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BACKGROUNDIn the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.METHODSWe conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.RESULTSAmong 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI), 0.46 to 1.07; P=0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).CONCLUSIONSAmong patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy.

Aortic aneurysm; Bicuspid aortic valve; Computed tomography Aneurisma aòrtic; Vàlvula aòrtica bicúspide; Tomografia computada Aneurisma aórtico; Válvula aórtica bicúspide; Tomografía computada Multimodality imaging is the basis of the diagnosis, follow-up, and surgical management of bicuspid aortic valve (BAV) patients. Transthoracic echocardiography (TTE) is used in our clinical routine practice as a first line imaging for BAV diagnosis, valvular phenotyping and function, measurement of thoracic aorta, exclusion of other aortic malformations, and for the assessment of complications such are infective endocarditis and aortic. Nevertheless, TTE is less useful if we want to assess accurately other aortic segments such as mid-distal ascending aorta, where computed tomography (CT) and magnetic resonance (CMR) could improve the precision of aorta size measurement by multiplanar reconstructions. A major advantage of CT is its superior spatial resolution, which affords a better definition of valve morphology and calcification, accuracy, and reproducibility of ascending aorta size, and allows for coronary artery assessment. Moreover, CMR offers the opportunity of being able to evaluate aortic functional properties and blood flow patterns. In this setting, new developed sequences such as 4D-flow may provide new parameters to predict events during follow up. The integration of all multimodality information facilitates a comprehensive evaluation of morphologic and dynamic features, stratification of the risk, and therapy guidance of this cohort of patients.

Additional file 1: Supplementary Material: detailed description of aortic flow dynamics descriptors and inter- and intra-observer reproducibility.

We present a case of acute myocarditis with left ventricular dysfunction and intracavitary thrombosis in a 55-year-old man with severe acute respiratory syndrome coronavirus 2 infection (coronavirus disease 2019) who was admitted with bilateral atypical pneumonia. The patient was treated with anticoagulation and optimal heart failure therapy and had an improvement of left ventricular function and thrombus resolution. (Level of Difficulty: Intermediate.), Graphical abstract

Esta investigação pretende dar um contributo para a compreensão do fenómeno do bullying na infância, em contexto escolar e de lazer. Para o efeito realizou-se um estudo qualitativo, tendo por base um guião de entrevistas semi-estruturada que foi conduzida com 12 crianças com idades entre os 9 e os 12 anos. Assim, os objetivos desta investigação foram: explorar de que forma os entrevistados ocupam os seus tempos livres, para saber se descrevem ocorrências de bullying espontaneamente; explorar o conhecimento que os entrevistados têm relativamente ao fenómeno do bullying; perceber se os entrevistados já sofreram algum tipo de bullying, se o já praticaram ou se já o observaram, ou seja, se já se encontraram no papel de vítima, agressor, vitima-agressora ou observador, e em que contexto ocorreu (escola, bairro, etc); perceber qual o papel do observador e de que forma e porquê o mesmo intervém ou não face a uma situação de bullying; e perceber como as situações de vitimação/agressão aconteciam e como eram resolvidas. Concluiu-se que a maioria das crianças tinha dificuldade em diferenciar agressão de bullying, que a maioria das crianças não conseguia explicar porque acontece o bullying, que metade das crianças ajudariam perante uma situação de bullying mas também que uma percentagem ainda grande não ajudaria numa situação de bullying, sendo a razão predominante o medo de futuras represálias. This research aims to contribute to the understanding of the phenomenon of childhood bullying in the school and leisure context. For this purpose, a qualitative study was conducted, based on a semi-structured interview guide that was conducted with 12 children aged 9 to 12 years. Taking that in account, the objectives of this investigation were: to explore how interviewed spend their free time, to know if spontaneous bullying occurrences are described; explore the knowledge that interviewed have about the bullying phenomenon; understand if interviewed have ever been bullied, practiced or observed, that is, whether they have been in the role of victim, perpetrator, victim or observer, and in what context (school, neighborhood , etc); understand the role of the observer and how and why he or she intervenes or not in the face of a bullying situation; and to understand how victimization / aggression situations happened and how they were resolved. It was concluded that most children had difficulty distinguishing aggression from bullying, that most children could not explain why bullying happens, that half of children would help in bullying situation but also that a still large percentage would not help in a situation of bullying, the predominant reason being fear of future reprisals.

Echocardiography (Echo) has been used to define restrictive physiology as any presence of end-diastolic forward flow (EDFF) on the pulmonary artery, despite constant small amount of EDFF is present in healthy children, being values lesser than in children with repaired right ventricular outflow tract obstructive lesions (RVOT). No information regarding EDFF quantitative assessment has been made in adult healthy controls (HC). Methods: 81 consecutive patients (mean age: 37 years; 53% men) with RVOT lesions were studied. Forty-three age-and-sex matched HC were evaluated. Echo parameters were: EDFF peak velocity in inspiration (EDFF_i), in expiration (EDFF_e), EDFF_i/EDFF_e ratio, maximum velocity-time integral EDFF (VTI_EDFF). Results: A small constant EDFF was present in HC. Mean values of EDFF_i, EDFF_e, VTI-EDFF were significantly lower in HC compared to patients: 26 cm/s (SD 6) vs 49.6 cm/s (SD ±22), 25 cm/s (SD ±6) vs 40 cm/s (SD ±19), 2.3 cm ( ±0.6) vs 6.2 cm ( ±3.5), respectively, p 2SD for the different parameters. VTI-EDFF could easily be used as a non-invasive parameter to distinguish patients from HC and provide a new definition of RP; the presence of respiratory variation should be considered a key factor to differentiate HC from patients. In conclusion, any amount of EDFF throughout the respiratory cycle is not useful for identifying abnormal EDFF. A new approach based on cut-off values obtained from HC and quantitative EDFF assessment is proposed to provide a new definition of abnormal EDFF.

Objectives This study sought to establish the best definition of left ventricular adverse remodeling (LVAR) to predict outcomes and determine whether its assessment adds prognostic information to that obtained by early cardiac magnetic resonance (CMR). Background LVAR, usually defined as an increase in left ventricular end-diastolic volume (LVEDV) is the main cause of heart failure after an ST-segment elevated myocardial infarction; however, the role of assessment of LVAR in predicting cardiovascular events remains controversial. Methods Patients with ST-segment elevated myocardial infarction who received percutaneous coronary intervention within 6 h of symptom onset were included (n = 498). CMR was performed during hospitalization (6.2 ± 2.6 days) and after 6 months (6.1 ± 1.8 months). The optimal threshold values of the LVEDV increase and the LV ejection fraction decrease associated with the primary endpoint were ascertained. Primary outcome was a composite of cardiovascular mortality, hospitalization for heart failure, or ventricular arrhythmia. Results The study was completed by 374 patients. Forty-nine patients presented the primary endpoint during follow-up (72.9 ± 42.8 months). Values that maximized the ability to identify patients with and without outcomes were a relative rise in LVEDV of 15% (hazard ratio [HR]: 2.1; p = 0.007) and a relative fall in LV ejection fraction of 3% (HR: 2.5; p = 0.001). However, the predictive model (using C-statistic analysis) failed to demonstrate that direct observation of LVAR at 6 months adds information to data from early CMR in predicting outcomes (C-statistic: 0.723 vs. 0.795). Conclusions The definition of LVAR that best predicts adverse cardiovascular events should consider both the increase in LVEDV and the reduction in LV ejection fraction. However, assessment of LVAR does not improve information provided by the early CMR.

Background Diseases of the descending aorta have emerged as a clinical issue in Marfan syndrome following improvements in proximal aorta surgical treatment and the consequent increase in life expectancy. Although a role for hemodynamic alterations in the etiology of descending aorta disease in Marfan patients has been suggested, whether flow characteristics may be useful as early markers remains to be determined. Methods Seventy-five Marfan patients and 48 healthy subjects were prospectively enrolled. In- and through-plane vortexes were computed by 4D flow cardiovascular magnetic resonance (CMR) in the thoracic aorta through the quantification of in-plane rotational flow and systolic flow reversal ratio, respectively. Regional pulse wave velocity and axial and circumferential wall shear stress maps were also computed. Results In-plane rotational flow and circumferential wall shear stress were reduced in Marfan patients in the distal ascending aorta and in proximal descending aorta, even in the 20 patients free of aortic dilation. Multivariate analysis showed reduced in-plane rotational flow to be independently related to descending aorta pulse wave velocity. Conversely, systolic flow reversal ratio and axial wall shear stress were altered in unselected Marfan patients but not in the subgroup without dilation. In multivariate regression analysis proximal descending aorta axial (p = 0.014) and circumferential (p = 0.034) wall shear stress were independently related to local diameter. Conclusions Reduced rotational flow is present in the aorta of Marfan patients even in the absence of dilation, is related to aortic stiffness and drives abnormal circumferential wall shear stress. Axial and circumferential wall shear stress are independently related to proximal descending aorta dilation beyond clinical factors. In-plane rotational flow and circumferential wall shear stress may be considered as an early marker of descending aorta dilation in Marfan patients.

O presente documento tem como principal objetivo descrever o trabalho desenvolvido no estágio realizado no primeiro ano do mestrado em educação pré-escolar e refletir em torno de um projeto denominado: viajar pelo Portugal dos Pequenitos, onde foram implementados dois projetos, um sobre São Tomé e outro sobre a Índia. A opção pela temática da multiculturalidade teve como finalidade alertar para a importância da multiculturalidade pois, apesar de este ser um tema atual, nem sempre é devidamente valorizado pelos profissionais da educação de infãncia. Por isso, e de certa forma, através da prática desenvolvida quisemos passar a mensagem de que é possível abordar este aspeto no jardim-de-infância, bem como dar a conhecer qual o papel do educador de infância relativamente à educação multicultural. Consideramos fundamental sensibilizar as crianças para outras culturas, para a multiculturalidade, e evidenciar que é primordial que cada um de nós tenha sempre em mente a inclusão de qualquer criança na sua sala de jardim-de-infância, independentemente da sua cultura. Concluimos que o uso da metodologia do trabalho por projetos é um caminho com enormes potencialidades numa abordagem multicultural, permitindo-nos viajar, sem sair fisicamente do lugar, para outras culturas, conhecer, compreender, dialogar, aceitar e re-elaborar modelos culturais pouco conhecidos ou préconcebidos.