as a predictor of in-hospital death, cardiovascular events and 1-year reintervention in patients with ACS treated initially by angioplasty.

Nutritional status coverage trend registered in the SISVAN web in seven municipalities of the Zona Da Mata Mineira, Brazil, from 2008 to 2017, and its association with socio-economic, demographic and organisation of health system variables.

We analysed the coverage trend of the evaluation of the nutritional status of users of public health services registered in the Food and Nutrition Surveillance System (SISVAN) between 2008 and 2017 in seven municipalities and verified the association of the coverage trend with the socio-economic, demographic and organisational aspects of health system variables. It is an ecological time-series study performed with secondary data extracted from health information systems. Descriptive statistics, linear regression model and repeated measures analysis were performed. The coverage of evaluation of nutritional status was low over the period. Five municipalities showed a tendency to increase coverage, although small, while two remained stable. The highest annual variation in coverage increase was concentrated in the group of pregnant women and the lowest in adolescents and older adults. There was a downward trend in follow-ups from the Bolsa Family Programme and a trend towards increased follow-ups from SUS Primary Care (e-SUS AB). SISVAN coverage was positively associated with the proportion of rural population (P ≤ 0·001) and coverage of community health agents (P < 0·001); and negatively associated with total population (P < 0·001), demographic density (P = 0·006) and gross domestic product per capita (P = 0·008). Despite the tendency to increase coverage in some municipalities, SISVAN still presents low coverage of nutritional status assessment, which compromises population monitoring. Knowing the factors that influence the coverage can subsidise the elaboration of strategies for its expansion.

Morphine and Cardiovascular Outcomes Among Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Undergoing Coronary Angiography.

BACKGROUND: Mechanistic studies have shown that morphine blunts the antiplatelet effects of oral adenosine diphosphate receptor blockers. However, the clinical relevance of this interaction is controversial. OBJECTIVES: This study sought to explore the association between morphine and ischemic events in 5,438 patients treated with concomitant clopidogrel presenting with non-ST-segment elevation acute coronary syndromes (NSTEACS) in the EARLY ACS (Early Glycoprotein IIb/IIIa Inhibition in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome) trial. Patients not treated with clopidogrel (n = 3,462) were used as negative controls. METHODS: Endpoints were the composite of death, myocardial infarction (MI), recurrent ischemia, or thrombotic bailout at 96 h (4-way endpoint) and the composite of death or MI at 30 days. RESULTS: In patients treated with clopidogrel, morphine use was associated with higher rates of the 4-way endpoint at 96 h (adjusted odds ratio [OR]: 1.40; 95% confidence interval [CI]: 1.04 to 1.87; p = 0.026). There was a trend for higher rates of death or MI at 30 days (adjusted OR: 1.29; 95% CI: 0.98 to 1.70; p = 0.072), driven by events in the first 48 h (adjusted hazard ratio: 1.54; 95% CI: 1.07 to 2.23; p = 0.021). In patients not treated with clopidogrel, morphine was not associated with either the 4-way endpoint at 96 h (adjusted OR: 1.05; 95% CI: 0.74 to 1.49; p = 0.79; pinteraction = 0.36 ) or death or MI at 30 days (adjusted OR: 1.07; 95% CI: 0.77 to 1.48; p = 0.70; pinteraction = 0.46). CONCLUSIONS: When used concomitantly with clopidogrel pre-treatment, morphine was associated with higher rates of ischemic events in patients with NSTEACS. (EARLY ACS: Early Glycoprotein IIb/IIIa Inhibition in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome; NCT00089895).

Síndrome de Apert. Reporte de caso / Apert syndrome. Case report

Introducción: El síndrome de Apert, o acrocefalosindactilia tipo I, es un síndrome caracte­rizado por craneosinostosis, acompañada de sindactilia simétrica en las cuatro extremidades, alteraciones maxilofaciales, cutáneas y retardo mental variable. Este síndrome se debe a una mutación en el gen del receptor 2 del factor del crecimiento fibroblástico (FGFR2), el cual se expresa de manera autosómica dominante (AD) Caso clínico: Se presenta caso de adolescente masculino de 24 años de edad, con las características fenotípicas clásicas de este síndrome como la acrocefalia y la sindactilia en manos y pies. Discusión: El síndrome de Apert hace parte de lo que hoy se denomina un espectro de enfermedades causadas por la mutación en el gen FGFR2 que se caracterizan por anorma­lidades en el cráneo y las extremidades. Este gen es necesario para la osificación normal y también está implicado en la diferenciación neural. Sus mutaciones producen un receptor anormal que funciona aun sin la unión de su ligando "ganancia de función", lo que se traduce en una osificación temprana de los huesos, en grados variables, dependiendo del sitio exacto de la mutación.

Introduction: Apert's syndrome or acrocefalosindactyly tipe I, is a syndrome character­ized by craniosynostosis, symmetric syndactylia in hands and feet's, maxillofacial and cutaneous disorders, and variable mental retardation. This syndrome is due to a mutation in the gene that encode the fibroblast growth factor Receptor 2 (FGFR2), which has an autosomal dominant inheritance (AD). Case report: We report a male24 yearsoldteen, with the classical phenotypic characteristics of this syndrome, as acrocefalia and syndactyly of hands and feet. Discussion: Apert's syndrome is part of what today is called a spectrum of disease caused by a mutation in the FGFR2 gene, which is characterized by abnormalities in the skull and extremities. This gene is required for normal ossification and is also involved in neural differentiation. Mutations cause an abnormal receptor that functions even without the binding of its ligand "gain of function", which translates into an early ossification of the bones, in varying degrees, depending on the exact site of the mutation.

Caracterización del síndrome de Wellens y su relación como predictor de obstrucción grave de la arteria descendente anterior. Unidad de Cuidados Coronarios Intensivos Hospital Manuel Fajardo 2016-2017 / Characterization of Wellens syndrome and its relationship as a predictor of severe obstruction of the left anterior descending artery. Intensive Coronary Care Unit Hospital Manuel Fajardo 2016-2017

RESUMEN Introducción: El síndrome de Wellens es un patrón electrocardiográfico que se ha sugerido desde la década del 80 como indicador de obstrucción grave de la arteria descendente anterior, a pesar de ello es poco conocido y no se encuentra en las principales guías de tratamiento de los síndromes coronarios agudos. Objetivo: Demostrar la utilidad del diagnóstico del síndrome de Wellens como predictor de obstrucción grave de la descendente anterior. Método: Se realizó un estudio transversal con componente analítico, que abarcó a los 40 pacientes ingresados en la Unidad de Cuidados Coronarios Intensivos del Hospital Manuel Fajardo, en el período enero de 2016 hasta diciembre de 2017, con diagnóstico de síndrome coronario agudo sin elevación del segmento ST, a los que se les realizó coronariografía. Resultados: Se encontró la presencia de síndrome de Wellens en un 13,5% de los pacientes ingresados con este tipo de síndrome coronario agudo. La edad, el sexo y la presencia de comorbilidades no se relacionaron significativamente con la presencia de este síndrome. El estudio angiográfico evidenció, en los pacientes con un síndrome de Wellens, un riesgo relativo 3,4 veces mayor que el resto, de presentar una obstrucción grave de la arteria descendente anterior. Conclusiones: La identificación oportuna del síndrome de Wellens y su relación con una obstrucción coronaria grave deben motivar una estrategia intervencionista precoz en estos casos.

ABSTRACT Introduction: Wellens syndrome is an electrocardiographic pattern that has been suggested, since the 1980s, as indicator of severe obstruction of the left anterior descending artery, although it is poorly understood and it is not found in the main treatment guidelines for acute coronary syndromes. Objective: To demonstrate the usefulness of the diagnosis of Wellens syndrome as a predictor of severe obstruction of the left anterior descending artery. Method: A cross-sectional study with an analytical component was carried out, covering the 40 patients admitted to the Intensive Coronary Care Unit of the Hospital Manuel Fajardo, in the period from January 2016 to December 2017, with a diagnosis of non-ST-segment elevation acute coronary syndrome, who underwent coronary angiography. Results: The presence of Wellens syndrome was found in 13.5% of the patients admitted with this type of acute coronary syndrome. Age, sex and the presence of comorbidities were not significantly related to the presence of this syndrome. The angiographic study showed, in patients with a Wellens syndrome, a relative risk -3.4 times greater than the rest- of presenting a severe obstruction of the left anterior descending artery. Conclusions: The timely identification of Wellens syndrome and its relationship with a severe coronary obstruction should motivate an early interventionist strategy in these cases.

Resource Utilization and Costs Associated With Percutaneous Coronary Intervention When Treating Patients With Acute Coronary Syndrome in the Mexican National Institute of Cardiology "Ignacio Chávez".

BACKGROUND: The treatment of acute coronary syndrome (ACS) using percutaneous coronary intervention (PCI) is a frequent intervention with a high economic impact. OBJECTIVE: This study investigates the resource use and cost of PCI in Mexico where heart disease is a leading cause of death, and a large segment of the population does not have formal healthcare coverage. METHODS: This retrospective observational study obtained resource utilization data from patient files and itemized costs from the pharmacy registry at the National Institute of Cardiology. Patients were aged >18 years, diagnosed with ACS, and treated with PCI and secondary prophylaxis with aspirin plus clopidogrel or prasugrel. Patients had a follow-up of >12 months at the institute. Statistical analysis was descriptive. RESULTS: The sample included 156 patients (mean age: 58.66 years; male: 77.9%). Patients were diagnosed with ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction, and unstable angina 64.9%, 27.2%, and 7.9%, respectively. The mean (standard deviation [SD]) total medical cost was estimated to be $145 677 ($98 326) Mexican pesos 2018. The highest category of spending was surgical materials (mean [SD]: $47 834 [$32 569], comprising 32.8% of total costs); medications and access to the operating room represented 14.2% and 11.8%, respectively. Mean (SD) hospital stay was 9.07 (6.2) days; for the 11.5% of patients admitted to the intensive care unit, the mean (SD) stay was 4.61 (2.06) days. The mean cost of standard hospitalization was $12 572, or 8.6% of spending; intensive care unit hospitalization comprised 17.7% of total costs (mean: $25 802). The cost of the intervention is subsidized up to 95% for patients with a low social economic status, with the exception of surgical materials such as stents. This results in the highest burden component of the intervention being placed on the patient and not the institute. CONCLUSION: The mean cost per patient shows that PCI is an expensive procedure in Mexico. A lack of subsidies for surgical equipment places a high economic burden on the patient and represents a barrier of access for a vulnerable population that likely increases mortality and morbidity rates in those patients unable to pay for treatment and a potential high burden of debt for those who do pay.