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Abstract Left ventricular (LV) hypertrophy is a common finding in patients with severe aortic stenosis (AS). Cardiac magnetic resonance (CMR) is the gold-standard technique to evaluate LV remodeling. Our aim was to assess the prevalence and describe the patterns of LV adaptation in AS patients before and after surgical aortic valve replacement (AVR). Prospective study of 130 consecutive patients (71y [IQR 68–77y], 48% men) with severe AS, referred for surgical AVR. Patterns of LV remodeling were assessed by CMR. Besides normal LV ventricular structure, four other patterns were considered: concentric remodeling, concentric hypertrophy, eccentric hypertrophy, and adverse remodeling. At baseline CMR study: mean LV indexed mass: 81.8 ± 26.7 g/m2; mean end-diastolic LV indexed volume: 85.7 ± 23.1 mL/m2 and median geometric remodeling ratio: 0.96 g/mL [IQR 0.82–1.08 g/mL]. LV hypertrophy occurred in 49% of subjects (concentric 44%; eccentric 5%). Both normal LV structure and concentric remodeling had a prevalence of 25% among the cohort; one patient had an adverse remodeling pattern. Asymmetric LV wall thickening was present in 55% of the patients, with predominant septal involvement. AVR was performed in 119 patients. At 3–6 months after AVR, LV remodeling changed to: normal ventricular geometry in 60%, concentric remodeling in 27%, concentric hypertrophy in 10%, eccentric hypertrophy in 3% and adverse remodeling (one patient). Indexes of AS severity, LV systolic and diastolic function and NT-proBNP were significantly different among the distinct patterns of remodeling. Several distinct patterns of LV remodelling beyond concentric hypertrophy occur in patients with classical severe AS. Asymmetric hypertrophy is a common finding and LV response after AVR is diverse.

Introduction and objectives: Current epidemiological data on heart failure (HF) in Portugal derives from studies conducted two decades ago. The main aim of this study is to determine HF prevalence in the Portuguese population. Using current standards, this manuscript aims to describe the methodology and research protocol applied. Methods: The Portuguese Heart Failure Prevalence Observational Study (PORTHOS) is a large, three-stage, population-based, nationwide, cross-sectional study. Community-dwelling citizens aged 50 years and older will be randomly selected via stratified multistage sampling. Eligible participants will be invited to attend a screening visit at a mobile clinic for HF symptom assessment, anthropomorphic assessment, N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing, one-lead electrocardiogram (ECG) and a sociodemographic and health-related quality of life questionnaire (EQ-5D). All subjects with NT-proBNP ≥125 pg/mL or with a prior history of HF will undergo a diagnostic confirmatory assessment at the mobile clinic composed of a 12-lead ECG, comprehensive echocardiography, HF questionnaire (KCCQ) and blood sampling. To validate the screening procedure, a control group will undergo the same diagnostic assessment. Echocardiography results will be centrally validated, and HF diagnosis will be established according to the European Society of Cardiology HF guidelines. A random subsample of patients with an equivocal HF with preserved ejection fraction diagnosis based on the application of the Heart Failure Association preserved ejection fraction diagnostic algorithm will be invited to undergo an exercise echocardiography. Conclusions: Through the application of current standards, appropriate methodologies, and a strong research protocol, the PORTHOS study will determine the prevalence of HF in mainland Portugal and enable a comprehensive characterization of HF patients, leading to a better understanding of their clinical profile and health-related quality of life. Resumo: Introdução e objetivos: Os dados epidemiológicos atuais sobre insuficiência cardíaca (IC) em Portugal provêm de estudos realizados há mais de duas décadas. O objetivo principal deste estudo é determinar a prevalência da síndrome de IC na população portuguesa com 50 ou mais anos, sendo, especificamente, objetivo deste artigo descrever as abordagens metodológicas e o protocolo de investigação aplicados. Métodos: O Estudo de Prevalência de Insuficiência Cardíaca em Portugal (PORTHOS) é um estudo observacional transversal de grande dimensão, de base populacional, nacional, constituído por três fases. Serão selecionados aleatoriamente por amostragem estratificada multietapas cidadãos com 50 ou mais anos residentes na comunidade em Portugal. Os participantes elegíveis serão convidados a participar numa visita de triagem, que decorrerá numa clínica móvel, durante a qual serão submetidos a avaliação de sintomas de IC, avaliação antropomórfica, um teste de N-terminal pró-peptídeo natriurético tipo B (NT-proBNP), eletrocardiograma de 1 derivação, questionários sociodemográficos e questionário de qualidade de vida relacionada à saúde (EQ-5D). Todos os participantes com NT-proBNP ≥125 pg/mL ou história prévia de IC serão submetidos a uma avaliação diagnóstica confirmatória composta por eletrocardiograma de 12 derivações, ecocardiografia completa, questionário de IC (KCCQ) e colheita de sangue. Para validar o procedimento de triagem, um grupo controlo passará pela mesma avaliação diagnóstica. Os resultados dos ecocardiogramas realizados serão validados centralmente e o diagnóstico de IC será confirmado de acordo com as recomendações de IC da Sociedade Europeia de Cardiologia. Uma subamostra aleatória de participantes com diagnóstico questionável de IC com fração de ejeção preservada (ICFEp), após a aplicação do algoritmo de diagnóstico de fração de ejeção preservada da Heart Failure Association (HFA-PEFF) será convidada a realizar ecocardiografia de esforço. Conclusão: Através da aplicação das recomendações atuais e abordagens metodológicas adequadas, o estudo PORTHOS irá determinar a prevalência da IC em Portugal Continental e permitir uma caracterização abrangente dos doentes com IC, para melhor compreensão do seu perfil clínico e qualidade de vida relacionada com a saúde.

Abstract Aims Increased collagen content of the myocardium modifies tissue reflectivity and integrated backscatter (IBS) indexes are suggested as markers of myocardial fibrosis (MF). We sought to assess the correlation between calibrated (c) IBS and bidimensional (2D) strain derived IBS with left ventricular (LV) MF in patients with severe aortic stenosis (AS). Methods and results We made a prospective observational cohort study including 157 patients with severe AS referred for surgical aortic valve replacement (AVR), with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of surgery. Two groups of 30 patients were specifically evaluated, with and without late gadolinium enhancement (LGE) at CMR. IBS was obtained at QRS peak from both parasternal long axis (PLAX) and apical-three-chamber (AP3C) views and measured in decibels (dB). Whole-cardiac cycle IBS at basal anterior septum was obtained from 2D longitudinal strain. Correlation analysis of reflectivity indexes was performed with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) (Masson´s Trichrome). IBS values were compared in both group of patients (LGE + vs. LGE –). 60 patients (74 [36–74] years, 45% male) with high gradient (mean gradient: 63 ± 20mmHg), normal flow (45 ± 10mL/m2) AS and preserved left ventricular ejection fraction (60 ± 9%) were included. Basal septum cIBS was − 17.45 (–31.2–10.95) and − 9.17 ± 9.45dB from PLAX and A3C views, respectively. No significant correlations were found between IBS and both non-invasive CMR tissue characterization and CVF: median MF of 9.7(2.1–79.9)%. Acoustic indexes were not significantly different according to the presence of pre-operative LGE. Conclusion In this group of patients with classical severe AS, IBS reflectivity indexes are of no added value to discriminate the presence of MF. Graphical Abstract

Acute venous thromboembolism (VTE) is a common worldwide disease admitted to emergency departments (ED), usually presenting as pulmonary embolism or lower limb deep vein thrombosis (DVT). Due to the lack of typical clinical and biomarker diagnostic features of unprovoked VTE, early identification is challenging and has direct consequences on correct treatment delay. Longitudinal, prospective, observational study. Patients admitted to ED with a suspicion of unprovoked acute VTE between October 2020 and January 2021 were included. Clinical and laboratorial variables were compared between VTE positive and negative diagnoses. Red cell distribution width (RDW) cut point was determinate through a receiver operating characteristic analysis. RDW accuracy, sensitivity, and specificity were calculated. Fifty-eight patients were analyzed. And 82.8% of suspected patients with VTE were diagnosed with an acute thrombotic event confirmed by imaging examination. In patients with VTE, RDW at admission in ED was higher than with other diagnosis, respectively, 14.3% (13.2-15.1) and 13.5% (13.0-13.8). Platelet count was the only additional characteristic that revealed difference between the 2 groups (264×10 9 /L for VTE and 209×10 9 /L for non-VTE). Logistic regression models showed good discriminatory values for RDW≥14%, with an area under the curve (AUC) = 0.685 (95% confidence interval, 0.535-0.834). These findings were more pronounced in isolated DVT, with a sensitivity of 76.9%, specificity 100%, and accuracy 85.7%. Our study demonstrated a significant association between an early high RDW and the diagnosis of acute unprovoked DVT. RDW ≥ 14% has an independent predictor of unprovoked VTE in adult patients.

Introduction and Objectives: To characterize patients with atherosclerosis, a disease with a high socioeconomic impact, in the Lisbon and Tagus Valley Health Region. Methods: A cross-sectional observational study was carried out through the Lisbon and Tagus Valley Regional Health Administration primary health care database, extracting data on the clinical and demographic characteristics and resource use of adult primary health care users with atherosclerosis during 2016. Different criteria were used to define atherosclerosis (presence of clinical manifestations, atherothrombotic risk factors and/or consumption of drugs related to atherosclerosis). Comparisons between different subpopulations were performed using parametric tests. Results: A total of 318 692 users were identified, most of whom (n=224 845 users; 71%) had no recorded clinical manifestations. The subpopulation with clinical manifestations were older (72.0±11.5 vs. 71.3±11.0 years), with a higher proportion of men (58.0% vs. 45.9%), recorded hypertension (78.3% vs. 73.5%) and dyslipidemia (55.8% vs. 53.5%), and a lower proportion of recorded obesity (18.2% vs. 20.8%), compared to those without clinical manifestations (p

Resumo: Introdução e objetivos: A Internet é fundamental na divulgação de informação médica. Contudo, a ausência de controlo de qualidade potencia a “desinformação” da população. Pretendemos caraterizar a relevância e qualidade da informação sobre enfarte agudo do miocárdio em língua portuguesa no site YouTube (www.youtube.com). Métodos: Analisaram‐se 1.000 vídeos correspondentes aos primeiros 100 resultados da pesquisa no YouTube dos termos: “ataque + cardíaco”, “ataque + coração”, “enfarte ‐ cerebral”, “infarto ‐ cerebral”, “enfarte + miocárdio”, “enfarte + agudo + miocárdio”, “infarto + miocárdio”, “infarto + agudo + miocárdio”, “trombose + coração” e “trombose + coronária”. Excluíram‐se vídeos irrelevantes (n = 316), duplicados (n = 345), sem áudio (n = 24) e de língua não portuguesa (n = 106). Os vídeos elegíveis foram analisados quanto a origem, tema, público‐alvo e imprecisões científicas. A qualidade foi avaliada com os scores Health on the Net Code (HONCode, de 0‐8) e DISCERN (0‐5) – quanto maior, melhor a qualidade. Resultados: Incluíram‐se 242 vídeos, a maioria de formadores independentes (n = 95, 39%) e destinados à população‐geral (n = 202, 83,5%). Um terço (n = 79) apresentou imprecisões; vídeos de sociedades científicas e instituições de saúde/governamentais não apresentaram quaisquer imprecisões. A qualidade média foi baixa/moderada; apenas um vídeo apresentou boa qualidade, sem imprecisões. Instituições de saúde/governamentais foram a fonte com melhor qualidade (HONCode 4±1, DISCERN 2±1). Conclusões: A informação sobre enfarte agudo do miocárdio em língua portuguesa é irrelevante em um terço dos casos e um terço dos vídeos relevantes é impreciso. A qualidade média da informação é reduzida, sendo importante definir estratégias de controlo de qualidade da informação médica online. Abstract: Introduction and objectives: The Internet is a fundamental aspect of health information. However, the absence of quality control encourages misinformation. We aim to assess the relevance and quality of acute myocardial infarction videos shared on YouTube (www.youtube.com) in Portuguese. Methods: We analyzed 1,000 videos corresponding to the first 100 search results on YouTube using the following terms (in Portuguese): “cardiac + arrest”; “heart + attack”; “heart + thrombosis”; “coronary + thrombosis”; “infarction – brain”, “myocardial + infarction” and “acute + myocardial + infarction”. Irrelevant (n=316), duplicated (n=345), without audio (n=24) or non‐Portuguese (n=106) videos were excluded. Included videos were assessed according to source, topic, target audience and scientific inaccuracies. Quality of information was assessed using The Health on the Net Code (HONCode from 0 to 8) and DISCERN (from 0 to 5) scores – the higher the score, the better the quality. Results: 242 videos were included. The majority were from independent instructors (n=95, 39.0%) and were addressed to the general population (n=202, 83.5%). One third of the videos (n=79) contained inaccuracies while scientific society and governmental/health institution videos had no inaccuracies. The mean video quality was poor or moderate; only one video was good quality without any inaccuracies. Governmental/health institutions were the source with the best quality videos (HONCode 4±1, DISCERN 2±1). Conclusions: One third of the videos had irrelevant information and one third of the relevant ones contained inaccuracies. The average video quality was poor; therefore it is important to define strategies to improve the quality of online health information.

Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure.The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis. Resumo: A arritmia mais comum na população adulta em todo o mundo, a fibrilhação auricular (FA), contribui decisivamente para a elevada mortalidade e morbilidade cardiovascular, com repercussões na economia da saúde. A anticoagulação oral (ACO) é a chave para a prevenção do acidente vascular cerebral na FA. Nos últimos anos, os resultados dos grandes ensaios clínicos com os ACO não antagonista da vitamina K mudaram o paradigma na trombocardiologia. Apesar deste avanço, o risco vascular residual associado à FA silenciosa, hemorragia, morte súbita prematura e insuficiência cardíaca continua a ser significativo.Os autores fazem uma revisão dos dados epidemiológicos da FA, a importância das novas ferramentas para a deteção precoce da FA, o papel atual da ablação por cateter no controlo do ritmo na FA, o estado da arte na ACO periprocedimento, a gestão ideal de hemorragias graves, as causas de morte prematura residual e estratégias futuras para a melhoria do prognóstico da FA.

Resumo: Introdução e objetivos: As doenças cardiovasculares são a principal causa de morte em Portugal, sendo a aterosclerose o processo fisiopatológico subjacente mais comum. O objetivo deste estudo foi quantificar o impacto económico da aterosclerose em Portugal através da estimação dos custos associados. Métodos: A estimativa dos custos foi realizada na ótica da prevalência e na perspetiva da sociedade. A prevalência das principais manifestações focais da aterosclerose foi estimada com recurso a três fontes epidemiológicas nacionais. O custo anual da aterosclerose incluiu custos diretos (consumos de recursos) e indiretos (impacto na produtividade da população). Estes custos foram estimados para o ano de 2016 com base nos dados da Base de Dados de Morbilidade Hospitalar, do Sistema de Informação da Administração Regional de Saúde de Lisboa e Vale do Tejo que integra informação da prática clínica real em ambiente de cuidados de saúde primários e do Inquérito Nacional de Saúde de 2014 e na opinião de peritos. Resultados: O custo da aterosclerose em 2016 totalizou cerca de 1,9 mil milhões de euros (58% e 42% correspondendo a custos diretos e indiretos, respetivamente). A maior parte dos custos diretos esteve associada aos cuidados de saúde primários (55%), seguindo‐se o ambulatório hospitalar (27%) e, por último, os episódios de internamento (18%). Os custos indiretos foram principalmente determinados pela não participação no mercado de trabalho (91%). Conclusões: A aterosclerose apresenta um importante impacto económico, correspondendo a uma despesa equivalente a 1% do Produto Interno Bruto nacional e a 11% da despesa corrente em saúde, em 2016. Abstract: Introduction and objectives: Cardiovascular disease is the leading cause of death in Portugal and atherosclerosis is the most common underlying pathophysiological process. The aim of this study was to quantify the economic impact of atherosclerosis in Portugal by estimating disease‐related costs. Methods: Costs were estimated based on a prevalence approach and following a societal perspective. Three national epidemiological sources were used to estimate the prevalence of the main clinical manifestations of atherosclerosis. The annual costs of atherosclerosis included both direct costs (resource consumption) and indirect costs (impact on population productivity). These costs were estimated for 2016, based on data from the Hospital Morbidity Database, the health care database (SIARS) of the Regional Health Administration of Lisbon and Tagus Valley including real‐world data from primary care, the 2014 National Health Interview Survey, and expert opinion. Results: The total cost of atherosclerosis in 2016 reached 1.9 billion euros (58% and 42% of which was direct and indirect costs, respectively). Most of the direct costs were associated with primary care (55%), followed by hospital outpatient care (27%) and hospitalizations (18%). Indirect costs were mainly driven by early exit from the labor force (91%). Conclusions: Atherosclerosis has a major economic impact, being responsible for health expenditure equivalent to 1% of Portuguese gross domestic product and 11% of current health expenditure in 2016.

Objective: To evaluate the impact of a real-time visual feedback device on CCs rate and depth delivered by healthcare professionals.Methods: In a simulated scenario a sensor was placed on a manikin’s chest and connected to a defibrillator which provided real-time visual feedback on the rate and depth of CCs. Thirty-two healthcare professionals performed sequentially 5 cycles of 30 CCs without (FeedOFF) and with (FeedON) feedback. CCs with a depth between 50 and 60mm and a rate between 100 and 120cpm were considered optimal.Results: Visual feedback resulted in a significant increase in the proportion of CCs with optimal depth (median 8.7 [interquartile range 0.7–55.5]% FeedOFF vs 63.3 [17.6–88.1]% FeedON, p=0.002) and optimal rate (median 51.3 [1.3–81.3]% FeedOFF vs 68.3 [45.3–86.1]% FeedON, p=0.018). Overall, CCs were too shallow and too fast in the FeedOFF cycle. There was also a significant increase in optimal CCs (optimal depth and rate) with the use of the feedback device (from median 0.7 [0–26.9]% FeedOFF to 31.9 [3.6-59.9]% FeedON, p=0.001). Participants’ factors such as age, sex, body mass index, job or time since last CPR training did not have a significant impact on CPR quality.Conclusion: In the absence of visual feedback, there is a tendency towards lower depth and higher rate of CCs. The use of feedback technology significantly improves the quality of CCs.

Resumo: Nos últimos anos, temos assistido a um aumento do número de doentes com necessidade de cuidados cardíacos agudos, com patologia cardiovascular progressivamente mais complexa, muitas vezes complicada por comorbilidades não cardiovasculares agudas ou crónicas, com impacto na abordagem e prognóstico destes doentes. As unidades coronárias têm evoluído para unidades de cuidados intensivos cardíacos, caracterizadas por cuidados de saúde altamente especializados ao doente cardíaco crítico. Tendo em conta que os recursos humanos e técnicos nesta área são limitados, considerámos ser urgente uma reflexão profunda sobre o modelo de organização dos cuidados ao doente cardíaco agudo, incluindo a definição do nível de cuidados, a constituição e formação da equipa e a criação de redes de referenciação.Paralelamente, é fundamental um investimento claro dos serviços nesta área central da cardiologia, de forma a alavancar o desenvolvimento contínuo e sustentado de outras áreas cardiológicas essenciais, nomeadamente a eletrofisiologia e a cardiologia de intervenção, assegurando cuidados de excelência e de elevada diferenciação a todos os doentes cardíacos críticos. Abstract: In recent years, the number of patients requiring acute cardiac care has increased, with progressively more complex cardiovascular conditions, often complicated by acute or chronic non‐cardiovascular comorbidities, which affects the management and prognosis of these patients. Coronary care units have evolved into cardiac intensive care units, which provide highly specialized health care for the critical heart patient. In view of the limited human and technical resources in this area, we consider that there is an urgent need for an in‐depth analysis of the organizational model for acute cardiac care, including the definition of the level of care, the composition and training of the team, and the creation of referral networks. It is also crucial to establish protocols and to adopt safe clinical practices to improve levels of quality and safety in the treatment of patients. Considering that acute cardiac care involves conditions with very different severity and prognosis, it is essential to define the level of care to be provided for each type of acute cardiovascular condition in terms of the team, available techniques and infrastructure. This will lead to improvements in the quality of care and patient prognosis, and will also enable more efficient allocation of resources.

Introduction: Coronary artery disease is becoming the leading cause of death in women in Western society. However, the available data shows that women are still underdiagnosed and undertreated with guideline-recommended secondary prevention therapy, leading to a significantly higher rate of in-hospital complications and in-hospital mortality. Objective: The main objective of this work is to assess the approach to acute coronary syndrome (ACS) in Portugal, including form of presentation, in-hospital treatment and in-hospital complications, according to gender and in three different periods. Methods: We performed an observational study with retrospective analysis of all patients included between 2002 and 2019 in the Portuguese Registry of Acute Coronary Syndromes (ProACS), a voluntary, observational, prospective, continuous registry of the Portuguese Society of Cardiology and the National Center for Data Collection in Cardiology. Results: A total of 49 113 patients (34 936 men and 14 177 women) were included. Obesity, hypertension, diabetes (p

Even with improvements in lifestyle interventions, better control of cardiovascular (CV) risk factors, and improvements in CV outcomes, cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in Portugal and Europe. Atherogenic dyslipidemias, particularly hypercholesterolemia, have a crucial causal role in the development of atherosclerotic CVD. The clinical approach to a patient with dyslipidemia requires an accurate diagnosis, based on harmonized and standardized lipid and lipoprotein laboratory assessments. Results and reports of these tests, together with assessment of total CV risk and the respective therapeutic targets, will help ensure that clinical guidelines and good clinical practices are followed, increasing the reliability of screening for lipid disorders, producing more accurate diagnoses and CV risk stratification, and improving CV prevention. To this end, this consensus aims to provide clinicians with practical guidance for the harmonization and standardization of laboratory lipid tests, focusing on the most recent dyslipidemia management guidelines. Resumo: Apesar da melhor intervenção nos estilos de vida, do melhor controlo dos fatores de risco cardiovascular (CV) e da melhoria dos resultados CV, a doença cardiovascular (DCV) continua a ser a principal causa de morbilidade e mortalidade em Portugal e na Europa. A dislipidemia aterogénica, nomeadamente a hipercolesterolemia, tem um papel causal no desenvolvimento de DCV aterosclerótica. A abordagem clínica de um doente com dislipidemia preceitua um diagnóstico atento, sustentado em procedimentos laboratoriais harmonizados e padronizados. Os resultados e relatórios dos testes de lipídios se ajuntarem o risco CV total e os respetivos alvos terapêuticos garantem que as diretrizes clínicas e as boas práticas clínicas estão a ser seguidas e respeitadas, o que aumenta a segurança no rastreio e no diagnóstico das alterações lipídicas e da estratificação de risco e melhora a prevenção CV. Nesse sentido, este consenso tem como objetivo fornecer aos clínicos orientações práticas para a harmonização e padronização dos testes laboratoriais lipídicos, com foco nas diretrizes mais recentes da abordagem das dislipidemias. Keywords: Dyslipidemia, Cardiovascular risk, Laboratory procedures, Laboratory reports, Harmonization, Standardization, Palavras-chave: Dislipidemia, Risco cardiovascular, Procedimentos laboratoriais, Relatórios laboratoriais, Harmonização, Padronização

Introduction and Objectives: The role of endothelial dysfunction (ED) in patients with ST-elevation myocardial infarction (STEMI) is poorly understood. Peripheral arterial tonometry (PAT) allows non-invasive evaluation of ED, but has never been used for this purpose early after primary percutaneous coronary intervention (P-PCI). Our purpose was to analyze the relation between ED assessed by PAT and both the presence of microvascular obstruction (MVO) and infarct extension in STEMI patients. Methods: ED was assessed by the reactive hyperemia index (RHI), measured by PAT and defined as RHI

The circular economy model offers great opportunities to companies, as it not only allows them to capture additional value from their products and materials, but also reduce the fluctuations of price-related risks and material supply. These risks are present in all kind of businesses not based on the circular economy. The circular economy also enables economic growth without the need for more resources. This is because each unit has a higher value as a result of recycling and reuse of products and materials after use. Following this circular economics framework, the Polytechnic University of Madrid (Universidad Politécnica de Madrid, UPM) has adopted strategies aimed at improving the circularity of products. In particular, this article provides the result of obtaining recycled PLA filament from waste originating from university 3D FFF (fused filament fabrication) printers and waste generated by “Coronamakers” in the production of visors and parts for PPEs (Personal Protective Equipment) during the lockdown period of COVID-19 in Spain. This filament is used in the production of 3D printed parts that university students use in their classes, so the circular loop is closed. The obtained score of Material Circularity Indicator (MCI) of this material has been calculated, indicating its high level of circularity.

We report a case of sarcoidosis with an unusual presentation, initially manifesting as bilateral pulmonary embolism and then as a cardiac form of the disease with an ominous clinical event consisting of sustained ventricular tachycardia. The diagnosis was established by clinical and magnetic resonance criteria despite normal conventional echocardiographic study. Detailed functional assessment provided by tracking techniques (speckle tracking echocardiography and cardiac magnetic resonance tissue tracking) enabled the detection of regional deformation abnormalities, indicating prominent circumferential strain and epicardial layer alterations, partly matching the structural changes depicted by distribution of delayed enhancement.We find this case notable for various issues it raises concerning diagnosis and management of cardiac sarcoidosis. These are mainly related to recent developments in imaging modalities that enable non-invasive identification of structural and functional abnormalities in this condition early, before overt deterioration in left ventricular ejection fraction. Information from different imaging modalities and tools provide information that could potentially assist preclinical diagnosis, with possible prognostic implications. Resumo: Apresenta-se o caso de um doente de 44 anos com o diagnóstico prévio de sarcoidose pulmonar, admitido consecutivamente no serviço de urgência por embolia pulmonar e taquicardia ventricular sintomática. Embora o estudo ecocardiográfico mostrasse normal fração de ejeção ventricular esquerda, o diagnóstico de sarcoidose cardíaca foi estabelecido por elementos de ordem clínica, em conjugação com os achados de ressonância magnética cardíaca. Quando se efetuou estudo funcional detalhado do ventrículo esquerdo por speckle (ecocardiografia) e tissue tracking (ressonância magnética), detetaram-se alterações regionais da deformação miocárdica, parcialmente coincidentes com a distribuição do realce tardio por ressonância. Para além da apresentação pouco habitual sob a forma de evento embólico, este caso de sarcoidose com subsequente documentação de envolvimento cardíaco, permitiu a aplicação de modalidades de imagem cardiovascular avançadas, colocou em evidência a afeção estrutural e funcional miocárdica, na presença de normal fração de ejeção ventricular esquerda. Keywords: Cardiac sarcoidosis, Pulmonary embolism, Speckle tracking, Tissue tracking, Palavras-chave: Sarcoidose cardíaca, Embolia pulmonary, Speckle tracking, Tissue tracking

Resumo: O pseudoaneurisma do ventrículo esquerdo é uma complicação rara do enfarte agudo do miocárdio, associada a elevada mortalidade. No entanto, pode manifestar‐se de modo inespecífico, dificultando e atrasando o seu diagnóstico.Os autores apresentam o caso de um doente de 65 anos, hipertenso, sem outros antecedentes relevantes conhecidos, em que toracalgia, tosse e derrame pleural esquerdo, inicialmente atribuídas a um processo pneumológico, foram as manifestações de um pseudoaneurisma do ventrículo esquerdo, após enfarte agudo do miocárdio silencioso. O diagnóstico foi suspeitado por ecocardiografia, confirmado por ressonância magnética cardíaca e o doente foi submetido a cirurgia de reparação do pseudoaneurisma com sucesso.Este caso ilustra uma forma de apresentação atípica de um pseudoaneurisma do ventrículo esquerdo, em que as manifestações resultaram da extensão pericárdico‐pleural do processo inflamatório associada à rotura miocárdica contida. O caso demonstra a necessidade de suspeitar o diagnóstico e o valor dos vários exames de imagem para a confirmação do mesmo, de modo a possibilitar a terapêutica cirúrgica adequada e assim modificar o curso da doença. Abstract: Left ventricular pseudoaneurysm is a rare complication of acute myocardial infarction, associated with high mortality. However, it can present in a non‐specific manner, complicating and delaying the diagnosis.The authors present the case of a 65‐year‐old patient, hypertensive, with no other known relevant medical history, who presented with chest pain, cough and left pleural effusion, initially attributed to a pulmonary process. However, these were in fact the result of a left ventricular pseudoaneurysm following silent acute myocardial infarction. The diagnosis was suspected on echocardiography and confirmed by cardiac magnetic resonance imaging, and the patient underwent successful surgical pseudoaneurysm repair.This case illustrates an atypical presentation of a left ventricular pseudoaneurysm, in which the manifestations resulted from pericardial and pleural extension of the inflammatory process associated with contained myocardial rupture. The case demonstrates the need for a high index of suspicion, and the value of imaging techniques to confirm it, in order to proceed with appropriate surgical treatment, and thus modify the course of the disease. Palavras‐chave: Pseudoaneurisma do ventrículo esquerdo, Ecocardiografia, Ressonância magnética cardíaca, Keywords: Left ventricular pseudoaneurysm, Echocardiography, Cardiac magnetic resonance

The United Arab Emirates is currently building and operating four units of the APR-1400 developed by a South Korean vendor, Korea Electric Power Corporation (KEPCO). This paper attempts to perform APR-1400 reactor core analysis by using the well-known two-step method. The two-step method was applied to the APR-1400 first cycle using the open-source nodal diffusion code, KOMODO. In this study, the group constants were generated using CASMO-4 fuel transport lattice code. The simulation was performed in Hot Zero Power (HZP) at steady-state and transient conditions. Some typical parameters necessary for the Nuclear Design Report (NDR) were evaluated in this paper, such as effective neutron multiplication factor, control rod worth, and critical boron concentration for steady-state analysis. Other parameters such as reactivity insertion, power, and fuel temperature changes during the Reactivity Insertion Accident (RIA) simulation were evaluated as well. The results from KOMODO were verified using PARCS and SIMULATE-3 nodal core simulators. It was found that KOMODO gives an excellent agreement.

Abstract Introduction: Foville syndrome (inferior medial pontine syndrome) is a clinical entity that makes part of a subclassification of a broader category of posterior circulation stroke. It is characterized by a blockage of the basilar artery caused by lesions in the pontine tegmentum. This syndrome has a very low incidence worldwide, but its clinical relevance is considerable. Case report: A 41-year-old patient without any medical history was admitted to the emergency department due to signs of focal neurologic deficits. Imaging findings were compatible with an ischemic lesion in the brainstem, and cerebral angiography showed involvement of the basilar artery territory. The patient was diagnosed and followed up in the intensive care unit (ICU) until his recovery. Conclusion: Foville syndrome is a rare disease with high morbidity and mortality. Early recognition and a multidisciplinary approach are decisive to improve the patient's prognosis.

One of the essential elements to achieving smile esthetics is the phenotype and gingival contour, which with their architecture influence the size of dental crowns. The term “periodontal phenotype” was standardized in the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. However, much has been said about the topic, with other nomenclatures. Evaluating different periodontal phenotypes is essential, as they provide us with information related to the characteristics of periodontal tissues and dental forms. In addition to making the treatment more predictable, it can avoid problems such as trauma, inflammation, and other clinical and surgical complications. The purpose of this literature review is to research the topic, periodontal phenotype, through the most relevant articles between the period 2017 to 2021, showing its classification, prevalence, and forms of diagnosis. There are several ways to diagnose the periodontal phenotype, and the one recommended by the World Workshop is the transparency of the gingival sulcus using the millimeter probe. We can observe a prevalence of the thin phenotype for the female gender, whereas the thick phenotype is prevalent for the male gender. There is still a lack of scientific evidence for the correct relationship of the periodontal phenotype with other factors such as age, smoking, hygiene habits, diet and, malocclusion.

The aim of this study was to present a literature review on the etiology, diagnosis and treatment of dentin hypersensitivity. Dentin hypersensitivity is characterized by short and acute pain, which arises from exposed dentin in response to stimuli, typically thermal, evaporative, tactile, osmotic or chemical and which cannot be attributed to any other dental defect or pathology. The term “Root Hypersensitivity” is used to describe the dentin hypersensitivity normally associated with gingival recessions, abrasions, erosions and abfractions. The etiology is multifactorial and the choice of the ideal treatment depends on a correct diagnosis. Other entities related to hypersensitivity are non-carious cervical lesions (NCCL), which are common conditions in a more distant society with new habits. All treatments presented, such as the use of blocking agents associated with desensitizing toothpaste, restorative procedures, the use of lasers and surgical procedures are effective in reducing dentinal hypersensitivity. An evaluation of the periodontal profile is also important especially when aiming at marginal stability and prevention of possible future NCCL. Thus, it can be concluded that dentin hypersensitivity and non-carious cervical lesions are conditions that require the dentist’s knowledge in relation to their etiology, forms of treatment and long-term maintenance.

Sugarcane orange rust, caused by Puccinia kuehnii (W. Krüger) EJ Butler, is one of the major diseases impacting sugarcane (Saccharum spp.) production worldwide. The objective of this work was to characterize by histology the development of P. kuehnii in leaves and the response of the cultivars to the disease. Four cultures with different degrees of infection response were inoculated in greenhouse. Microscopy studies were performed in leaf fragments of plants at 5 and 15 days after inoculation. It was shown that the development of fungus structures, prior to foliar tissue penetration, are similar in all cultivars regardless of the type of plant response. It was found that cultivar with grade 1 developed response similar to the hypersensitive response, while grade 2 suggests resistance based on the quantitative contribution of several genes. The results are a contribution towards understanding the genetic basis of orange rust resistance in sugarcane.

Advanced Power Reactor (APR-1400) is a Generation III + Pressurized Water Reactor (PWRs) and has gained popularity among energy mix community. APR-1400 features enhanced safety limits to prevent a “Fukushima-type” accident scenario for a duration up to 8 h. This work proposes a system that enhances APR 1400 passive cooling (Thermosyphon Cooling System, TCS) capabilities to guarantee at least double the coping time before core meltdown. TCS provides enough cooling to the reactor core in the case of loss of offsite power, known as Station Black-Out (SBO) accident. This work invites to use the In-containment Refueling Water Storage Tank (IRWST) to further extend the APR1400 capability to passively cool the reactor core after an SBO accident. This work is designed and tested by 3Keymaster simulator platform developed by Western Service Corporation. Simulation has modified the existing model of APR1400 in the simulator by adding pipes, valves and heat exchanger. Results show the system will cool the reactor core for almost 18 h after the SBO accident. The system works initially in parallel with steam generators then it continues cooling the reactor core for extra 18 h resulting in providing more time for restoring the on-site power sources and preventing core meltdown.

La Cruceta es un yacimiento situado en Tauste, en la provincia de Zaragoza. Se trata de un asentamiento rural, que cumplía las funciones de puesto de vigilancia, ocupado entre los siglos XIII y XIV d.C. Durante su excavación, se documentaron estructuras de habitación y de funciones auxiliares, así como cerámica decorada, monedas y elementos metálicos de indumentaria militar. Además, se recuperó una abundante cantidad de restos faunísticos. En este trabajo, se presenta el estudio arqueozoológico de La Cruceta, uno de los primeros para reino de Aragón en época medieval. Los resultados han permitido documentar, además de una funcionalidad estratégica, la existencia de una economía centrada en el ganado ovino y caprino. Los productos explotados son variados (carne, leche, materias primas, etc.), lo que junto a las pautas de procesado parece indicar que La Cruceta, además de puesto de vigilancia, tuvo funciones de producción. ______________________________________________________________________ The Kingdom of Aragon expanded territorially during the 12th and 13th centuries. This expansion was linked to the growth and development of the Aragonese economy, being the agricultural activities the predominant ones. Aragonese husbandry was linked to this territorial and economic expansion of the Kingdom of Aragon, with the increase of the livestock population that took place throughout the 13th century. Studies on this period in the Kingdom of Aragon are practically non-existent, due to the absence of local specialists for this type of study and the scarce interest that has traditionally been given to it. Within this context we find the site of La Cruceta, a Late Medieval settlement located in the municipality of Tauste, in the province of Zaragoza. This settlement was occupied between the beginning of the 13th century and the middle of the 14th century, and it is not clear who promoted this construction. Documentary sources have led to the conclusion that it could have been promoted by the Santa Cristina de Somport Hospital, by the Casa de los Luna or by the municipality of Tauste within a climate of rivalry for the control and exploitation of natural resources. The aims of this work are: 1) to document livestock practices and 2) to show the livestock products exploited by those who occupied La Cruceta, seeking to characterise the economic strategy carried out there. The results have shown how the inhabitants of La Cruceta had a livestock focused on the exploitation of sheep and goats. The dominance of these two species can be observed during most of the Middle Ages in the Iberian Peninsula, but especially from the 13th century onwards, when they formed 50% of the domestic livestock. Furthermore, pigs, cattle, horses and birds also made up the livestock in La Cruceta, although with much lesser quantitative importance. Finally, hunting of species such as red deer also formed part of the economic activities of the site. The results have also shown how the community that occupied La Cruceta exploited a great diversity of animal products (meat, milk, raw materials), highlighting the limited role that wool exploitation could have played. In addition, the presence of perinatal animals led to the conclusion that they were bred at the site. With regard to butchering, the absence of elements such as humerus and femurs from sheep and goats, with a high meat content, stands out. In conclusion, our hypothesis is that in addition to being a strategic settlement for the control of the area, La Cruceta was also a settlement with livestock production for the self-consumption of the community that inhabited the site and perhaps for the supply (mainly of meat) of some settlement near the site. This hypothesis is based on the specialization of production in sheep and goats, the mortality profile of both species and the representation of the anatomical regions, which shows a notable absence of elements with higher meat content in these species.

La pornografía puede definirse como el material audiovisual que presenta de forma explícita actividades sexuales y genitales de manera inocultable, con el objetivo de excitar al espectador. El objetivo de este trabajo es identificar las principales causas y consecuencias de la adicción a la pornografía en hombres y mujeres. Se empleó la metodología de la revisión sistemática de literatura (RSL), tomando como referencia investigaciones previas publicadas en bases de datos científicas y publicaciones web especializadas. Este trabajo concluye que la adicción a la pornografía puede generar problemas físicos, mentales, psicológicos y sociales, que son equiparables con los que genera la adicción al consumo de sustancias psicoactivas. Establecer estrategias de autocontrol, incrementar la actividad física y la participación en actividades sociales son algunas de las alternativas que pueden ayudar a combatir y prevenir la adicción.