Documento de posición para la mejora en la reperfusión del infarto agudo de miocardio con elevación del ST en Latinoamérica / Position statement for improvement in reperfusion of ST-elevation myocardial infarction in Latin America

Resumen El tratamiento del infarto agudo de miocardio con elevación del segmento ST tiene barreras dependiendo de la región geográfica. La angioplastia coronaria primaria es el tratamiento de elección, siempre y cuando sea realizada dentro de tiempo y por operadores experimentados. Sin embargo, cuando no está disponible, la administración de fibrinólisis y el envío para angioplastia de rescate, en caso de reperfusión negativa, es la mejor estrategia. De la misma manera, la angioplastia coronaria, como parte de una estrategia farmacoinvasiva, es la mejor alternativa cuando hay reperfusión positiva. El desarrollo de redes de tratamiento del infarto aumenta el número de pacientes reperfundidos dentro de los tiempos recomendados y mejora los desenlaces. En América Latina, los programas nacionales para el tratamiento del infarto deben centrarse en mejorar los resultados y el éxito a largo plazo depende de trabajar hacia objetivos definidos y obtener métricas de rendimiento, por lo tanto, estos deben desarrollar métricas para cuantificar su desempeño. El siguiente documento discute todas estas alternativas y sugiere oportunidades de mejora.

Abstract The treatment of ST-segment elevation myocardial infarction has barriers depending on the geographic region. Primary coronary angioplasty is the treatment of choice, if it is performed on time and by experienced operators. However, when it is not available, the administration of fibrinolysis and referral for rescue angioplasty, in case of negative reperfusion, is the best strategy. In the same way, coronary angioplasty, as part of a pharmacoinvasive strategy, is the best alternative when there is positive reperfusion. The development of infarct treatment networks increases the number of patients reperfused within the recommended times and improves outcomes. In Latin America, national myocardial infarction treatment programs should focus on improving outcomes, and long-term success depends on working toward defined goals and enhancing functionality, therefore programs should develop capacity to measure their performance. The following document discusses all of these alternatives and suggests opportunities for improvement.

[Position statement for improvement in reperfusion of ST-elevation myocardial infarction in Latin America]. / Documento de posición para la mejora en la reperfusión del infarto agudo de miocardio con elevación del ST en Latinoamérica.

The treatment of ST-segment elevation myocardial infarction has barriers depending on the geographic region. Primary coronary angioplasty is the treatment of choice, if it is performed on time and by experienced operators. However, when it is not available, the administration of fibrinolysis and referral for rescue angioplasty, in case of negative reperfusion, is the best strategy. In the same way, coronary angioplasty, as part of a pharmacoinvasive strategy, is the best alternative when there is positive reperfusion. The development of infarct treatment networks increases the number of patients reperfused within the recommended times and improves outcomes. In Latin America, national myocardial infarction treatment programs should focus on improving outcomes, and long-term success depends on working toward defined goals and enhancing functionality, therefore programs should develop capacity to measure their performance. The following document discusses all of these alternatives and suggests opportunities for improvement.

El tratamiento del infarto agudo de miocardio con elevación del segmento ST tiene barreras dependiendo de la región geográfica. La angioplastia coronaria primaria es el tratamiento de elección, siempre y cuando sea realizada dentro de tiempo y por operadores experimentados. Sin embargo, cuando no está disponible, la administración de fibrinólisis y el envío para angioplastia de rescate, en caso de reperfusión negativa, es la mejor estrategia. De la misma manera, la angioplastia coronaria, como parte de una estrategia farmacoinvasiva, es la mejor alternativa cuando hay reperfusión positiva. El desarrollo de redes de tratamiento del infarto aumenta el número de pacientes reperfundidos dentro de los tiempos recomendados y mejora los desenlaces. En América Latina, los programas nacionales para el tratamiento del infarto deben centrarse en mejorar los resultados y el éxito a largo plazo depende de trabajar hacia objetivos definidos y obtener métricas de rendimiento, por lo tanto, estos deben desarrollar métricas para cuantificar su desempeño. El siguiente documento discute todas estas alternativas y sugiere oportunidades de mejora.

Breast Cancer: How Hippotherapy Bridges the Gap between Healing and Recovery-A Randomized Controlled Clinical Trial.

BACKGROUND: Breast cancer is the most diagnosed women's cancer, and has a high survival rate. Despite great progress in detection and treatment, life reconstruction requires comprehensive cross-sectoral approaches between different disciplines and deeper consideration of the patient's challenges. Hippotherapy is an emerging specialized rehabilitation approach, performed by accredited health professionals and equine specialists, on specially trained horses via their movement, activating major paths for physical, mental, psychic and social reinforcement, and is synergistic to rehabilitative and supportive care. METHODS: We conducted a randomized open, prospective, two-armed, controlled trial on the effectiveness of hippotherapy versus conventional supportive care on adult women with a diagnosis of breast cancer, after the period of primary treatment (surgery, chemotherapy, radiotherapy). The 6-month program included, in the treated group, an initial 1-week daily hippotherapy session, followed by three short 2-day sessions with an interval of 2 months between each, where the patients received conventional supportive care. The control group received 6 months of conventional supportive care. The primary end point was quality of life. Cognitive performances, fatigue, anxiety, depression, and body image were the secondary end points. Measurements were done through self-reported questionnaires. RESULTS: We observed statistical differences in the evolution of the measured parameters over time between the two groups. The hippotherapy group showed a much faster, favorable and continuous improvement until the end of the program for each function assessed. The most striking improvements were observed in global quality of life, and fatigue, while breast cancer-specific quality of life, cognitive performance, anxiety and depression and body image showed a less marked but still statistically significant difference at the final post-treatment evaluation. CONCLUSIONS: We demonstrate the therapeutic relevance of hippotherapy, a one-health approach, as a key initial stage after cancer diagnosis and treatment to foster recovery. Furthermore, hippotherapy has a strong impact on cancer treatments' efficiency and reconstruction of patient's life and ecosystem. This work reveals a layer of complexity that needs to be broadly considered. TRIAL REGISTRATION: ClincalTrials.gov NCT04350398 accessed on 1 January 2022. Registered 17 April 2020, retrospectively registered; French Clinical Trials in Cancer Register RECF3818. Registered 18 March 2019, retrospectively registered.

After 55 Years of Neurorehabilitation, What Is the Plan?

Neurological disorders often cause severe long-term disabilities with substantial activity limitations and participation restrictions such as community integration, family functioning, employment, social interaction and participation. Increasing understanding of brain functioning has opened new perspectives for more integrative interventions, boosting the intrinsic central nervous system neuroplastic capabilities in order to achieve efficient behavioral restitution. Neurorehabilitation must take into account the many aspects of the individual through a comprehensive analysis of actual and potential cognitive, behavioral, emotional and physical skills, while increasing awareness and understanding of the new self of the person being dealt with. The exclusive adoption by the rehabilitator of objective functional measures often overlooks the values and goals of the disabled person. Indeed, each individual has their own rhythm, unique life history and personality construct. In this challenging context, it is essential to deepen the assessment through subjective measures, which more adequately reflect the patient's perspective in order to shape genuinely tailored instead of standardized neurorehabilitation approaches. In this overly complex panorama, where confounding and prognostic factors also strongly influence potential functional recovery, the healthcare community needs to rethink neurorehabilitation formats.

Neurorehabilitation through Hippotherapy on Neurofunctional Sequels of Stroke: Effect on Patients' Functional Independence, Sensorimotor/Cognitive Capacities and Quality of Life, and the Quality of Life of Their Caregivers-A Study Protocol.

BACKGROUND: Stroke is a high burden illness and the second leading cause of worldwide disability with generally poor recovery rates. Robust benefits of hippotherapy, a novel neurorehabilitation approach, in functional recovery following various severe neurological disabling conditions has been shown. In the present study, we will analyze the effect of a hippotherapy program on the outcome of post-stroke patients in the first year post-stroke. METHOD: A randomized controlled clinical trial on the effectiveness of hippotherapy (4 weeks/18 weeks hippotherapy/conventional neurorehabilitation) versus conventional neurorehabilitation alone (22 weeks) will be conducted over 48 weeks. In the treated group, one-hour daily hippotherapy sessions will be exclusively conducted during the hippotherapy's cycles, alternated with periods of conventional neurorehabilitation. A test battery will measure both the functional and psychological outcomes. The primary endpoint will be the patient's functional independence. The secondary endpoints will measure the sensorimotor function, autonomy, and quality of life, as well as the caregivers' quality of life. RESULTS AND CONCLUSION: Individual brain connectome, life history and personality construct influence the brain's functional connectivity and are central to developing optimal tailored neurorehabilitation strategies. According to our current practice, hippotherapy allows the enhancement of substantial neuroplastic changes in the injured brain with significant neurological recovery. The protocol aims to confirm those issues. Trial registration in ClinicalTrials.gov NCT04759326 accessed on 19 February 2021.

Functional Weight of Somatic and Cognitive Networks and Asymmetry of Compensatory Mechanisms: Collaboration or Divergency among Hemispheres after Cerebrovascular Accident?

The human brain holds highly sophisticated compensatory mechanisms relying on neuroplasticity. Neuronal degeneracy, redundancy, and brain network organization make the human nervous system more robust and evolvable to continuously guarantee an optimal environmental-related homeostasis. Nevertheless, after injury, restitution processes appear dissimilar, depending on the pathology. Following a cerebrovascular accident, asymmetry, within- and across-network compensation and interhemispheric inhibition are key features to functional recovery. In moderate-to-severe stroke, neurological outcome is often poor, and little is known about the paths that enable either an efficient collaboration among hemispheres or, on the contrary, an antagonism of adaptative responses. In this review, we aim to decipher key issues of ipsilesional and contralesional hemispheric functioning allowing the foundations of effective neurorehabilitation strategies.

Acute myocardial infarction with right bundle branch block at presentation: Prevalence and mortality.

AIMS: Right Bundle Branch Block (RBBB) has been reported in 5-11% of the acute myocardial infarctions (AMI), and it could be the only electrocardiographic abnormality in this group of patients. We investigated the mortality in patients with AMI and the presence of RBBB. MATERIALS AND METHODS: A retrospective cohort study was conducted between January 2011 to December 2017 at a university hospital in Bogotá, Colombia. Records were obtained from all patients who presented at the emergency department with AMI; patients with early transfer and incomplete follow-up were excluded. RESULTS: 1015 patients were included, the mean age was 66 years, 67% of the patients were men, and 38% had STEMI. RBBB was documented in 8% of patients and LBBB in 4% of patients. In-hospital mortality was higher in the group of patients with RBBB vs. patients without RBBB (8.64% vs. 3.74%, p = 0.034). The percentage of patients with Killip ≥II classification was higher in patients with new RBBB vs. patients with old or unknown duration RBBB (23% vs. 13%, p = 0.216). CONCLUSIONS: In patients with AMI, the presence of RBBB was associated with a statistically significant increase of in-hospital mortality.

Inter-Day Reliability and Changes of Surface Electromyography on Two Postural Muscles Throughout 12 Weeks of Hippotherapy on Patients with Cerebral Palsy: A Pilot Study.

Cerebral palsy (CP) is an umbrella term covering a group of permanent developmental disorders of movement and posture characterized by highly variable clinical features. The aim of this study was to assess the short-term and mid-term effects of neurorehabilitation via hippotherapy on the contractile properties of two key postural muscles during functional sitting in such patients. Thirty-minute hippotherapy sessions were conducted biweekly for 12 weeks in 18 patients (18.1 ± 5.7 years old). Surface electromyography (EMG) was implemented bilaterally in rectus abdominis and adductor magnus. We quantitatively analyzed the amplitude of EMG signals in the time domain and its spectral characteristics in the frequency domain. EMGs were recorded at the beginning and end of each session on day one and at week six and week twelve. Statistical analysis revealed a substantial inter-day reliability of the EMG signals for both muscles, validating the methodological approach. To a lesser extent, while beyond the scope of the current study, quantitative changes suggested a more selective recruitment/contractile properties' shift of the examined muscles. Exploring postural control during functional activities would contribute to understanding the relationship between structural impairment, activity performance and patient capabilities, allowing the design of neurorehabilitation programs aimed at improving postural and functional skills according to each individual's needs. The present study provides basic quantitative data supporting the body of scientific evidence making hippotherapy an approach of choice for CP neurorehabilitation.

Short- and Mid-Term Improvement of Postural Balance after a Neurorehabilitation Program via Hippotherapy in Patients with Sensorimotor Impairment after Cerebral Palsy: A Preliminary Kinetic Approach.

There is still a lack of studies focused on trunk neurorehabilitation. Accordingly, it is unclear which therapeutic modalities are the most effective in improving static/dynamic balance after brain damage. We designed a pilot study on hippotherapy to assess its short- and mid-term effect on dynamic postural balance in patients with moderate-to-severe sensorimotor impairment secondary to cerebral palsy. Five patients aged 15.4 ± 6.1 years old were recruited. All of them had moderate-to-severe alterations of the muscle tone with associated postural balance impairment. Standing and walking were also impaired. Ten minutes horse riding simulator followed by twenty minutes hippotherapy session were conducted during five session days separated by one week each. We analyzed the displacement of the Center of Pressure (COP) on the sitting surface of the simulator's saddle by means of a customized pressure pad. We measured the general behavior of the COP displacement as well as the postural adjustments when pace changed from walk to trot to walk during the sessions and among sessions. Statistical analysis revealed an improved postural control both by the end of the session and from session 1 to session 5. These results suggest that hippotherapy might support regularization of postural control in a long-term neurorehabilitation context.

Cardiomiopatía periparto / Peripartum cardiomyopathy

Resumen La cardiomiopatía periparto es una causa poco común de la insuficiencia cardiaca aguda por la disfunción sistólica ventricular izquierda en las mujeres que se encuentran en el tercer trimestre del embarazo o durante los meses siguientes al puerperio. Se expone el caso de una paciente de 37 años de edad primigestante con fertilización in vitro que ingresa con cuadro clínico de preeclampsia severa y estado fetal insatisfactorio, llevada a cesárea de emergencia, presentando posteriormente clínica de insuficiencia cardiaca aguda calientehúmeda. Se presenta una revisión de la literatura de esta patología con el diagnóstico, las manifestaciones clínicas, el tratamiento y el pronóstico.

Abstract Peripartum cardiomyopathy is a rare cause for acute heart failure caused by left ventricular systolic dysfunction in women in their third trimester of pregnancy or during the months of the postpartum period. The case of a 37 year-old primiparous patient with in vitro fertilisation is presented; she was admitted with symptoms of severe preeclampsia and fetal distress, hence she was taken for emergency c-section, later showing symptoms of hot-humid acute heart failure. A literature review of this condition with the diagnosis, clinical manifestations, treatment and prognosis is presented.

Enfoque semiológico de las palpitaciones / Semiologic approach to palpitations

Las palpitaciones son un síntoma frecuente en la consulta y son utilizadas por los pacientes para referirse a la conciencia de los latidos cardíacos. Sus causas incluyen patología cardíaca y no cardíaca, por lo que es importante determinar las características de las palpitaciones, los factores de riesgo y las circunstancias en que se presentaron para orientar el diagnóstico.

Palpitations are a common symptom, used to refer to the awareness of the patient's heartbeat. Its causes include cardiac diseases and non-cardiac pathology. It is important to determine its characteristics, risk factors and circumstances when palpitations develop to guide the diagnosis.

Early functional outcomes and histological analysis after spinal cord compression injury in rats.

OBJECT: Neuroprotective and repair strategies in spinal cord injuries (SCIs) have been so far largely unsuccessful. One of the prerequisites is the use of appropriate preclinical models to decipher pathophysiological mechanisms; another is the identification of optimal time windows for therapeutic interventions. The authors undertook this study to characterize early motor, sensory, autonomic, and histological outcomes after balloon compression of the spinal cord at the T8-9 level in adult rats. METHODS: A total of 91 rats were used in this study. Spinal cord balloon compression was performed at T8-9 in adult rats by inflation of a 2 Fr Fogarty catheter into the epidural space. The authors first characterized early motor, sensory, and autonomic outcomes of 2 volumes of compression (10 and 15 microl) using behavioral tests and then examined histological outcomes in the spinal cord using Luxol fast blue staining. To further substantiate the characterization of the epidural balloon-compression model, they used a noncompetitive N-methyl-D-aspartate antagonist, GK11, and demonstrated the involvement of excitotoxicity in this model. RESULTS: Proportional and reproducible functional impairment resulted from compression caused by balloon inflation with either 10 or 15 microl of water and corresponded to the extent of the lesion. Indeed, during the early phase following SCI (1 week postinjury), recovery of locomotor function and bladder control correlated with the volume of inflation, whereas outcomes with respect to sensory function and reflexes were independent of compression severity. Treatment with GK11 significantly improved motor function in all groups of rats 1 week after injury and bladder voiding in the 10-microl injured rats compared to the 15-microl injured rats. CONCLUSIONS: The results of this study demonstrate that spinal balloon-compression injury in the rat is a well-characterized, reproducible, and predictable model to analyze early events following SCI.

A remotely controlled model of spinal cord compression injury in mice: toward real-time analysis.

OBJECT: To date, there has been no efficient therapeutic approach to spinal cord injuries (SCIs). This may be attributable, at least in part, to difficulties in forming predictive and accurate experimental animal models. The authors' previous studies have identified 2 relevant conditions of such a model. The first condition is the ability to compare data derived from rat models of SCI by developing mouse models of SCI that permit access to a large range of transgenic models. The second condition is that the exploration of the consequences of each mechanism of spinal trauma requires modeling the different etiologic aspects of the injury. METHODS: To fulfill these 2 conditions a new model of mouse spinal cord compression injury was devised using a thread-driven olive-shaped compressive device. The authors characterized early motor, sensory, and histological outcomes using 3 olive diameters and different compression durations. RESULTS: A gradual and reproducible functional severity that correlated with lesion extension was demonstrated in 76 mice. To further substantiate the characterization of this model, a noncompetitive N-methyl-d-aspartate antagonist was administered in 30 mice, which demonstrated the involvement of excitotoxicity in this model. CONCLUSIONS: The study demonstrated that spinal olive-compression injury in the mouse is a reproducible, well-characterized, and predictable model for analyzing early events after SCI. The nonmagnetic and remotely controlled design of this model will allow completion of the lesion while the animal is in the MR imaging apparatus, thus permitting further real-time MR imaging studies that will provide insights into the characterization of early events in the spatial and temporal evolution of SCI. Moreover, this model lays the foundation for future in vivo studies of functional and histological outcomes following SCI in genetically engineered animals.

Minimum information about animal experiments: supplier is also important.

It has now been established that functional recovery after spinal cord injury (SCI) depends on several parameters, including animal strain. Here we demonstrate that rats from the same strain (Wistar) but from two independent commercial suppliers present different motor, sensory, and autonomic outcomes after a standard model of SCI, the so-called compression model. Recovery is correlated with the extension of the lesion, and we show that the vertebral canal diameter varies between the two suppliers. To substantiate this point, we carried out another set of experiments, with the so-called contusion model, which requires bone ablation and thus whose extension is not related to vertebral canal diameter. We show that there is no difference between the two suppliers. The purpose of our communication is to alert researchers on how crucial it is to control experimental parameters as closely as possible and to establish a standard for animal experiment in order to avoid unexpected biases.

Time course of acute phase in mouse spinal cord injury monitored by ex vivo quantitative MRI.

During the acute phase of spinal cord injury (SCI), major alterations of white and grey matter are a key issue, which determine the neurological outcome. The present study with ex vivo quantitative high-field magnetic resonance microimaging (MRI) was intended in order to identify sensitive parameters of tissue disruption in a well-controlled mouse model of ischemic SCI. MR imaging evidenced changes as early as the second hour after the lesion in the dorsal horns, which appear swollen. After 4 h, alterations of the white matter of dorsal and lateral funiculi were reflected by a progressive loss of white/grey matter contrast with further ventral extension by the 24th hour. Diffusion tensor imaging and multi-exponential T2 measurements permitted to quantify these physicochemical, time-related, alterations during the 24-h period. This characterization of spatial and temporal evolution of SCI will contribute to better define both the most appropriate targets for future therapies and more accurate therapeutic windows. Upcoming directions include the use of these parameters on in vivo animal models and their application to clinics. Indeed, magnetic resonance techniques appear now as a major non-invasive translation tool in CNS pathologies based on the development of more appropriate pre-clinical models.

Nuclear magnetic resonance microimaging of mouse spinal cord in vivo.

The spinal cord is the site of traumatic injuries, the devastating consequences of which constitute a public health problem in our societies. So far, there is no efficient repair therapeutic approach, and this is mainly due to the great difficulty for elaborating predictive experimental models of this pathology. Up to now, most pathophysiological studies were based on postmortem evaluation of the quantity and extent of the lesions, and their comparison in-between human and rodent specimen. Recent progresses of magnetic resonance imaging provide new tools to examine in vivo rodent central nervous system, and eventually to monitor the progression of lesions. However, up to now, mice spinal cord has been inaccessible to such studies, due to specific physiological characteristics and to the small size of the cord. In this study, the first diffusion-weighted images depicting the mouse thoracic spinal cord in vivo are shown. Motion-related artifacts are significantly reduced by respiratory gating using a dedicated sensor. By changing the direction of diffusion-sensitizing gradients, different contrasts were obtained that are compared with ex vivo MRI and histological preparations. In addition, preliminary results obtained on pathological cords are presented.

Strategies for regeneration and repair in spinal cord traumatic injury.

Spinal cord injury is frequently followed by the loss of supraspinal control of sensory, autonomic and motor functions at the sublesional level. In order to enhance recovery in spinal cord-injured patients, we have developed three fundamental strategies in experimental models. These strategies define in turn three chronological levels of postlesional intervention in the spinal cord. Neuroprotection soon after injury using pharmacological tools to reduce the progressive secondary injury processes that follow during the first week after the initial lesion. This strategy was conducted up to clinical trials, showing that a pharmacological therapy can reduce the permanent neurological deficit that usually follows an acute injury of the central nervous system (CNS). A second strategy, which is initiated not long after the lesion, aims at promoting axonal regeneration by acting on the main barrier to regeneration of lesioned axons: the glial scar. Finally a mid-term substitutive strategy is the management of the sublesional spinal cord by sensorimotor stimulation and/or supply of missing key afferents, such as monoaminergic systems. These three strategies are reviewed. Only a combination of these different approaches will be able to provide an optimal basis for potential therapeutic interventions directed to functional recovery after spinal cord injury.

A mouse model of acute ischemic spinal cord injury.

Mice models of spinal cord injury (SCI) should improve our knowledge of the mechanisms of injury and repair of the nervous tissue. They represent a powerful tool for the development of therapeutic strategies in the fields of pharmacological, cellular, and genetic approaches of neurotrauma. We demonstrate here that the photochemical graded ischemic spinal cord injury model, described in rats, can be successfully adapted in mice, in a reliable and reproducible manner. Following the intravenous injection of Rose Bengal, the translucent dorsal surface of the T9 vertebral laminae of C57BL/6 female mice was irradiated with a 560-nm wavelength-light (3-8 min depending on the experimental group). Animals were sacrificed at 1 day or 7 days after injury. Functional tests were performed daily for motor, sensory, autonomic, and reflex responses. Lesion histopathology was assessed for lesion length, percentage of residual white matter, and astrocytic reactivity. Experimental groups demonstrated a functional deficit, which was correlated to the increase of the irradiation time and, therefore, to the severity of the injury. Histopathological and immunocytochemical data were reliable morphological measurements characterizing the degree of injury, which were strongly correlated to the severity of the functional impairment. Despite differences in the mechanism of injury, the wound healing response described in other traumatic SCI mice models was confirmed (no cavitation and, conversely, the formation of a dense connective tissue matrix). In this context, the precise understanding of the mechanisms of healing response after SCI in mice and of neurochemical kinetics appear to be crucial in the development of therapeutic strategies of CNS repair. Thus, the possible use of an increasing collection of transgenic mice offers a new dimension for experimental research in this area. The ischemic photochemical model of SCI in mice represents a relevant model that can play a key role in this new era of neurotrauma research.