Acute Mitral Regurgitation Secondary to Spontaneous Left Atrial Appendage Occluder Migration.

A patient underwent left atrial appendage occlusion due to recurrent stroke despite new oral anticoagulant therapy. The patient later presented with severe acute mitral regurgitation secondary to occluder device migration, which was retrieved percutaneously from the descending aorta via the femoral artery. Mitral surgical repair was required and successfully performed. (Level of Difficulty: Intermediate.).

Prevalence and prognostic impact of subclinical pulmonary congestion at discharge in patients with acute heart failure.

AIMS: Residual pulmonary congestion at hospital discharge can worsen the outcomes in patients with heart failure (HF) and can be detected by lung ultrasound (LUS). The aim of this study was to analyse the prevalence of subclinical pulmonary congestion at discharge and its impact on prognosis in patients admitted for acute HF. METHODS AND RESULTS: This is a post-hoc analysis of the LUS-HF trial. LUS was performed by the investigators in eight chest zones with a pocket device. Physical exam was subsequently performed by the treating physicians. Primary outcome was a combined endpoint of rehospitalization, unexpected visit for HF worsening or death at 6- month follow-up. Subclinical pulmonary congestion at discharge was defined as the presence of ≥5 B-lines in LUS in absence of rales in the auscultation employing the area under the ROC curve. At discharge, 100 patients (81%) did not show clinical signs of pulmonary congestion. Of these, 41 had ≥5 B-lines. Independent factors related with the presence of subclinical pulmonary congestion were anaemia, higher New York Heart Association (NYHA) class, and N terminal pro brain natriuretic peptide (NT-proBNP). After adjusting by propensity score analysis including age, renal insufficiency, atrial fibrillation, NYHA class, NT-proBNP levels, clinical congestion, and the trial intervention, the presence of subclinical pulmonary congestion at discharge was a risk factor for the occurrence of the primary outcome (hazard ratio 2.63; 95% confidence interval: 1.08-6.41; P = 0.033). CONCLUSIONS: Up to 40% of patients considered 'dry' according to pulmonary auscultation presents subclinical congestion at hospital discharge that can be detected by LUS and implies a worse prognosis at 6- month follow-up. Comorbidities, high values of natriuretic peptides, and higher NYHA class are the factors related with its presence.

Lung ultrasound-guided treatment in ambulatory patients with heart failure: a randomized controlled clinical trial (LUS-HF study).

AIMS: Lung ultrasound (LUS) is a useful tool with which to assess subclinical pulmonary congestion and to stratify the prognosis of patients with heart failure (HF). The aim of this study was to evaluate whether an LUS-guided follow-up protocol improves the outcomes of patients with HF. METHODS AND RESULTS: In this single-blind clinical trial, 123 patients admitted for HF were randomized to either a standard follow-up (n = 62, control group) or a LUS-guided follow-up (n = 61, LUS group). The primary endpoint was a composite of urgent visit, hospitalization for worsening HF and death during follow-up. Visits were scheduled at 14, 30, 90 and 180 days after discharge. Treating physicians were encouraged to modify diuretic therapy in accordance with the number of B-lines recorded by LUS. The mean ± standard deviation (SD) age of the patients was 69 ± 12 years and 72% were male. The mean ± SD left ventricular ejection fraction was 39 ± 14%. The hazard ratio for the primary outcome in the LUS group was 0.518 [95% confidence interval (CI) 0.268-0.998; P = 0.049], mainly resulting from a decrease in the number of urgent visits for worsening HF. The number of patients needed to treat to avoid an event was 5 (95% CI 3-62). Other secondary endpoints such as N-terminal pro-B-type natriuretic peptide reduction were not achieved. The safety parameters were similar in the two groups. Patients in the LUS group received more loop diuretics [51 (91%) vs. 42 (75%); P = 0.02] and showed an improvement in the distance achieved in the 6-min walking test [60 m (interquartile range: 29-125 m) vs. 37 m (interquartile range: 5-70 m); P = 0.023]. CONCLUSIONS: Tailored LUS-guided diuretic treatment of pulmonary congestion in this proof-of-concept study reduced the number of decompensations and improved walking capacity in patients with HF. LUS is a non-invasive, safe and easy-to-use technique with potential clinical applicability to guide pulmonary congestion treatment in patients with HF.

Electrocardiographic Distinction of Left Circumflexand Right Coronary Artery Occlusion in PatientsWith Inferior Acute Myocardial Infarction.

Previously reported electrocardiographic (ECG) criteria to distinguish left circumflex (LCCA) and right coronary artery (RCA) occlusion in patients with acute inferior ST-segment elevation myocardial infarction (STEMI) afford a modest diagnostic accuracy. We aimed to develop a new algorithm overcoming limitations of previous studies. Clinical, ECG, and coronary angiographic data were analyzed in 230 nonselected patients with acute inferior STEMI who underwent primary percutaneous coronary intervention. A decision-tree analysis was used to develop a new ECG algorithm. The diagnostic accuracy of reported ECG criteria was reviewed. LCCA occlusion occurred in 111 cases and RCA in 119. We developed a 3-step algorithm that identified LCCA and RCA occlusion with a sensitivity of 77%, specificity of 86%, accuracy of 82%, and Youden index of 0.63. The area under the ROC curve was 0.85 and resulted 0.82 after a 10-fold cross validation. The key leads for LCCA occlusion were V3 (ST depression in V3/ST elevation in III >1.2) and V6 (ST elevation ≥0.1 mV or greater than III). The key leads for RCA occlusion were I and aVL (ST depression ≥ 0.1 mV). Fifteen of 21 reviewed studies had less than 20 cases of LCCA occlusion, only 48% performed primary percutaneous coronary intervention, and previous infarction or multivessel disease were often excluded. The diagnostic accuracy of reported ECG criteria decreased when applied to our study population. In conclusion, we report a simple and highly discriminative 3-step ECG algorithm to differentiate LCCA and RCA occlusion in an "all comers" population of patients with acute inferior STEMI. The diagnostic key ECG leads were V3 and V6 for LCCA and I and aVL for RCA occlusion.

Determination of Nine Fungicides in Grape and Wine Using QuEChERS Extraction and LC/MS/MS Analysis.

An analytic procedure was developed for the determination of the fungicides ametoctradin, boscalid, cyazofamid, dimethomorph, fenhexamid, kresoxim-methyl, mepanipyrim, metrafenone, and pyraclostrobin in grape and wine. A modified QuEChERS (Quick, Easy, Cheap, Effective, Rugged, and Safe) procedure was used for the extraction. Analysis of the extract was performed by LC/triple quadrupole-MS/MS. A Poroshell 120 EC-C18 column was used with a programmed gradient mobile phase consisting of (A) acetonitrile containing 0.1% formic acid and (B) water containing 0.1% formic acid and 2 mM ammonium formate. The acceptance criteria for the method were those proposed in the SANCO guide. The method was linear for the range of concentration studied (5-100 µg/L), and R2 values were higher than 0.998 and RSD values below 18%. Recovery was over 73.2% in grape and 76.7% in wines, and there was no case of more than 100% recovery. The recovery RSDs in reproducibility conditions were below 17.13% in grape and 15.6% in wines.

Does bariatric surgery reduce cancer risk? A review of the literature / Cirugía bariática reduce el riesgo de cáncer? Una revisión de la literatura

INTRODUCTION: Bariatric surgery has been shown to provide sustained weight loss and to decrease obesity-related mortality in most patients with morbid obesity, but its effect on cancer risk is less clear. Our aim was to review the published studies on the association between bariatric surgery and cancer risk. METHODS: A literature search for relevant articles published in English, with no limitation on the year of publication, was conducted using PubMed. Studies reporting data on preoperative cancer, case reports, and publications with no abstract available were excluded. RESULTS: Overall, the published literature suggests that bariatric surgery may decrease risk of cancer, although this effect appears to be limited to women. However, two recent studies contradict these findings and state that risk of cancer has not been actually shown to decrease after surgery, and an increased risk of colorectal cancer has even been seen. Although most studies report lower cancer risk after bariatric surgery, the main limitations include their designs, which do not achieve the highest levels of evidence. Moreover, several mechanisms have been proposed to explain the protective effect of surgery, but the exact mechanisms have not been elucidated yet, which suggests the need for further research. CONCLUSIONS: Bariatric surgery may have a protective effect from overall cancer risk, mainly in women, but additional research is needed. Further research is also required to better examine the relationship between bariatric surgery and risk of colorectal cancer before confirming or dismissing the above reported higher risk, as well as the risk of esophagogastric cancer, which has not been adequately studied to date

INTRODUCCIÓN: La cirugía bariátrica proporciona una pérdida de peso mantenida y una reducción de la mortalidad relacionada con la obesidad en la mayoría de pacientes con obesidad mórbida, no obstante, su efecto sobre el riesgo de cáncer es menos claro. Nuestra intención fue revisar los estudios publicados hasta la fecha sobre la asociación entre cirugía bariátrica y riesgo de cáncer. MÉTODOS: Se realizó una búsqueda bibliográfica utilizando Pubmed para artículos relevantes, publicados en inglés sin límite de fechas de publicación. Los estudios que relataban datos sobre cáncer preoperatorio, los casos clínicos y publicaciones sin resumen disponible no fueron incluidos. RESULTADOS: En conjunto, los artículos publicados en la literatura sugieren que la cirugía bariátrica puede disminuir el riesgo de cáncer, aunque el efecto beneficioso parece limitado a las mujeres. No obstante, 2 estudios recientes contradicen estos hallazgos, revelando que no se ha podido comprobar realmente que mejore el riesgo de cáncer después de la cirugía bariátrica, y que incluso se ha observado un aumento del riesgo de cáncer colorrectal. Aunque la mayoría de estudios refieren disminución del riesgo de cáncer después de la cirugía, las principales limitaciones son los diseños, que no alcanzan los niveles más elevados de evidencia. Además, se han propuesto varios mecanismos para explicar el efecto protector de la cirugía, no obstante, aún no se conocen con precisión, indicando la necesidad de más investigación. CONCLUSIONES: La cirugía bariátrica podría tener un efecto protector sobre el riesgo general de cáncer, principalmente en mujeres, pero se necesita más investigación para su confirmación. De la misma manera, se requiere más investigación para examinar la relación entre la cirugía bariátrica y el riesgo de cáncer de colon antes de confirmar o desmentir el aumento del riesgo referido recientemente. También son necesarios más estudios sobre el riesgo de cáncer gastroesofágico poscirugía bariátrica, ya que no se ha estudiado adecuadamente hasta la actualidad

Does bariatric surgery reduce cancer risk? A review of the literature.

INTRODUCTION: Bariatric surgery has been shown to provide sustained weight loss and to decrease obesity-related mortality in most patients with morbid obesity, but its effect on cancer risk is less clear. Our aim was to review the published studies on the association between bariatric surgery and cancer risk. METHODS: A literature search for relevant articles published in English, with no limitation on the year of publication, was conducted using PubMed. Studies reporting data on preoperative cancer, case reports, and publications with no abstract available were excluded. RESULTS: Overall, the published literature suggests that bariatric surgery may decrease risk of cancer, although this effect appears to be limited to women. However, two recent studies contradict these findings and state that risk of cancer has not been actually shown to decrease after surgery, and an increased risk of colorectal cancer has even been seen. Although most studies report lower cancer risk after bariatric surgery, the main limitations include their designs, which do not achieve the highest levels of evidence. Moreover, several mechanisms have been proposed to explain the protective effect of surgery, but the exact mechanisms have not been elucidated yet, which suggests the need for further research. CONCLUSIONS: Bariatric surgery may have a protective effect from overall cancer risk, mainly in women, but additional research is needed. Further research is also required to better examine the relationship between bariatric surgery and risk of colorectal cancer before confirming or dismissing the above reported higher risk, as well as the risk of esophagogastric cancer, which has not been adequately studied to date.