Application of artificial intelligence to optimize the diagnosis and treatment of acute coronary syndrome: a real experience

BACKGROUND/INTRODUCTION: cardiovascular disease (CVD) is the leading cause of death in the world, with acute myocardial infarction (AMI) being the main responsible for this leadership. One of the determining factors in the outcome of Acute Coronary Syndrome (ACS) is the time to start treatment. An extremely promising path for obtaining earlier diagnosis and treatment has been the use of technological innovations in emergency care units. PRUPOSE: this study was carried out to assess the impact of applying a technology hub in the chest pain scenario in the emergency room, regarding the feasibility and potential reduction of time for diagnosis and treatment of ACS. METHODS: data obtained from 10 hospitals in the public health system in Brazil, which implemented the technology hub in the last 7 months (May to October 2021), were analyzed. This technology hub uses Artificial Intelligence (AI) to identify electrocardiograms (ECGs) with a high probability of alterations, which must be reported within 5 minutes by the cardiologist on shift (24/7) on the platform. RESULTS: 5,506 ECGs were entered into the platform, of which 53.77% (2,961) were considered abnormal; of these, 9.92% (294) had alterations compatible with ischemic events (currents of injury or myocardial ischemia). The median time for the ECG report made by the specialist was 2 minutes and 51 seconds. CONCLUSION: the implementation of a technology hub in the chest pain scenario in the emergency room proved to be feasible and has great potential for reducing the distance between symptoms and the treatment of patients with ACS.

STAGdb: a 30K SNP genotyping array and Science Gateway for Acropora corals and their dinoflagellate symbionts.

Standardized identification of genotypes is necessary in animals that reproduce asexually and form large clonal populations such as coral. We developed a high-resolution hybridization-based genotype array coupled with an analysis workflow and database for the most speciose genus of coral, Acropora, and their symbionts. We designed the array to co-analyze host and symbionts based on bi-allelic single nucleotide polymorphisms (SNP) markers identified from genomic data of the two Caribbean Acropora species as well as their dominant dinoflagellate symbiont, Symbiodinium 'fitti'. SNPs were selected to resolve multi-locus genotypes of host (called genets) and symbionts (called strains), distinguish host populations and determine ancestry of coral hybrids between Caribbean acroporids. Pacific acroporids can also be genotyped using a subset of the SNP loci and additional markers enable the detection of symbionts belonging to the genera Breviolum, Cladocopium, and Durusdinium. Analytic tools to produce multi-locus genotypes of hosts based on these SNP markers were combined in a workflow called the Standard Tools for Acroporid Genotyping (STAG). The STAG workflow and database are contained within a customized Galaxy environment (https://coralsnp.science.psu.edu/galaxy/), which allows for consistent identification of host genet and symbiont strains and serves as a template for the development of arrays for additional coral genera. STAG data can be used to track temporal and spatial changes of sampled genets necessary for restoration planning and can be applied to downstream genomic analyses. Using STAG, we uncover bi-directional hybridization between and population structure within Caribbean acroporids and detect a cryptic Acroporid species in the Pacific.

Role of RAS inhibition in the regulation of Cu/Zn-SOD in the cardiac and peripheral arterial beds in humans.

Inhibition of the renin-angiotensin system (RAS) improves hemodynamics and may ameliorate oxidative stress in heart failure (HF). Through activation of nicotinamide adenine dinucleotide phosphate oxidase, angiotensin II induces superoxide, which is primarily cleared by cytosolic copper-zinc superoxide dismutase (Cu/Zn-SOD). We examined the interdependency of hemodynamics and levels of Cu/Zn-SOD and oxidized low-density lipoprotein (oxLDL) in HF patients, using a randomized, double-blinded, crossover design to compare (i) the outcomes of single-agent therapy with either benazepril or valsartan alone vs. the combination thereof and (ii) the outcome of single-agent treatment with benazepril vs. single-agent treatment with valsartan. After each treatment, arterial (ART) and coronary sinus (CS) blood samples were collected. Cu/Zn-SOD and oxLDL levels were higher in CS samples than in ART samples. Furthermore, patients under combined treatment exhibited the highest CS levels of Cu/Zn-SOD, whereas there was no significant difference between the groups on either benazepril or valsartan alone. This finding suggests an augmentation of the cardiac antioxidative potential under more complete RAS inhibition. Cu/Zn-SOD and oxLDL levels correlated with measures of afterload rather than preload, which in turn suggests a beneficial effect of afterload reduction on oxidative stress in HF.

Improvements in physical and mental domains of quality of life by anti-ischaemic drug and revascularisation treatment in elderly men and women with chronic angina.

BACKGROUND: The severity of angina is related to a reduction in global quality of life (QoL), which may be improved by anti-ischaemic treatment. It is not known, however, whether improvements relate only to physical or also to mental and social domains of QoL and whether women benefit in a similar way to men. OBJECTIVES: To relate improvements in angina severity through anti-ischaemic treatment to physical and mental domains of QoL in elderly men and women and to assess differences in this relation between the sexes. METHODS: Angina severity and full assessment of QoL by structured, self-administered and validated questionnaires were measured prospectively at baseline and after 6 months' optimal drug or revascularisation treatment in all 301 patients of the Trial of Invasive versus Medical therapy in Elderly (TIME) patients with chronic angina. RESULTS: At baseline, angina severity correlated significantly with physical domains of QoL (trend test at least p<0.02) and daily activities (p = 0.05). At similar angina levels, women had significantly lower QoL scores than men. With anti-ischaemic treatment, physical as well as mental and social QoL domains and daily activities improved, together with a relief in angina (trend tests at least p<0.02). This was true for women and men and was more pronounced after revascularisation than with medical treatment. CONCLUSIONS: These findings confirm the relation between angina severity and physical limitation. In addition, they show that anti-ischaemic treatment not only relieves angina and improves physical components of QoL but also improves mental and social domains. This is true for women as well as for men despite the lower overall scores for women.

Headache features in patients with dengue virus infection.

The aim of this study was to describe the frequency and features of headache among patients with confirmed dengue virus infection and to compare the headache features in patients with dengue fever and dengue haemorrhagic fever, primary and secondary dengue infection, and patients with and without neurological involvement. Patients with classic dengue fever had a more intense headache than those with the more severe form of the disease, dengue haemorrhagic fever.

Selection bias of elderly patients with chronic angina referred for catheterization.

BACKGROUND: Registry patients are generally older and more sick than patients enrolled in trials questioning the generalizability of trial results. We assessed whether such a selection bias also exists in elderly patients with chronic angina referred for catheterization. METHODS AND RESULTS: All 119 patients age>or=75 years with Trial of Invasive versus Medical Therapy in the Elderly (TIME) inclusion but no major exclusion criteria referred for catheterization during the TIME trial inclusion period in four TIME centers were registered and followed-up for one year. Registry patients differed from the 188 trial patients in the same hospitals in that they were younger, somewhat more frequently male, with less antianginal drugs and studied more often after acute chest pain at rest but with more comorbidities than study patients. Left ventricular ejection fraction and vessel disease were similar. One year mortality was 11.4% in registry and 9.6% in invasive TIME patients but differences disappeared after adjustment for baseline differences. Symptomatic status after one year was similar too. CONCLUSIONS: In elderly patients with chronic angina, a bias in the selection for invasive management exists which seems different from that reported in younger patient settings. After adjustment for these selection factors, however, one-year outcome was remarkably similar in registry and trial patients.

[An uncommon case of lupus]. / Ein aussergewöhnlicher Fall von Lupus.

A 44-year-old patient was referred with weight loss of some 6 kg in two months, weakness and diarrhoea. According to the criteria of the American College of Rheumatology (ACR), systemic lupus erythematosus (SLE) was diagnosed: photodermatosis, nephropathy, and pancytopenia with positive antinuclear antibodies and antibodies against native DNA. In addition, adrenal failure was diagnosed with hyponatraemia, relapsing fever, low baseline cortisol and impaired response to ACTH stimulation. Clinical features of SLE may obscure signs of adrenal insufficiency, and hence, diagnosis is jeopardized. SLE combined with Addition's disease is rare. In some patients with both disorders, antiphospholipid antibodies, as found in our patient, are considered responsible for the development of Addison's disease. Possible pathogenetic mechanisms such as adrenal haemorrhage or (micro)thrombosis are discussed. The patient's condition significantly improved under steroid therapy. The progression of renal insufficiency (histology: mesangioproliferative glomerulonephritis), however, required additional immunosuppression with cyclophosphamide.

Local epinephrine facilitates laparoscopic Heller myotomy.

Incomplete myotomy and mucosal perforation are the most common technical complications of laparoscopic esophageal myotomy. The muscle layers of the lower esophagus are infiltrated with a 1:100,000 epinephrine solution using a thin needle. Gentle pressure is applied with a peanut sponge to diminish the edema produced by the injections. The longitudinal fibers are separated with a dissector and the semicircular fibers are lifted from the submucosa with a dissector or a hook. The muscle transection is done simply by tearing the fibers or cutting them with scissors. No coagulation is required. Infiltration and topical application of epinephrine solution allowed the performance of 22 laparoscopic esophageal myotomies with excellent visualization, complete muscle division, and without any esophageal or gastric perforation. Injection and topical application of epinephrine solution to the area of the esophagus and stomach which will be subjected to myotomy greatly facilitates the procedure and helps to avoid complications.

Laparoscopic anatomy of the region of the esophageal hiatus.

BACKGROUND: The wide patient acceptance of hiatal and gastroesophageal surgery performed by laparoscopy has suddenly generated a large volume of procedures frequently done by surgeons with limited experience in this area. This has resulted in an excessive number of complications. Knowledge of the normal and pathologic laparoscopic anatomy is essential for safe dissection around the esophageal hiatus. METHODS: This description is based on the experience gained during 850 open and 150 laparoscopic surgeries in and around the hiatus and on the review of the literature. RESULTS: Laparoscopic approach, dissection, and accessibility of the hiatus and surrounding organs are different than those experienced through cadaveric dissection and open surgeries. CONCLUSIONS: Clear understanding of the normal and pathologic anatomy and its variations facilitates laparoscopic dissection of the hiatus and neighboring structures and should help the surgeon avoid complications.

Laparoscopic cholecystostomy with delayed cholecystectomy as an alternative to conversion to open procedure.

BACKGROUND: Acute cholecystitis carries the highest incidence of conversion from planned laparoscopic cholecystectomy to open surgery due to unclear anatomy, excessive bleeding, complications, or other technical reasons. METHODS: Laparoscopic tube cholecystostomy was performed instead of immediate conversion to laparotomy in 9 patients with acute cholecystitis after unsuccessful attempts at laparoscopic dissection. Elective laparoscopic cholecystectomy was done 3 months later. RESULTS: Following this approach eight patients were treated successfully. After 3 months the acute process had subsided sufficiently to allow a safe laparoscopic cholecystectomy. One additional patient died of acute leukemia 6 weeks after cholecystostomy. Before adopting this technique we subjected 171 patients with acute calculous cholecystitis to laparoscopic cholecystectomy; there was an 11% (19 cases) rate of conversion. Since cholecystostomy has begun to be offered as an alternative to conversion, 121 patients with acute cholecystitis have had laparoscopic cholecystectomy and only 2 cases (1.5%) have been converted to immediate open cholecystectomy. CONCLUSIONS: We recommend the alternative of performing a cholecystostomy with delayed laparoscopic cholecystectomy instead of conversion to open procedure when facing a case of acute cholecystitis not amenable to laparoscopic cholecystectomy.

Intraoperative trans-gallbladder cholangiography intended to delineate bile duct anatomy.

Intraoperative cholangiography has been recommended to lower the incidence and severity of biliary tract injury during laparoscopic cholecystectomy. However a literature review of common bile duct (CBD) injuries does not appear to support this concept. Most cystic duct cholangiographies disclose the injury after the fact. This study was designed to compare the technical difficulties and complications of laparoscopic cholecystectomy in three groups of patients: Group 1 underwent intraoperative cholangiography through the gallbladder (n = 288), group 2 underwent intraoperative cholangiography through the cystic duct (n = 162), and group 3 did not undergo cholangiography (n = 227). Cholecystectomies were defined as "difficult" if there was a need to convert to open procedure in the absence of an accidental complication, or if estimated blood loss was over 100 ml, and/or if operating time was over 2 h. Difficult cholecystectomies were encountered in 34% of patients in group 2 and 28.2% of patients in group 3, but in only 7.6% of patients in group 1. Technical complications (bleeding, bile leak, common bile duct injury, retained common bile duct stones, false positive choledocholithiasis, pancreatitis, and trocar injuries) occurred in 11.7% of cases in group 2, 4.4% in group 3, and in only 1.4% of group 1. Intraoperative cholangiography performed through the gallbladder before any dissection was initiated significantly facilitated the operation and helped decrease the incidence of technical complications.

Relation of cyclosporine blood levels to adverse effects on lipoproteins.

Hyperlipidemia is common in renal allograft recipients. To elucidate the role of cyclosporine in posttransplant hyperlipidemia, we measured lipids, lipoprotein lipids, and apolipoproteins of thirty-five renal allograft recipients and evaluated their relation to trough cyclosporine blood levels. All patients were on a triple immunosuppressive regimen with equal doses of prednisone and azathioprine, and had stable graft function. Cyclosporine blood levels were significantly correlated to total plasma cholesterol (P = 0.028), low-density lipoprotein cholesterol (P = 0.022), apolipoprotein B (P = 0.017), and the cholesterol/high-density lipoprotein cholesterol ratio (P < 0.002), but not to plasma triglycerides. Significant inverse correlations were found between cyclosporine blood levels and high-density lipoprotein cholesterol (P = 0.034), high-density lipoprotein3 cholesterol (P = 0.025), and apolipoprotein A-1 (P = 0.047), but not high-density lipoprotein2 cholesterol. The independent relation of cyclosporine blood levels to each of the measured lipid parameters was investigated by a stepwise regression model including age, body mass index, interval from transplantation, diabetes mellitus, plasma creatinine, and intake of diuretics and beta-blockers. After correction for these 7 variables, cyclosporine blood levels remained significantly associated with high-density lipoprotein cholesterol, high-density lipoprotein3 cholesterol, apolipoprotein A-1, apolipoprotein B, low-density lipoprotein cholesterol, and the cholesterol/high-density lipoprotein cholesterol ratio. These data suggest that cyclosporine causes atherogenic dyslipidemia.

Attempts to aid the adaptation of pelvic pouch before temporary ileostomy closure.

Most patients experience a high stool frequency immediately following the closure of the temporary ileostomy after total colectomy and ileoanal pouch reconstruction. Adaptation occurs within the ensuing weeks to reach a plateau in about three months. Increasing volumes of liquid nutrients were injected, twice daily for two months, into the pelvic pouch through a mucous ileal fistula proximal to the pouch before closing the temporary ileostomy. With this method the number of evacuations per 24 hours was significantly reduced during the first few weeks following the reestablishment of intestinal continuity, compared with a control group (average, 8.5 vs. 18.2, respectively). Patients also had better continence and less urgency to defecate. We suggest this technique in patients undergoing pelvic ileal reconstruction with temporary ileostomy.

Laparoscopic technique for repair of paraesophageal hiatal hernias.

Paraesophageal hernias represent a distinct group of hiatal hernias characterized by their potential for devastating complications. Between 1976 and 1992, a total of 270 surgeries were performed for hiatal hernias at Scripps Clinic, La Jolla, California, of which 33 were pure paraesophageal, without reflux. Starting in September 1991, a laparoscopic technique was used for repair of five out of six attempted cases of paraesophageal hiatal hernias. The closure of the hiatal defect was accomplished with mesh stapled to the edges of the hiatus in front of the esophagus. A gastropexy was added attaching the stomach to the diaphragm. This procedure proved to be technically easy and safe, and resulted in less discomfort and faster recovery of the patients when compared to the open procedure. This laparoscopic repair should be considered as a good alternative to the open techniques for paraesophageal hiatal hernias without reflux.

Pharmacologic hemostasis in laparoscopy: topical epinephrine facilitates cholecystectomy.

Bleeding may become a major impediment to accurate and safe dissection by laparoscopy. The traditional maneuvers of pressure, dumping, irrigation, and aspiration frequently applied during open procedures to maintain a clear field of dissection are cumbersome through laparoscopy. Several pharmacologic agents have been used topically or by local injection to stop bleeding or to prevent excessive blood loss during surgical procedures. They include calcium alginate, aluminum salts, silver nitrate, formalin, and coagulating agents like thrombin and collagens, all of which leave a layer of damaged tissue or foreign material on the surface. Epinephrine and vasopressin have been employed mostly by local injections. We report the use of topical epinephrine applied before and during the dissection of the cystic duct and artery area in the course of laparoscopic cholecystectomy. A 3/8-inch gauze sponge, impregnated with a 1:10,000 epinephrine solution, was used to blanch the tissues and to bluntly dissect the cystic duct and artery. It was also used to control minor bleeding in the gallbladder fossa. The prophylactic bleeding control with topical epinephrine proved to be an easy and safe maneuver, and greatly facilitated the dissection of the most critical areas during laparoscopic cholecystectomy. This technique may be applicable to laparoscopic dissection for other procedures.

Intraoperative cholangiography for laparoscopic cholecystectomy.

Intraoperative cholangiography in the course of laparoscopic cholecystectomy is not only valuable to detect common bile duct stones, but also to delineate the anatomy of the biliary ducts, facilitate the dissection, avoid injuries to the biliary tract and identify other abnormalities, such as fistulas, cysts and tumors of the biliary system. Most surgeons use a variation of the transcystic injection of contrast. We describe herein a technique of cholangiography through the gallbladder, performed before starting any dissection in the cystic duct area, which has resulted in a rate of 92 percent of adequate cholangiograms and has proved to be easier, by far, and safer than the transcystic technique. A comparison was made between 405 instances of open cholecystectomies and 200 laparoscopic cholecystectomies with transcystic cholangiograms and 105 laparoscopic cholecystectomies with cholangiograms done through the gallbladder. All instances were done for symptomatic chronic or acute calculous cholecystitis. Satisfactory cholangiograms were obtained in 95 percent of open cholecystectomies and in only 68 percent of transcystic laparoscopic attempts. Complications and false-positive findings were seen in transcystic laparoscopic procedures in five and six instances, respectively. Cholangiography performed through the gallbladder was 100 percent successful among 73 patients with chronic cholecystitis and in 66 percent of 32 patients with acute calculous cholecystitis. For optimal visualization of the bile ducts, it is essential to exert pressure on the gallbladder after the injection of contrast to advance the contrast through the cystic duct. This is greatly facilitated by the use of a double-balloon catheter to avoid leak at the site of the gallbladder puncture.

The role of laparoscopy in the diagnosis of acute appendicitis.

Patients with acute appendicitis who present with an atypical clinical picture are frequently subjected to a series of laboratory and x ray tests and sometimes to prolonged observation before surgery. There is a significant number of normal appendixes found at laparotomy, particularly in some subgroups of patients such as the immunocompromised, the elderly, and the young woman. Laparoscopy was done in 38 patients with right lower quadrant pain of undetermined cause after extensive diagnostic efforts. This group of patients included men and women with an even distribution of ages between 20 and 78 years. Laparoscopy was done under local anesthesia to better establish the site of pain if no obvious pathology could be visualized. Acute appendicitis was confirmed in only 26.3 per cent of the cases, and a wide variety of nonappendiceal diseases were identified, the majority of them requiring no surgery. Diagnostic laparoscopy performed under local anesthesia should be considered in patients suspected to have acute appendicitis, regardless of age and sex, who present with an atypical picture and who still offer diagnostic doubts after other available conventional tests.

[Laparoscopy in acute appendicitis]. / Laparoscopia en la apendicitis aguda.

Our experience shows that laparoscopy is an excellent diagnostic method in cases where acute appendicitis is suspected, but when the clinical picture and tests are equivocal. Laparoscopy can help diagnose other abdominal conditions mimicking acute appendicitis and, in addition, may be used to remove the appendix in most cases, with advantages over open surgery.

Diaphragmatic hernia through the foramen of Morgagni: laparoscopic repair case report.

Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 67-year-old woman with symptoms of partial colon obstruction is described. The patient had a prompt and complete recovery with no evidence of recurrence one year after surgery. The technique, which incorporates the rectus abdominal fascia in the repair, may be suitable for other laparoscopic surgical procedures.