Sensor-Controlled Digital Game for Heart Failure Self-management: Protocol for a Randomized Controlled Trial

BACKGROUND

Heart failure (HF) is the leading cause of hospitalization among older adults in the United States. There are substantial racial and geographic disparities in HF outcomes, with patients living in southern US states having a mortality rate 69% higher than the national average. Self-management behaviors, particularly daily weight monitoring and physical activity, are extremely important in improving HF outcomes; however, patients typically have particularly low adherence to these behaviors. With the rise of digital technologies to improve health outcomes and motivate health behaviors, sensor-controlled digital games (SCDGs) have become a promising approach. SCDGs, which leverage sensor-connected technologies, offer the benefits of being portable and scalable and allowing for continuous observation and motivation of health behaviors in their real-world contexts. They are also becoming increasingly popular among older adults and offer an immersive and accessible way to measure self-management behaviors and improve adherence. No SCDGs have been designed for older adults or evaluated to test their outcomes.

OBJECTIVE

This randomized clinical trial aims to assess the efficacy of a SCDG in integrating the behavioral data of participants with HF from weight scale and activity tracker sensors to activate game progress, rewards, and feedback and, ultimately, to improve adherence to important self-management behaviors.

METHODS

A total of 200 participants with HF, aged ≥45 years, will be recruited and randomized into 2 groups: the SCDG playing group (intervention group) and sensor-only group (control group). Both groups will receive a weight scale, physical activity tracker, and accompanying app, whereas only the intervention group will play the SCDG. This design, thereby, assesses the contributions of the game. All participants will complete a baseline survey as well as posttests at 6 and 12 weeks to assess the immediate effect of the intervention. They will also complete a third posttest at 24 weeks to assess the maintenance of behavioral changes. Efficacy and benefits will be assessed by measuring improvements in HF-related proximal outcomes (self-management behaviors of daily weight monitoring and physical activity) and distal outcomes (HF hospitalization, quality of life, and functional status) between baseline and weeks 6, 12, and 24. The primary outcome measured will be days with weight monitoring, for which this design provides at least 80% power to detect differences between the 2 groups.

RESULTS

Recruitment began in the fall of 2022, and the first patient was enrolled in the study on November 7, 2022. Recruitment of the last participant is expected in quarter 1 of 2025. Publication of complete results and data from this study is expected in 2026.

CONCLUSIONS

This project will generate insight and guidance for scalable and easy-to-use digital gaming solutions to motivate persistent adherence to HF self-management behaviors and improve health outcomes among individuals with HF.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05056129; https://clinicaltrials.gov/ct2/show/NCT05056129.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45801.

Assessment of no-reflow phenomenon by non-constrast computed tomography in patients with acute myocardial infarction undergoing primary percutaneous coronary angioplasty

Funding Acknowledgements

Type of funding sources: None.

Background

  Coronary no-reflow phenomenon after primary percutaneous coronary angioplasty (pPCI) is an independent predictor of adverse clinical outcomes after AMI regardless of infarct size. The incidence of no-reflow varies widely depending on the diagnostic methods used.

 

Purpose

Showing whether non-contrast CT performed after pPCI might be usefull as a diagnosis of no-reflow phenomenon.

Methods

Six STEMI patients (mean age = 68.3 y/o) underwent revascularization by pPCI and stent placement within 6 hours after onset of angina and within less than 90 minutes of door-to-balloon time.  Due to the outbreak of SARS-Cov-2, chest CT scanning was indicated in all patients before coronary unit admission (192 ± 102 mins after pPCI).  

Results

  Three patients with a higher time than the mean angina time and than the mean door-to-ballon time (190 ± 149.3 versus 170 ± 107.5 and 63 ± 6.08 vs 56 ± 11.5, respectively) developed an interventional type of no-reflow phenomenon (Table 1) and CT scanning showed regional myocardial contrast retention related to the culprit coronary artery (Figure 1).  On the other hand, three patients with a lower time than the mean angina time and than the mean door-to-ballon time showed TIMI III flow after pPCI (Table 1) and CT scanning showed no regional myocardial contrast retention (Figure 2). 

Conclusion

Myocardial regional contrast retention, evaluated by non-contrast and non-ECG-gated computed tomography after pPCI, might be usefull for no-reflow diagnosis.

TABLE 1

AGE ANGINA-TIME DOOR-TO-BALLON-TIME  BASAL/cTnT  POST-pPCI/cTnT  CHANGE/cTnT

PTS 68 ± 17y/o 170 ± 107mins 56 ± 11mins 1635 ± 2549ng/L 9621 ± 4586ng/L 588% 

(N = 6)

NO-REFLOW

PATS 65 ± 25y/o 190 ± 149mins 63 ± 6mins 761 ± 837ng/L 11151 ± 2787ng/L 1465%

(N = 3)

TIMI-III FLOW

PTS 72 ± 9y/o 117 ± 76mins 49 ± 12mins 2219 ± 3653ng/L 18091 ± 6148ng/L 364%

(N = 3)

Nighttime Agitation in Persons with Dementia as a Manifestation of Restless Legs Syndrome

OBJECTIVES

Nighttime agitation or "sundowning" is challenging for clinicians and caregivers to manage in older adults in the dementia stage of Alzheimer's disease (AD-D). Our research previously revealed that nighttime agitation might be a manifestation of restless legs syndrome (RLS). The current study aims to describe the characteristics of older adults with AD-D, nighttime agitation, and RLS, and to evaluate sleep disturbance and iron status in relation to nighttime agitation severity.

DESIGN

An observational study with baseline descriptive and correlational data from a clinical trial.

SETTING AND PARTICIPANTS

Long-term care (n = 69) and independent living (n = 7); age 82.91 ± 9.46 years, with AD-D, nighttime agitation, and RLS.

MEASUREMENTS

Trained observers counted nighttime agitation behaviors. Independent variables were age; cognition measured by the Mini-Mental State Examination; minutes slept from actigraphy; transferrin saturation percentage (TS%) and transferrin from fasting blood samples; and illness severity using the Cumulative Illness Rating Scale for Geriatrics. Bivariate and multivariable linear regression models were generated.

RESULTS

In the multivariable model, sleep minutes (P = .002) and TS% (P = .003) were negatively associated with frequency of nighttime agitation behaviors, and they explained 20% of the variance. Seventy-nine percent received 1 or more medications that worsen RLS symptoms, such as antihistamines and serotonin reuptake inhibitors.

CONCLUSIONS AND IMPLICATIONS

We encourage clinicians to consider nighttime agitation as a manifestation of RLS. Treatment of iron deficiency indicated by low TS% and deprescribing medications that exacerbate RLS may decrease nighttime agitation, improve sleep, and enhance quality of life in older adults with AD-D.

Nighttime Agitation and Restless Legs Syndrome in Persons With Alzheimer's Disease: Study Protocol for a Double-Blind, Placebo-Controlled, Randomized Trial (NightRest)

Nighttime agitation is a prevalent symptom in persons with Alzheimer's disease (AD). Effective treatments are absent due to our limited knowledge of its etiology. We hypothesized that restless legs syndrome (RLS), a common neurological sensorimotor disorder of uncomfortable leg sensations that appear at night and interfere with sleep, might be a cause for nighttime agitation in persons with AD. RLS is infrequently identified in persons with AD because traditional diagnosis is dependent on patients answering complex questions about their symptoms. With a validated observational tool for RLS diagnosis, the Behavioral Indicators Test-Restless Legs, we aim to diagnose RLS and determine the effect of gabapentin enacarbil (GEn) compared to placebo on nighttime agitation, sleep, antipsychotic medications, and the mechanism for these effects. We hypothesize that frequency of RLS behaviors will mediate the relationship between GEn and nighttime agitation. This study is an 8-week, double-blind, placebo-controlled, randomized pilot clinical trial, followed by an 8-week open-label trial, that is being conducted in long-term care settings and private homes. The results of this study may shift, personalize, and improve standards of care for treatment of nighttime agitation; reduce aggression and other nighttime agitation behaviors; and improve sleep.

TARGETS

Persons with AD with nighttime agitation potentially caused by RLS.

INTERVENTION DESCRIPTION

Diagnose RLS and determine the effect of GEn.

MECHANISMS OF ACTION

The frequency of RLS behaviors will mediate the relationship between GEn and nighttime agitation.

OUTCOMES

Determine the effect of GEn on nighttime agitation, sleep, and antipsychotic medications.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03082755 (Date of registration March 6, 2017). [Research in Gerontological Nursing, 13(6), 280-288.].

0438 Automatic Nighttime Agitation and Sleep Disruption Detection Using a Wearable Ankle Device and Machine Learning

Introduction

Nighttime agitation behavior such as wandering and restlessness during awake and sleep in people with Alzheimer’s disease (AD) is expensive to manage and adversely affects sleep. Nighttime agitation is mostly noted by subjective caregiver reports. An automated process for this assessment would improve clinical management. Here we report on the RestEaZeTM system that uses an ankle band and machine learning to automatically classify sleep status and nighttime agitation behaviors in older adults with AD.

Methods

We collected data on 7 adults (mean: 81 years, SD: 10.6) with AD. They wore the RestEaZeTM ankle band with a 3-axis accelerometer, a 3-axis gyroscope, and three textile capacitive sensors. A trained Research Assistant (RA) continuously observed for wandering, restlessness, wake, and sleep between 5pm and 7am using the Cohen Mansfield Agitation Inventory (CMAI). We merged, and band-pass filtered the data and divided it into 10-second non-overlapping windows. CMAI labels and time-series features (scaled using StandardScaler) extracted from the RestEaZeTM data were used to train a Random Forest binary classifier. The significant features were extracted based on the impact on the p-value for the classifier. We used the Synthetic Minority Oversampling Technique (SMOTE) to balance the dataset and performed 5-fold cross-validation with a 67-33 train-test split.

Results

We report the sensitivity, specificity, accuracy, and Area-under-the Curve (AUC) for the ROC curve for the classifiers: (1) Sleep/Awake: sensitivity=0.95, specificity=0.87, accuracy=0.92, AUC=0.97; (2) Wandering/Non-Wandering: sensitivity=0.85, specificity=0.99, accuracy=0.98, AUC=0.99; and (3) Restless/Non-Restless: sensitivity=0.84, specificity=0.84, accuracy=0.84, AUC=0.92. The significant features were related to the intensity of movements.

Conclusion

Our preliminary results show the feasibility of using RestEaZeTM for quantitatively measuring nighttime agitation. These can provide clinically useful objective measures of agitation that can be automatically transmitted to clinical or research records with minimal staff time requirements.

Support

The authors acknowledge the funding support from the National Institute on Aging under award R01AG051588 and Arbor Pharmaceuticals for support for Horizant and the matching placebo.

Comparing Delivery Approaches to Teaching Abnormal Psychology: Investigating Student Perceptions and Learning Outcomes

This study compares the academic performance and perceptions of 114 undergraduate students enrolled in an abnormal psychology course. Specifically, this study focuses on whether face-to-face (F2F) or blended modalities are associated with student learning outcomes. In this study, data analysis was based upon the examination of end-of-course grades, final exams, and an end-of-course survey. The data revealed that the same course presented in a F2F and a hybrid modality was associated with nearly identical learning outcomes in terms of student evaluations and final exam scores. However, students did note differences in course delivery in terms of time, assessment, and overall structure.

Non-amyloid and amyloid prion protein deposits in prion-infected mice differ in blockage of interstitial brain fluid

AIMS

Prion diseases are characterized by brain deposits of misfolded aggregated protease-resistant prion protein (PrP), termed PrPres. In humans and animals, PrPres is found as either disorganized non-amyloid aggregates or organized amyloid fibrils. Both PrPres forms are found in extracellular spaces of the brain. Thus, both might block drainage of brain interstitial fluid (ISF). The present experiments studied whether ISF blockage occurred during amyloid and/or non-amyloid prion diseases.

METHODS

Various-sized fluorescein-labelled ISF tracers were stereotactically inoculated into the striatum of adult mice. At times from 5 min to 77 h, uninfected and scrapie-infected mice were compared. C57BL/10 mice expressing wild-type anchored PrP, which develop non-amyloid PrPres similar to humans with sporadic Creutzfeldt-Jakob disease, were compared with Tg44+/+ mice (transgenic mice secreting anchorless PrP) expressing anchorless PrP, which develop amyloid PrPres similar to certain human familial prion diseases.

RESULTS

In C57BL/10 mice, extensive non-amyloid PrPres aggregate deposition was not associated with abnormal clearance kinetics of tracers. In contrast, scrapie-infected Tg44+/+ mice showed blockage of tracer clearance and colocalization of tracer with perivascular PrPres amyloid.

CONCLUSIONS

As tracer localization and clearance was normal in infected C57BL/10 mice, ISF blockage was not an important pathogenic mechanism in this model. Therefore, ISF blockage is unlikely to be a problem in non-amyloid human prion diseases such as sporadic Creutzfeldt-Jakob disease. In contrast, partial ISF blockage appeared to be a possible pathogenic mechanism in Tg44+/+ mice. Thus this mechanism might also influence human amyloid prion diseases where expression of anchorless or mutated PrP results in perivascular amyloid PrPres deposition and cerebral amyloid angiopathy.

Lack of influence of prion protein gene expression on kainate-induced seizures in mice: studies using congenic, coisogenic and transgenic strains

Prion protein (PrP) is a glycosylphosphatidylinositol (GPI) anchored cell surface protein expressed by many cells, including those of the mammalian nervous system. At present the physiologic functions of PrP remain unclear. Deletion of Prnp, the gene encoding PrP in mice, has been shown to alter normal synaptic and electrophysiologic activities, indicating a potential role in seizure susceptibility. However, published efforts to link PrP with seizures, using both in vivo and in vitro models, are conflicting and difficult to interpret due to use of various mouse backgrounds and seizure induction techniques. Here we investigated the role of PrP in kainic acid (KA)-induced seizure sensitivity, using three types of mice. In contrast to previous published results, Prnp-/- mice on the C57BL/10SnJ background had a significant decrease in KA-induced seizure susceptibility. In genetic complementation experiments using a PrP-expressing transgene, genes derived from strain 129/Ola, which flanked the Prnp-/- locus in C57BL/10SnJ mice, rather than Prnp itself, appeared to account for this effect. Furthermore, using coisogenic 129/Ola mice differing only at Prnp, this difference was not reproduced when comparing PrP-negative and PrP-positive mice. In contrast, substrains of PrP-expressing C57BL mice, showed large variations in KA-induced seizure sensitivity. The magnitude of these differences in susceptibility was larger than that associated with the presence of the Prnp gene, suggesting extensive influence of genes other than Prnp on seizure sensitivity in this system.

Pelvis and total hip arthroplasty acetabular component orientations in sitting and standing positions: measurements reproductibility with EOS imaging system versus conventional radiographies

INTRODUCTION

The literature has recently underlined the interest of pelvic and acetabular component orientation measurements in the standing and sitting position. Radiographic follow-up of total hip arthroplasty (THA) is based on standard AP and lateral X-rays. The use of EOS™ 2D imaging system reduces patient's radiation exposure compared to conventional X-rays. However, using this system, the validity and reproducibility of angular measurements, have not been studied yet for the measurement of pelvic and acetabular parameters in patients with THA.

HYPOTHESIS

The EOS™ 2D imaging system offers similar advantages to conventional X-rays in the measurement of pelvic and acetabular orientation parameters which are commonly used.

PATIENTS AND METHOD

Five angular parameters characterizing pelvic tilt and acetabular cup orientation were determined using the same digital measurement Imagika™ software based on two series of standard X-rays and EOS™ 2D images acquired in both standing and sitting positions. Radiographs from 50 patients with unilateral THA were measured three times by two observers. Intra- and interobserver reproducibility using each method was independently studied then paired comparison was performed.

RESULTS

The ICC and Spearman rank correlation coefficient demonstrated an excellent EOS/conventional X-ray correlation. According to the parameters, the mean difference between these two imaging modalities ranged from 0.30° to 3.43° (P<0.05). The intra- and interobserver variability ranged from ± 2.97° to ± 6.46° using the EOS™ imaging system and from ± 4.26° to ± 10.22° using conventional X-rays (P<0.05).

DISCUSSION

The EOS™ 2D imaging system may replace conventional X-rays in the assessment and monitoring of pelvic and acetabular cup orientation in THA.

LEVEL OF EVIDENCE

Level III. Prospective diagnostic study.

The EOS imaging system for understanding a patellofemoral disorder following THR

An aspect of patellofemoral syndrome secondary to total hip replacement (THR) is mainly suggestive of a problem of femoral implant torsion. We here present the first reported case of patellofemoral syndrome secondary to THR relating to limb-length discrepancy, with no abnormality of femoral torsion. The pelvis adapted to the length inequality by axial rotation rather than frontal tilt, and this went undetected on standard X-ray and CT-scan. 3D imaging in upright posture on the EOS system enabled the situation to be clearly described and analyzed, and adapted surgical correction to be indicated.

Transgenes in Mexican maize: molecular evidence and methodological considerations for GMO detection in landrace populations

A possible consequence of planting genetically modified organisms (GMOs) in centres of crop origin is unintended gene flow into traditional landraces. In 2001, a study reported the presence of the transgenic 35S promoter in maize landraces sampled in 2000 from the Sierra Juarez of Oaxaca, Mexico. Analysis of a large sample taken from the same region in 2003 and 2004 could not confirm the existence of transgenes, thereby casting doubt on the earlier results. These two studies were based on different sampling and analytical procedures and are thus hard to compare. Here, we present new molecular data for this region that confirm the presence of transgenes in three of 23 localities sampled in 2001. Transgene sequences were not detected in samples taken in 2002 from nine localities, while directed samples taken in 2004 from two of the positive 2001 localities were again found to contain transgenic sequences. These findings suggest the persistence or re-introduction of transgenes up until 2004 in this area. We address variability in recombinant sequence detection by analyzing the consistency of current molecular assays. We also present theoretical results on the limitations of estimating the probability of transgene detection in samples taken from landraces. The inclusion of a limited number of female gametes and, more importantly, aggregated transgene distributions may significantly lower detection probabilities. Our analytical and sampling considerations help explain discrepancies among different detection efforts, including the one presented here, and provide considerations for the establishment of monitoring protocols to detect the presence of transgenes among structured populations of landraces.

Towards an objective evaluation of tolerances for beam modeling in a treatment planning system

The performance of a convolution/superposition based treatment planning system depends on the ability of the dose calculation algorithm to accurately account for physical interactions taking place in the tissue, key components of the linac head and on the accuracy of the photon beam model. Generally the user has little or no control over the performance of the dose calculation algorithm but is responsible for the accuracy of the beam model within the constraints imposed by the system. This study explores the dosimetric impact of limitations in photon beam modeling accuracy on complex 3D clinical treatment plans. A total of 70 photon beam models was created in the Pinnacle treatment planning system. Two of the models served as references for 6 MV and 15 MV beams, while the rest were created by perturbing the reference models in order to produce specific deviations in specific regions of the calculated dose profiles (central axis and transverse). The beam models were then used to generate 3D plans on seven CT data sets each for four different treatment sites (breast and conformal prostate, lung and brain). The equivalent uniform doses (EUD) of the targets and the principal organs at risk (OARs) of all plans ( approximately 1000) were calculated and compared to the EUDs delivered by the reference beam models. In general, accurate dosimetry of the target is most greatly compromised by poor modeling of the central axis depth dose and the horns, while the EUDs of the OARs exhibited the greatest sensitivity to beam width accuracy. Based on the results of this analysis we suggest a set of tolerances to be met during commissioning of the beam models in a treatment planning system that are consistent in terms of clinical outcomes as predicted by the EUD.

An oligoarray for the detection of human papillomavirus type 16 variants

On the basis of human papillomavirus (HPV) E6 gene mutations, there are more than five variants of HPV 16. We applied a sensitive and specific stacking hybridization assay using an oligoarray for the detection of Asian–American (AA) and European (E) (E350G) HPV 16 variants. A simple glass slide was coated with capture probes consisting of short oligonucleotide DNA sequences (7–9 mers) specific for AA and E variants. Two different regions of the E6 HPV 16 gene were amplified with a set of two primers, which were used as target DNA. These targets were preannealed with auxiliary labeled oligonucleotides and hybridized to the oligoarray in the presence of specific and complementary capture probes. Our designed array based on shorter capture probes successfully discriminated between HPV 16 AA and E variants. The present DNA oligoarray system could be useful as a reliable technique for HPV 16 detection and does not require specialized equipment; nevertheless, further intra- and interlaboratory studies are needed.

Unusual giant patent ductus arteriosus associated with ventricular septal defect and discrete aortic coarctation. A case report

The authors present the case of a 26 years old female, 56 kg weight and 154 cm height, with a giant patent ductus arteriosus (2.4 cm of internal diameter), ventricular septal defect, discrete preductal narrowing of the aortic arch and pulmonary artery hypertension that did not diminished after 100% oxygen breathing. The authors speculate about the origin of the giant ductus here presented, based on hemodynamic and embryological data.

Left ventricular diastolic dysfunction secondary to hyperglycemia in patients with type II diabetes

Diabetes mellitus type II, a cause of preclinical left ventricular dysfunction that can progress to cardiac insufficiency ventricular dysfunction in diabetic patients, is attributed to systemic arterial hypertension, or ischemic cardiopathy. Diastolic ventricular dysfunction takes place during the course of diabetes mellitus. The purpose of the present article is to report on the influence of hyperglycemia on the left ventricular diastolic dysfunction independently of dyslipidemia, obesity, and systemic arterial hypertension, usually present in diabetic patients. Left ventricular diastolic function was studied by Doppler echocardiography in asymptomatic type II diabetic patients without ischemic or valvular cardiopathies, cardiomegaly, or systemic arterial hypertension. Two groups of patients were integrated: patients with and without left ventricular diastolic dysfunction, i.e., groups A and B, respectively. Glycemia, cholesterol, triglycerides, and body mass index (BMI) were determined in each subject. Bivariate statistical tests (Student t, chi-square, or Mann-Whitney U tests) were applied to study the influence of the previously mentioned variables on the ventricular diastolic function. To evaluate the influence of hyperglycemia on ventricular diastolic function separately from dyslipidemia, systemic arterial hypertension, and the influence of obesity, logistic regression, and multivariate statistical analysis were applied. Independently of dyslipidemia and obesity, a relationship was found between hyperglycemia and diastolic dysfunction of the left ventricle in patients belonging to group A (p <0.05, odds ratio [OR] 12.1). No statistical significance was found between glycemia and the diastolic function of the left ventricle in group B patients. Even in type II diabetic patients without cardiopathy, uncontrolled hyperglycemia provokes diastolic left ventricular dysfunction.

[Ergotism caused by automedication]

The authors report 7 cases of gangrenous ergotism (six women and one man) secondary to an overdose of ergotamine ingested in order to relieve migraine crisis. In all cases, patients presented symptoms and signs of severe arterial constriction confirmed by echography and angiography. Hallucinations were absent. Ergotamine ingestion was discontinued and treatment was based on vasodilators and sympathectomy. After treatment, all seven patients showed clinical improvement with disappearance of the vasospastic symptoms and signs, and an increase in the plethysmographic index of blood perfusion, measured by Doppler echography. These changes were observed even in a patient who lost two toes of the right foot. Although, none of the patients presented hallucinations, the authors made reference to the historical first use of the ergot in magic and religious rites that took place in Eleusis, at the time of classic Greece, as well as the more recent mystic use of ergot in Salem, New England, in 1692. Migraine is indeed a serious disease, frequently causing despair to the patient, who attempts to alleviate the migraneous crisis with an overdose of ergotamine. Accordingly, physicians must be aware of prophylactic vasodilating drugs, reducing the risk of ergotism.

Aortic origin of the right pulmonary artery associated with ductus arteriosus in an adult. A case report

We describe the case of a 26-year-old female in functional class I (NYHA), with aortic origin of the right pulmonary artery associated with a persistent ductus arteriosus and severe pulmonary artery hypertension (101/40-70 mm Hg), which remained elevated (89/40-60 mm Hg) after the administration of 100% oxygen. Right pulmonary artery pressure (125/60-86 mm Hg) was higher than that of main pulmonary artery and similar to aorta pressure. The patient was successfully treated: surgical closure of the ductus arteriosus and end-to-end anastomosis between the pulmonary artery and right pulmonary artery were carried out. Systolic pulmonary arterial pressure, estimated by echocardiography Doppler, was 60 mm Hg six months after surgery. Cross-sectional echocardiogram showed the anastomosis of the right pulmonary artery with the main pulmonary artery. Pulmonary gammagraphy showed both lungs perfused through the main pulmonary artery; right lung perfusion was lesser than left lung perfusion, 30 vs. 70% respectively. Aortic origin of a right or left pulmonary artery is a heart disease seen in patients during the course of the first year of life. Its frequency is < 1% among all the congenital cardiopathies and the survival rate to adult life is very low. The originality of this paper is the presentation of a rare congenital cardiopathy treated surgically in an adult.

[Control of inhaled triggering factors decreases prolonged drug therapy requirements in patients with asthma]

The past decade of research has led to a greater understanding of the pathogenesis of asthma and, in particular, the pivotal role of the underlying inflammatory process. Along with inheritance in atopic patients, the presence of inhaled triggering allergens are considered the predominant predisposing factors in the development of the disease. We have conducted a longitudinal clinical therapeutic study, which included 45 pediatrics patients with asthma, in order to evaluate whether the removal of any potential inhaled triggering factor, could decrease the requirement of drug based anti-inflammatory therapy. Patients admitted in this study presented at least, two monthly asthma attacks during the last four months. A single treatment with theophylline (group A), beclomethasone (group B) or salbutamol (group C), was prescribed during the first 2 weeks, along with specific instructions to avoid inhaled allergens. Regardless of the drug used, patients showed impressive and prolonged clinical improvement during 6 months, reduction of total IgE serum levels in the three groups (p < 0.02; 0.005 and 0.02 respectively) and favorable modification of force expiratory volume at the first second, forced vital capacity and flow expiratory peak. During the observation period a constant monitoring of mites allergens concentrations was performed, showing a decrease of these antigens, associated with clinical improvement, and only in those patients who remained symptomatic (group A 31%, group B 29% and group C 9%), failures performing the measures designed to reduce their exposure to environmental allergens, was demonstrated. These results suggest that reduction of inhaled triggering factors may decrease the requirement of anti-inflammatory drug therapy to control the symptoms in patients with asthma.

Endomyocardial fibrosis (Davies disease) coincidental with systemic lupus erythematosus

This is the case of a 27 years-old woman with signs and symptoms of severe untreatable congestive heart failure, anemia, gingival mucosa ulcers, photosensitivity and alopecia. The electrocardiographic, echocardiographic, angiographic and hemodynamic data oriented the diagnosis of restrictive cardiomyopathy, mitral insufficiency secondary to mitral prolapse and bi-atrial dilation. The histologic study of the endomyocardial biopsy, performed during catheterization, showed signs of endomyocardial fibrosis, and immunological analysis was compatible with systemic lupus erythematosus. As far as we know, this is the first case of endomyocardial fibrosis (Davies disease) associated with systemic lupus erythematosus published in the medical literature. The etiology of Davies disease remains unrevealed and its association with systemic lupus erythematosus suggest a probable autoimmune origin.

Slender versus threatening angiodysplasias: observe, operate or obturate? A delusive decision

Beside the immediate success of surgery and of embolization of angiodysplasias, certain number of patients return to medical consultation, because recanalization of the arteriovenous fistulae after their resection or obturation. From the presentation of two clinical cases of thoracic angiodysplasia: one of them slender, and threatening the other, the authors point out the complications and recurrence after surgical resection or arterial embolization. The recurrence takes place even when only one artery remains permeable after resection or embolization of the fistula. There are cases where the affected limb has to be amputated. However, angiodysplasia shows itself in the stump of the amputee limb. Uncontrolled angio-genesis is the natural history or postoperatory evolution of angiodysplasias, probably originated by an erroneous genetic program, which persist in spite of resection of the vascular malformation, causing a therapeutic failure.

[Low-molecular-weight heparin in unstable angina pectoris]

We studied the therapeutic effect of standard heparin (HS) compared with low-molecular-weight (HBPM) in two homogeneous groups of 14 patients heparin selected at random, with clinical history and electrocardiographic signs of unstable angina pectoris. Patients received the conventional treatment with platelets' inhibitors, nitrates, adrenergic beta-blockers or calcium antagonists. Both heparins, separately, showed statistical therapeutic effect on the symptoms and signs of unstable angina pectoris. They decreased to zero the number and duration of symptomatic myocardial ischemic events observed by ambulatory electrocardiogram (EKG-Holter). The symptoms of the angina pectoris disappeared at the same elapsed time: in 51.9 +/- 20.2 min. for the HS, and in 48.14 +/- 20.7 min. for the HBPM. They decreased the frequency of the silent myocardial ischemia observed at the EKG-Holter: 9 events decreased to 4 with the HS, and 8 events decreased to 3 with the HBPM. They decreased the total elapsed time of the silent ischemia from 52 min. to 15 min., and the mean elapsed time of the silent ischemia decreased from 3.71 +/- 3.29 min. to 1.07 +/- 1.81 min. with the HS (P < 0.001). With HBPM it decreased the total elapsed time of the silent ischemia from 60 min to 10 min, and the mean elapsed time of the silent ischemia decreased from 4.28 +/- 4.49 min. to 0.71 +/- 1.43 min. (P < 0.02). Both heparins considerably decreased the frequency of the lethal arrhythmias. Although in this study we did not find statistical differences in the therapeutic action of either heparins, HBPM reduced rapidly angina symptoms and the events associated to angina pectoris, cardiac arrhythmias, specially lethal extrasystolia, conduction defects and atrial paroxysmal tachycardia. Compared to HS, HBPM is easily applied, does not produce side effects on coagulation or bleeding time.

[Percutaneous mitral commissurotomy in patients with mitral valve stenosis and thrombosis of the left atrium]

Mitral percutaneous valvotomy (MPV) is an effective therapeutic alternative in the treatment of patients with mitral stenosis (MS) and thrombus in the left atrium have been an absolute contraindication to this procedure. The aim of our study is to evaluate the safety of MPV in patients with MS and thrombus in the appendix of the left atrium (ALA). Between September 1996 and April 1997, we performed ten procedures of MPV with Inoue's technique in patients with MS and thrombus in ALA. Nine females and 1 male were included. Their were 41 +/- 7.6 years old. The Wilkins score in our patients were 8 +/- 1.2. All were treated with oral anticoagulants between three and twelve months but the thrombus did not resolved. With transesophagic echocardiogram and fluoroscopic control we avoided the contact between wires and Inoue's catheter with ALA. Results were positive. Mitral valve area increased from 0.8 +/- 0.2 cm2 to 1.95 +/- 0.3 cm2. There was no case of systemic embolism or others major complications during the MVP and during following one year.

CONCLUSION

MPV is a safe and efficient therapeutic alternative in the treatment of selected patients with MS and thrombus in ALA.

Interruption of the aortic arch in adults

The interruption of the aortic arch is a rare cardiac congenital disease; such patients may occasionally survive to adulthood without surgery. The associated intracardiac malformations may modify survival. Our aim is to report three young adults (18-19 years of age) with interruption of the aortic arch. Two had type C, and the other had type B with subpulmonic ventricular septal defect and pulmonary valve insufficiency. We review 106 cases collected from the medical literature into 3 groups: 1) the whole group of patients; 2) patients with isolated interruption of the aortic arch, and 3) patients with interruption of the aortic arch associated with ventricular septal defect. In the whole group we found 18 cases of interruption of the aortic arch type A, and 25 cases of interruption of the aortic arch type B; 37 cases of isolated interruption of the aortic arch and 43 cases associated with ventricular septal defect. Fifty percent of the patients died before 15 days of life (0.042 years). According to the cumulative frequency graphic, only 5% of the patients survived beyond the age of 5 years. We found no information to relate patient's survival rate and anatomic type of the interruption of the aortic arch. From adolescence, the survival of the patients with interruption of the aortic arch associated to septal ventricular defect was 7%, and a 14% survival was found in patients with isolated interruption of the aortic arch. No statistical difference was found between the means of the ages of these two groups (P > 0.25).

Myocardial infarction in patients with systemic lupus erythematosus with normal findings from coronary arteriography and without coronary vasculitis--case reports

The authors present the cases of two young patients, a man and a woman, who presented with myocardial infarction, in the absence of ischemic heart disease or stenosis of the coronary arteries. The woman was known to have systemic lupus erythematosus (SLE) for the past 3 years (the immunoglobulin M [IgM] anticardiolipins antibodies were positive), without a history of coronary risk factors. Suddenly she presented with acute chest pain on rest that lasted 4 hours and culminated in anterior wall myocardial infarction. She was admitted to the coronary care unit, where no thrombolysis was given. She did not have echocardiographic evidence of Libman-Sacks endocarditis, but myocardial infarction was evident at the electrocardiogram (ECG). The young man had SLE (the IgM anticardiolipins were absent, but he was positive for lupus anticoagulant antibodies), he was hyperlipidemic, was a moderate smoker and moderately obese, and had no history of ischemic heart disease. He suddenly presented with an acute myocardial infarction documented by ECG, enzymes, and gammagraphy. In both patients, coronary angiography findings were normal and myocardial biopsy did not show evidence of arteritis. The relevance of these cases is the rare association of ischemic heart disease in SLE, with normal coronary arteries and without evidence of arteritis or verrucous endocarditis.

Dermatophagoides sp. and IgE anti-D. pteronyssinus and D. farinae detection in a Venezuelan community at more than 2000 m above the sea level

BACKGROUND

It has been reported that the concentration of Dermatophagoides sp. population, the main trigger of asthma in sensitized atopic subjects, is inversely related with altitude and probably directly with humidity and that this population are scarcely found over 1750 m above sea level.

OBJECTIVE

We studied the presence of Dermatophagoides sp. in a Venezuelan community between 2040 and 2600 m above sea level, and also the IgE response to D. pteronnyssinus and D. farinae in atopic subjects living on that region.

METHODS

The presence of Dermatophagoides sp. was determined by microscopic identification of mites in dust, obtained by brushing the mattresses surface in 93 randomly selected houses between 2040 and 2600 m above sea level. The indoor relative humidity was also measured. The specific IgE serum levels were studied in 65 subjects classified as asthmatics, allergic non-asthmatics and non-allergic.

RESULTS

A mean concentration of 188 mites/g of room dust was determined in 82.4% of houses with an indoor relative humidity ranging from 89% and 92% independently of altitude. The density of Dermatophagoides sp. was sufficiently high to sensitize the atopic subjects, IgE levels were 6.8 PRU mean value for asthmatic, against 0.38 PRU in non-atopic.

CONCLUSIONS

We conclude that: (a) Dermatophagoides sp. can be found up to 2600 m above sea level in a Venezuelan neotropical region where a high indoor relative humidity is characteristic of most dwellings; (b) sensitization by D. pteronyssinus and D. farinae were demonstrated in atopic subjects resident at that region.

Immediate results of the Inoue mitral valvotomy in patients with previous surgical mitral commissurotomy. Preliminary report

BACKGROUND

The objective of this study is to evaluate the immediate result of the percutaneous mitral valvotomy in patients with previous surgical mitral commissurotomy, compared with patients considered ideal for the performance of the procedure.

METHODS

The authors of this paper compared the immediate results of the percutaneous mitral valvotomy (PMV) performed on two groups of patients. Group I included 20 patients who were good candidates for PMV, with an echocardiographic score of < or = 8, without evidence of left atrial thrombus, and with no recent embolic event. Group II included seven patients with previous mitral commissurotomy (MC).

RESULTS

According to the Wilcoxon non-parametric t test analysis, the hemodynamic variables changed significantly in the patients of group I: the mitral area increased from 1.21 +/- 0.41 to 2.62 +/- 0.75 cm2 (P = < 0.001); the mean left atrial pressure decreased from 17.2 +/- 7.2 mmHg to 9.2 +/- 4.5 mmHg (P = < 0.001), and the pressure transmitral gradient decreased 12.4 +/- 6.8 to 3.3 +/- 1.26 mmHg (P = < 0.001). No statistically significant difference in the hemodynamic changes of the patients of group II after the PMV was found: the mitral area increased from 1.2 +/- 0.2353 to 1.96 +/- 0.57 cm2; the mean left atrial pressure decreased from 17.42 +/- 10.35 to 12.42 +/- 7.3 mmHg, and the pressure mitral gradient decreased from 11.47 +/- 6.5 to 5.7 +/- 4.8 mmHg. The mitral area determined by echocardiographic procedure showed the same tendency in patients with previous MC.

CONCLUSIONS

In spite of this tendency, during the follow-up after PMV the NYHA functional class decreased from II-IV to I in the patients with previous MC. Because a second surgical MC results in higher mortality, PMV is indicated in patients with previous MC, delaying or avoiding a second MC or valve replacement.

[Acute myocardial infarction with normal coronary arteries as initial manifestation of polyarteritis nodosa. A case report]

A thirty four-year-old-white man in good health developed an acute anterior wall myocardial infarction (AMI), Killip II with normal coronary arteries. No thrombolytic therapy was given. Selective angiography revealed multiple aneurysms in mesenteric and renal arteries. The diagnosis of polyarteritis nodosa (PAN) was performed. AMI in PAN is secondary to arteritis with thrombosis, or to atherosclerosis due to steroid therapy. This case, having multiorgan vascular aneurysms involvement without previous cardiac symptomatology nor steroid therapy, presented as his first cardiac complication an AMI with normal coronary arteries probably due to selective arteritis.

[Occlusion of interventricular septal rupture in 2 patients with an infarction]

We describe two women with interventricular septal rupture secondary to a myocardial infarction due to a total obstruction of the anterior descendent coronary artery. With the aim to stabilize the hemodynamic state of the patients before the surgical closure of the defect, we inserted a balloon-catheter introducing it to the left ventricle from the aorta and inflating it in the right ventricle after passing it through the septal orifice. After occlusion, we observed decreases in the pulmonary to systemic blood flow ratio (6% in one patient and 26% in the other) and in the arteriovenous blood flow shunt (8 and 31%); a 10% systemic blood flow increase was observed in one patient. Since the pulmonary arterial pressure did not change and the pulmonary blood flow increased, an increase of the pulmonary arterial resistance was observed but no modification of the pulmonary and systemic arterial pressure occurred. In the following days, the oxymetric differences between the pulmonary artery and the right atrium showed a tendency to remain below the figures before occlusion and the pulmonary blood flow and pressure showed a tendency to decrease. One patient died 14 days after the surgical closure of the rupture, and the other, seven days after the balloon occlusion of the rupture before any surgery. We present the physiological evolution of the patients.

A case of giant arteriovenous shunt in a renal carcinoma

We present the case of a 51 year-old-white male with a giant right renal arteriovenous fistula secondary to a carcinoma. Neither the aorta nor the kidneys were visualized after the injection of 60 mL of contrast media into the abdominal aorta. Moreover, the right kidney could not be visualized after 30 mL of contrast media were injected selectively into the right renal artery. This was due to a great arteriovenous shunt through the right kidney. The right renal angiogram was obtained through digital imaging, after injecting contrast media into the right renal artery, previously occluded by a balloon-catheter. The image of an hypervascularized nephroma was obtained, depicting an important arteriovenous shunt of the contrast material toward the inferior vena cava from a fistula located in the right inferior renal pole. The occlusion of the right renal artery was partially achieved by injecting 40 mL of boiling contrast media, followed by small fragments of Gelfoam suspended in the contrast substance. The balloon-catheter remained inflated in the right renal artery until a nephrectomy was performed. As far as we know, a case in which the aorta and renal circulation are unable to be seen by means of conventional angiography, because of the presence of a renal arteriovenous shunt to the fistula, has not been described.

A case of a coronary artery arising from the pulmonary artery

We present a case of an anomalous origin of the left coronary artery arising from the pulmonary artery in a 60 year old woman with ventricular arrhythmias and ischemic electrocardiographic changes but who had tolerated eleven normal pregnancies and deliveries without complications. No cardiac surgical repair has been performed and she is asymptomatic and has been well controlled with diisopyramide during a ten year follow up.