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Resumen Introduccion y objetivos Se presentan las caracteristicas clinicas y los resultados de los trasplantes cardiacos realizados en Espana con la actualizacion correspondiente a 2019. Metodos Se describen las caracteristicas clinicas y los resultados de los trasplantes cardiacos realizados en 2019, asi como las tendencias de estos en el periodo 2010-2018. Resultados En 2019 se realizaron 300 trasplantes (8.794 desde 1984; 2.745 entre 2010 y 2019). Respecto a anos previos, los cambios mas llamativos son el descenso hasta el 38% de los trasplantes realizados en codigo urgente, y la consolidacion en el cambio de asistencia circulatoria pretrasplante, con la practica desaparicion del balon de contrapulsacion (0,7%), la estabilizacion del uso del oxigenador extracorporeo de membrana (9,6%) y el aumento de los dispositivos de asistencia ventricular (29%). La supervivencia en el trienio 2016-2018 es similar a la del trienio 2013-2015 (p = 0,34), y ambas mejores que la del trienio 2010-2012 (p = 0,002 y p = 0,01 respectivamente). Conclusiones Se mantienen estables tanto la actividad del trasplante cardiaco en Espana como los resultados en supervivencia en los ultimos 2 trienios. Hay una tendencia a realizar menos trasplantes urgentes, la mayoria con dispositivos de asistencia ventricular.

Aim: To ascertain the clinical profile and management of edoxaban in clinical practice. Materials & methods: Prospective, noninterventional postauthorization study of nonselected patients with atrial fibrillation treated with edoxaban from 12 European countries. Patients’ baseline characteristics are presented. Results: A total of 13,638 patients (73.6 ± 9.5 years; 76.6/23.4% edoxaban 60/30 mg; CHA2DS2-VASc 3.1; 838 [6.1%] from Spain) were included. In Spain, the percentage of very elderly and fragile patients was greater and the risk of thromboembolism (CHA2DS2-VASc ≥2, 98.0 vs 87.3%; p < 0.001) and bleeding (HAS-BLED, 3.2 vs 2.7; p < 0.001) was greater in patients treated with edoxaban 30 mg. The proportion of patients taking edoxaban 30 mg was similar than in ENGAGE AF-TIMI 48. Conclusion: In Spain, patients treated with edoxaban were older and fragile.

Resumen La insuficiencia cardiaca es una enfermedad que precisa un tratamiento multidisciplinario, dadas la diversidad de causas y entornos clinicos implicados que las tratan y las diferentes estrategias terapeuticas que precisan la participacion indispensable de diversas disciplinas. La presencia en los servicios de cardiologia de unidades de insuficiencia cardiaca centradas en el tratamiento de los pacientes con esta afeccion y unidades de rehabilitacion cardiaca que, entre sus indicaciones para la reduccion de la morbimortalidad, tambien estan implicadas en la atencion de esos mismos pacientes puede causar dificultades de coordinacion y perdida de una atencion integral centrada en el paciente. Por estos motivos, en el presente documento se plantea una estrategia de coordinacion entre las diferentes unidades implicadas en el tratamiento de los pacientes dentro de los servicios de cardiologia y la continuidad asistencial con atencion primaria, tanto tras haber conseguido la estabilidad como la interrelacion para una coordinacion posterior mas efectiva.

Background Subcutaneous implantable cardioverter-defibrillator (S-ICD) is gaining in popularity for primary and secondary prevention of sudden cardiac death. The objective was to evaluate the safety and clinical effectiveness of the S-ICD for prevention of sudden cardiac death compared to transvenous cardioverter-defibrillator (TV-ICD). Methods A systematic review with meta-analyses was performed. The electronic databases MEDLINE, EMBASE, SCI, and Cochrane Central Register of Controlled Trials were consulted in March 2018 with no restrictions on publication date. Predefined criteria were used to determine inclusion of studies and to assess their methodologic quality. Results Ten longitudinal-observational studies with comparison group presenting moderate methodologic flaws were included (N = 7820). The combination of results indicates that health-related quality of life is not significantly different between S-ICD and TV-ICD groups (Physical health: MD = 2.90; 95% CI = -3.88, 9.68/Mental health: MD = 0.13; 95% CI = -2.11, 2.37). Mortality occurred in 4.4% of S-ICD patients and 5.9% of TV-ICD patients died (OR = 0.79; 95% CI = 0.50, 1.24). The incidence of infections (OR = 1.79; 95% CI = 0.93, 3.43) and inappropriate shocks (OR = 1.28, 95% CI = 0.91, 1.78) is not significantly different between both groups. The S-ICD reduces complications related to electrodes/leads (OR = 0.13, 95% CI = 0.05, 0.29) and has lower electrodes/leads movement compared with TV-ICD (OR = 0.26; 95% CI 0.10, 0.67). In contrast, pneumothorax is more likely in TV-ICD than S-ICD (OR = 0.17; 95% CI = 0.03, 0.97). Conclusions S-ICD reduces electrodes/leads movement, electrodes/leads related complications, and pneumothorax. Our study did not demonstrate a statistically significant difference in mortality, health-related quality of life, and infection rate between S-ICD and TV-ICD.

Wilms tumor (WT) is the most frequently diagnosed malignant renal tumor in children. With current treatments, ~90% of children diagnosed with WT survive and generally present with tumors characterized by favorable histology (FHWT), whereas prognosis is poor for the remaining 10% of cases where the tumors are characterized by cellular diffuse anaplasia (DAWT). Relatively few studies have investigated microRNA-related epigenetic regulation and its relationship with altered gene expression in WT. Here, we aim to identify microRNAs differentially expressed in WT and describe their expression in terms of cellular anaplasia, metastasis, and association with the main genetic alterations in WT to identify potential prognostic biomarkers. Expression profiling using TaqMan low-density array was performed in a discovery cohort consisting of four DAWT and eight FHWT samples. Relative quantification resulted in the identification of 109 (48.7%) microRNAs differentially expressed in both WT types. Of these, miR-10a-5p, miR-29a-3p, miR-181a-5p, miR-200b-3p, and miR-218-5p were selected and tested by RT-qPCR on a validation cohort of 53 patient samples. MiR-29a and miR-218 showed significant differences in FHWT with low (P = 0.0018) and high (P = 0.0131) expression, respectively. To discriminate between miRNA expression FHWTs and healthy controls, the receiver operating characteristic (ROC) curves were obtained; miR-29a AUC was 0.7843. Furthermore, low expression levels of miR-29a and miR-200b (P = 0.0027 and P = 0.0248) were observed in metastatic tumors. ROC curves for miR-29a discriminated metastatic patients (AUC = 0.8529) and miR-200b (AUC = 0.7757). To confirm the differences between cases with poor prognosis, we performed in situ hybridization for three microRNAs in five DAWT and 17 FHWT samples, and only significant differences between adjacent tissues and FHWT tumors were found for miR-181a, miR-200b, and miR-218, in both total pixels and nuclear analyses. Analysis of copy number variation in genes showed that the most prevalent alterations were WTX (47%), IGF2 (21%), 1q (36%) gain, 1p36 (16%), and WTX deletion/1q duplicate (26%). The five microRNAs evaluated are involved in the Hippo signaling pathway and participate in Wilms tumor development through their effects on differentiation, proliferation, angiogenesis, and metastasis.

Introduction and objectives The present report describes the clinical characteristics and outcomes of heart transplants in Spain and updates the data to 2019. Methods We describe the clinical characteristics and outcomes of heart transplants performed in Spain in 2019, as well as trends in this procedure from 2010 to 2018. Results In 2019, 300 transplants were performed (8794 since 1984; 2745 between 2010 and 2019). Compared with previous years, the most notable findings were the decreasing rate of urgent transplants (38%), and the consolidation of the type of circulatory support prior to transplant, with an almost complete disappearance of counterpulsation balloon (0.7%), stabilization in the use of extracorporeal membrane oxygenation (9.6%), and an increase in the use of ventricular assist devices (29.0%). Survival from 2016 to 2018 was similar to that from 2013 to 2015 (P=.34). Survival in both these periods was better than that from 2010 to 2012 (P=.002 and P=.01, respectively). Conclusions Heart transplant activity has remained stable during the last few years, as have outcomes (in terms of survival). There has been a trend to a lower rate of urgent transplants and to a higher use of ventricular assist devices prior to transplant.

Resumen Introduccion y objetivos Las restricciones a la prescripcion de los anticoagulantes orales directos (ACOD) para la fibrilacion auricular no valvular (FANV) impuestas en Espana por el Informe de Posicionamiento Terapeutico (IPT) de 2013 pueden limitar el acceso a estos. Con el fin de valorar su efecto, se analizaron los motivos para la prescripcion del ACOD rivaroxaban, el perfil de pacientes tratados y el tiempo hasta recibirlo en hospitales de Sistema Nacional de Salud (SNS), de forma global y por comunidades autonomas ( CC .AA.). Metodos Estudio observacional, transversal, multicentrico en consultas de especialistas del SNS entre pacientes con FANV tratados con rivaroxaban. Las CC.AA. se agruparon segun condiciones de prescripcion mas frecuentes: ficha tecnica (FT), IPT o IPT mas restrictivo/modificado (IPTm). Resultados Participaron 73 investigadores/1.727 pacientes. El 90,6% de los pacientes presentaba un riesgo tromboembolico alto (CHA2DS2-Vasc ≥ 2) y el 46,2% un riesgo hemorragico alto (HAS-BLED ≥ 3). Tardaron una mediana de 21,1 meses desde el diagnostico de la FANV hasta recibir rivaroxaban. El 57,0% habia recibido antagonistas de la vitamina K (AVK). Los pacientes de CC.AA. IPT/IPTm tenian un riesgo tromboembolico y hemorragico superior, recibieron mas frecuentemente AVK y tardaron una mediana de ∼ 20 meses mas en recibir rivaroxaban vs. CC.AA. FT. Conclusiones Los pacientes tratados con rivaroxaban en Espana presentan un riesgo tromboembolico y hemorragico alto y tardan una mediana de 21,1 meses en recibirlo. La diferente adherencia al IPT genera desigualdades entre CC.AA. Los pacientes de CC.AA. IPT/IPTm tardan ∼ 20 meses mas en recibir rivaroxaban y presentan mayor riesgo tromboembolico/hemorragico.

Naranjilla (Solanum quitoense Lam.), is an economic input of vital importance for the Ecuadorian Amazon due to multiple benefits that offers, although it requires studies that provide a basis for the naranjilla cultivation management. The aim of this research was to determine the influence of socioeconomic variables on the naranjilla production from the rural community of Wamani, Napo province in the Ecuadorian Amazon. For the study, a group-type questionnaire was conducted to 40 rural producers of naranjilla in the region, which was structured based on three levels, which included data on the property, crop management and socio-economic aspects. Additionally, a factor analysis was applied to reduce the variables dimensionality. The results showed a pattern of own land distribution which is favorable to develop the family economy. It was found that naranjilla cultivation is the most important item in the community, although there are other crops that guarantee the diversification of the productive systems, which is reflected in the socioeconomic indicators. The T-test of independent samples, indicated that there are no significant differences among indicators for clean and chemical crop management (p≥0.05), which demonstrates the feasibility of use for the cultivation of clean naranjilla as a healthier product with additional benefits for rural producers. The factorial analysis have allowed the reduction of the 16 evaluated variables in three components associated with the economic, social and productive indicators, which explained 79.46% of the total accumulated variance. La naranjilla (Solanum quitoense Lam.), constituye un rubro económico de vital importancia para la Amazonía ecuatoriana debido a los múltiples beneficios que brinda, aunque requiere de estudios que permitan fundamentar las bases para el manejo del cultivo de la naranjilla. El objetivo de esta investigación fue determinar la influencia de variables socioeconómicas en la producción de naranjilla de la comunidad de Wamaní, provincia Napo en la Amazonía Ecuatoriana. Para el estudio, se realizó un cuestionario de tipo grupal a 40 productores de naranjilla en la región, el cual se estructuró con base a tres niveles, los cuales comprendieron datos sobre la propiedad, manejo del cultivo y aspectos socio-económicos. Adicionalmente, se aplicó un análisis factorial para reducir la dimensionalidad de las variables. Los resultados mostraron un patrón de distribución de tierras propio lo cual es favorable para desarrollar la economía familiar. Se constató que el cultivo de la naranjilla es el rubro de mayor importancia en la comunidad aunque existen otros cultivos que garantizan la diversificación de los sistemas productivos lo cual se refleja en los indicadores socieconómicos. La prueba T de muestras independientes, indicó que no existen diferencias significativas entre los indicadores para la forma de manejo limpia y con químicos (p≥0.05), lo que demuestra la factibilidad de uso para el cultivo de naranjilla limpia como un producto más sano con beneficios adicionales para los productores rurales. El análisis factorial permitió la reducción de las 16 variables estudiadas en tres componentes asociados a lo económico, social y productivo, que explicaron el 79.46% de la varianza total acumulada.

Background and aims Lifestyle has been found to play an important role in the prevention of cardiovascular disease (CVD). There is evidence to suggest that if lifestyle factors are modified successfully, the relative risk of CVD can be reduced. Risk factors for CVD such as high blood pressure, diabetes mellitus and dyslipidaemias can be modified by lifestyle changes. The main aim of this article is to provide best practice approaches and support for healthcare professionals on the role of lifestyle changes in the prevention of CVD. Methods A working group of experts discussed existing guidelines, clinical practice and evidence, and provided their recommendations on ten topics concerning the role of lifestyle in CVD prevention. These topics covered important lifestyle factors as well as tools/approaches to assess or encourage lifestyle changes. Results The group of clinical experts collaborated to provide their opinion on the following topics: one diet versus customised diets; the role of alcohol consumption in a healthy diet; a diet based on nutrient composition or on whole foods; a Mediterranean versus low-fat diet; the role of dietary supplements; physical activity; smoking cessation; the role of a nutritionist/dietitian in a CVD risk multidisciplinary team; tools to be implemented to assess diet, physical activity and smoking status; and the most effective approaches to encourage lifestyle changes. Conclusions The expert working group agreed that lifestyle changes were important in preventing CVD and provided recommendations which complemented current guidance and increased clarity on several topics.

Nous exposons le cas d’une patiente de 47 ans qui presente un syndrome coronarien aigu et une probable embolie arterielle du membre inferieur droit dans l’etude duquel nous detectons la presence de la mutation du gene de la prothrombine G201210A associee a la presence de facteur anticoagulant lupique. La patiente a beneficie d’une transplantation cardiaque avec bonne evolution clinique.

Sexual dysfunction in patients with chronic fatigue syndrome is attracting growing interest but, to date, few studies have analyzed it. For this reason, the authors evaluated sexual dysfunction in women with chronic fatigue syndrome (using the Golombok Rust Inventory of Sexual Satisfaction) and explore correlations with fatigue and other symptoms. Sexual dysfunction was greater in patients with chronic fatigue syndrome (n = 615) with a higher number of cognitive, neurological, and neurovegetative symptoms, concomitant fibromyalgia, Sjogren's syndrome, or myofascial pain syndrome, and more intense fatigue (p

Introduccion y objetivos El implante de un electrodo a traves del seno coronario (SC) puede ser dificultoso debido a obstaculos anatomicos que limitan el acceso a la vena. Por ello es fundamental conocer la anatomia venosa coronaria. El objetivo es analizar la utilidad de la senovenografia de retorno con hiperemia en el implante de dispositivos de resincronizacion cardiaca comparandolo con la senovenografia oclusiva retrograda. Metodos Se estudio la anatomia venosa coronaria en 200 pacientes, mediante la filmacion del retorno venoso coronario optimizado con la induccion de hiperemia y mediante senovenografia oclusiva, puntuandose la visibilidad de las distintas porciones del sistema venoso coronario. Resultados En general, se obtuvo una informacion anatomica adecuada en el 99,5% de los individuos. Las puntuaciones de visibilidad para el SC y la vena lateral fueron ligeramente superiores en el grupo estudiado mediante senovenografia oclusiva retrograda, aunque no hubo diferencias significativas entre ambas tecnicas. Por el contrario, la vena cardiaca media y la vena interventricular anterior se visualizaron con mayor detalle mediante la senovenografia de retorno. No hubo complicaciones en el grupo estudiado mediante senovenografia de retorno, mientras que en 3 pacientes estudiados con senovenografia oclusiva se produjo la diseccion de la gran vena cardiaca, aunque no impidio el implante del electrodo. Conclusiones La angiografia coronaria de retorno define con precision la anatomia venosa de la region lateral del ventriculo izquierdo y permite anticipar el nivel de dificultad del implante del electrodo.

Aldosterone produces retention of Na + and water and loss of K + , as well as substantial independent effects on epithelia. The use of mineralocorticoid receptor blockers reduces the damage produced by aldosterone in patients with cardio-renal dysfunction. Eplerenone, a novel and specific antagonist of mineralocorticoid receptors, has been approved for the treatment of patients with left ventricular systolic dysfunction after myocardial infarction. In this brief review, we analyze the effects of aldosterone, mineralocorticoid receptor blockade, and the molecule eplerenone, as well as the actions of this drug at different levels and its adverse effects.

Introduction and objectives. Implantation of electrodes via the coronary sinus (CS) can be very challenging because access to the target vessel is restricted by anatomical obstacles. Consequently, prior knowledge of coronary venous anatomy is crucial. The objective of this study was to evaluate the usefulness of hyperemic venous return angiography relative to that of occlusive retrograde venography prior to cardiac resynchronization device implantation. Methods. Coronary venous anatomy was studied in 200 patients both by videoing venous coronary return, which was optimized by inducing hyperemia, and by occlusive venography. The visibility of different portions of the coronary venous system was scored. Results. Overall, sufficient anatomic information was obtained in 99.5% of patients. Visibility scores for the CS and the lateral vein of the left ventricle were slightly higher in the group studied using occlusive venography, though there was no significant difference between the 2 techniques. In contrast, the middle cardiac vein and the anterior interventricular vein could be visualized in greater detail using venous return angiography. There were no complications in the group studied using venous return angiography whereas dissection of the great cardiac vein occurred in 3 patients studied using occlusive venous angiography, though this did not prevent electrode implantation. Conclusions. With venous return angiography, it was possible to visualize accurately the venous anatomy of the lateral wall of the left ventricle and, consequently, to anticipate the level of difficulty posed by electrode implantation.

La tecnica de la guia retenida se ha descrito como una alternativa para la estabilizacion del electrodo ventricular izquierdo en caso de migracion intraoperatoria repetida. En el presente articulo analizamos a 3 (1,6%) de 185 pacientes tratados con resincronizacion cardiaca, que precisaron el uso de esta tecnica tras objetivarse dislocacion recurrente. Los parametros del electrodo en el implante se encontraron dentro de limites normales. A pesar de no objetivarse migracion macroscopica del electrodo, en to-dos los pacientes se observaron alteraciones en los parametros de sensado y estimulacion a los 6 meses-1 ano del implante, con una marcada elevacion de la impedancia. El analisis de laboratorio mostro deformacion y fractura de las espirales conductoras, asi como deterioro de las capas aislantes. En conclusion, nuestra experiencia muestra que la tecnica de la guia retenida no debe utilizarse debido al deterioro diferido del electrodo.

Introduccion y objetivos El implante de un electrodo ventricular izquierdo a traves del seno coronario plantea, en ocasiones, cierta dificultad debido a obstaculos anatomicos que limitan el acceso a la vena diana. El objetivo es analizar la experiencia del Hospital Universitario de Gran Canaria Dr. Negrin con la tecnica de la doble guia en el implante de un electrodo venoso ventricular izquierdo. Metodos De 170 pacientes consecutivos (67 ± 9 anos, 72% varones) a los que se implanto un dispositivo de resincronizacion se recurrio, en 20 de ellos (12%), al uso de una segunda guia hidrofilica en paralelo para el implante del electrodo en la vena diana, dada la imposibilidad de implante sin esta tecnica. Resultados Las causas de imposibilidad de implante con la tecnica convencional fueron: tortuosidad extrema del vaso en su desembocadura (5 pacientes, 25%), angulo marcado en la desembocadura de la vena diana (7 pacientes, 35%), presencia de una valvula venosa en dicha localizacion (8 pacientes, 40%) y, finalmente, escaso soporte del cateter guia (4 pacientes, 20%), bien por valvula de Tebesio fenestrada (2 pacientes) o por valvula de Vieussens restrictiva (2 pacientes) que no permitia el avance del cateter guia y/o del electrodo. En 4 casos (20%) hubo mas de un factor. En todos los casos, tras avanzar una segunda guia hidrofilica se pudo realizar el implante en la vena diana sin complicaciones. Conclusiones El uso de una segunda guia en paralelo (tecnica de la doble guia) es un procedimiento seguro y eficaz para el implante del electrodo ventricular izquierdo en pacientes con anatomia desfavorable.

Objective.Pulmonary arterial hypertension (PAH) prevalence has been reported to be between 0.5% and 17% in systemic lupus erythematosus (SLE). This study assessed PAH prevalence and predictors in an SLE cohort.Methods.The Borg dyspnea scale, DLCO, N-terminal pro–brain natriuretic peptide (NT-proBNP), and Doppler echocardiographic (DE) were performed. An echocardiographic Doppler exercise test was conducted in selected patients. When DE systolic pulmonary arterial pressure was ≥ 45 mmHg or increased during exercise > 20 mmHg, a right heart catheterization was performed. Hemodynamic during exercise was measured if rest mean pulmonary arterial pressure was < 25 mmHg.Results.Of the 203 patients with SLE, 152 were included. The mean age was 44.9 ± 12.3 years, and 94% were women. Three patients had known PAH. The algorithm diagnosed 1 patient with chronic thromboembolic pulmonary hypertension and 5 with exercise-induced pulmonary artery pressure increase (4 with occult left diastolic dysfunction). These patients had significantly more dyspnea, higher NT-proBNP, and lower DLCO.Conclusion.These data confirm the low prevalence of PAH in SLE. In our cohort, occult left ventricular diastolic dysfunction was a frequent diagnosis of unexplained dyspnea. Dyspnea, DLCO, and NT-proBNP could be predictors of pulmonary hypertension in patients with SLE.

La platipnea-ortodesoxia es un sindrome poco frecuente que se caracteriza por disnea e hipoxemia en situacion de bipedestacion, con mejoria de los sintomas y recuperacion de la hipoxemia con el decubito. La asociacion de este sindrome con un foramen oval permeable y un cortocircuito derecha-izquierda es muy frecuente. Describimos 2 casos de cierre percutaneo con dispositivo Amplatzer en pacientes en las que se observo un foramen oval permeable mediante estudio ecocardiografico transtoracico y transesofagico, con paso derecha-izquierda en reposo y tras Valsalva, en mayor cantidad en la posicion de sedestacion respecto al decubito y asociado con una desaturacion arterial y disnea. Estos casos demuestran que el cierre del foramen oval permeable es un tratamiento eficaz de la platipnea-ortodesoxia.

Platypnea-orthodeoxia is a rare syndrome characterized by the occurrence of dyspnea and hypoxemia on adoption of an upright posture (i.e., orthodeoxia) and by the absence of symptoms and hypoxemia in decubitus. This syndrome is frequently related to patent foramen ovale and right-to-left shunting. We describe two patients in whom patent foramen ovale with right-to-left shunting was observed on transthoracic and transesophageal echocardiography and who had platypnea-orthodeoxia in the absence of pulmonary disease. They underwent transcatheter closure using an Amplatzer device. The echocardiographic diagnosis and closure procedure are discussed. These case reports demonstrate that closure of patent foramen ovale is an effective treatment for platypnea-orthodeoxia.

Inhaled nitric oxide (iNO) has been shown to be a potent and selective vasodilator in pulmonary arterial hypertension (PAH). However, the clinical experience in prolonged treatment is limited. We assess the safety and effectiveness of long-term administration of iNO in severe PAH. Two female patients were admitted to our hospital because of severe dyspnea (World Health Organization functional class IV) and hypoxemia. They were diagnosed with PAH (primary and secondary to congenital heart disease) and treated with iNO for 2 years. The delivery system consisted of an NO tank of 800 ppm, a modified gas-pulsing device, and nasal cannulas. On iNO treatment the patients showed remarkable improvement of symptoms, oxygenation and 6-min walk distance. After 16 months the patients began to experience a progressive rebound of symptoms. A phosphodiesterase type 5 inhibitor (dipyridamole) was added to iNO. This intervention proved useful in improving clinical deterioration and hemodynamics. This is the first study reporting 2-year iNO therapy in 2 patients with primary and secondary pulmonary hypertension. The combination of dipyridamole with iNO augments the pulmonary vasodilatation and may be useful in managing PAH.

Chronic fatigue syndrome (CFS) is a disabling disorder with implications in employment status. We enrolled 60 patients who fulfilled the CDC diagnostic criteria of Holmes and those of Fukuda. All patients underwent a protocol involving a structured questionnaire to record diagnostic criteria items, clinical features of fatigue, social features and associated symptoms; application of the Fatigue Impact Scale (FIS); an employment repercussion questionnaire; and information on evolution of the symptoms. Statistical comparisons were performed with the Mann-Whitney U test and correlations with the Spearman test. A close correlation was found between work inactivity and higher scores in the FIS cognitive dimension. Patient age and duration of symptoms also correlated with high cognitive scores. Chronic fatigue syndrome patients report a considerable decrease in quality of life, and most of them have work limitations, particularly those with poor overall FIS scores and cognitive function scores.

We report the clinical case of a 77-years-old woman with cardiogenic shock caused by dynamic left ventricular outflow tract (LVOT) obstruction that appeared after anterior acute myocardial infarction. Dynamic LVOT obstruction has been reported in various circumstances aside from hypertrophic obstructive cardiomyopathy, such as acute myocardial infarction. In a patient with cardiogenic shock and a heart murmur after acute myocardial infarction, an acute mechanical complication, ventricular septal defect, and acute mitral regurgitation must be ruled out because the treatment of these conditions differs completely. We describe the diagnostic and therapeutic measures used in the diagnosis and treatment of this complication.

SUMMARY Background: Several lines of evidence support the involvement of inflammatory and immunologic abnormalities in chronic fatigue syndrome (CFS). Since recent studies have shown that α-1 antitrypsin (AAT) possesses anti-inflammatory properties, the potential therapeutic effect of AAT treatment on CFS has been investigated. Case presentation: A 49-year-old woman diagnosed with CFS was treated with intravenous infusions of a human plasma-derived AAT concentrate (60 mg/kg body weight weekly for 8 consecutive weeks). The patient’s monocyte elastase, a regulator of inflammatory processes, was 1170 U/mg. At completion of treatment, improvement in maximal workload was observed (54.0–71.7% of predicted). Additionally, amelioration in working memory (scores: 83–94) and perceptual organization (scores: 75–83) were detected on the Wechsler Adult Intelligence Scale-III test. Monocyte elastase decreased to a normal range (

El mixoma es el tumor primario mas frecuente que afecta al corazon. La infeccion de estos tumores es infrecuente y, en ocasiones, su presentacion clinica es indistinguible de un mixoma no infectado. Describimos el caso de una mujer de 58 anos con una infeccion faringea previa que desarrollo infeccion sobre un mixoma auricular izquierdo, complicado con embolia sistemica en los miembros inferiores. Se aislo Streptococcus oralis en los hemocultivos y en el material embolico. El tumor se reseco y la evolucion clinica posterior resulto sin incidencias. La frecuencia del mixoma infectado es muy baja y una revision de la bibliografia se ha de basar en los casos aislados publicados.

The aim of this paper was to review the cost-effectiveness studies of implantable cardioverter defibrillators (ICD) for primary or secondary prevention of sudden cardiac death (SCD). A systematic review of the literature published in English or Spanish was performed by electronically searching MEDLINE and MEDLINE in process, EMBASE, NHS-EED, and EconLit. Some keywords were implantable cardioverter defibrillator, heart failure, heart arrest, myocardial infarction, arrhythmias, syncope, sudden death. Selection criteria were the following: (1) full economic evaluations published after 1995, model-based studies or alongside clinical trials (2) that explored the cost-effectiveness of ICD with or without associated treatment compared with placebo or best medical treatment, (3) in adult patients for primary or secondary prevention of SCD because of ventricular arrhythmias. Studies that fulfilled these criteria were reviewed and data were extracted by two reviewers. The methodological quality of the studies was assessed and a narrative synthesis was prepared. In total, 24 studies were included: seven studies on secondary prevention and 18 studies on primary prevention. Seven studies were performed in Europe. For secondary prevention, the results showed that the ICD is considered cost-effective in patients with more risk. For primary prevention, the cost-effectiveness of ICD has been widely studied, but uncertainty about its cost-effectiveness remains. The cost-effectiveness ratios vary between studies depending on the patient characteristics, methodology, perspective, and national settings. Among the European studies, the conclusions are varied, where the ICD is considered cost-effective or not dependent on the study.

Background Inhaled nitric oxide (iNO) is a potent pulmonary vasodilator, but therapeutic experience in patients with severe pulmonary hypertension is scarce. Methods Eleven patients with severe pulmonary hypertension, 6 due to pulmonary arterial hypertension and 4 due to chronic thromboembolic disease, were selected for iNO therapy. A phosphodiesterase type 5 inhibitor (PDE5i) was added in cases of clinical worsening. In this study we evaluate the clinical effectiveness and safety of long-term treatment with iNO either alone or combined with a PDE5i. Results After 1 month of iNO administration, improvements were observed in World Health Organization functional class, Borg scale ( p = 0.003), brain natriuretic peptide levels ( p = 0.002) and 6-minute walk test ( p = 0.003). After 6 months of treatment, 7 patients had clinical deterioration that was reversed upon adding a PDE5i. One of these patients died in Month 8 and another underwent pulmonary transplantation in Month 9. The clinical condition of the remaining 9 patients was unchanged after 1 year. A second right catheterization showed improvement in mean pulmonary arterial pressure (66 ± 15 mm Hg to 56 ± 18 mm Hg; p = 0.01), pulmonary vascular resistance (1,234 ± 380 dyn/s/cm 5 to 911 ± 410 dyn/s/cm 5 ; p = 0.008) and cardiac index (2.0 ± 0.4 liters/min/m 2 to 2.5 ± 0.4 liters/min/m 2 ; p = 0.04). There was no significant increase in methemoglobin, no worsening of pulmonary function and no sudden withdrawal syndrome. Conclusions We suggest that iNO therapy alone or in combination with a PDE5i could be a therapeutic alternative for severe pulmonary hypertension.

The retained guidewire technique has been proposed as an alternative method for stabilizing the left ventricular lead in patients who experience repetitive intraoperative dislocation. This article concerns three patients, out of a total of 185 (1.6%) undergoing cardiac resynchronization therapy, who had to be treated using the retained guidewire technique because of demonstrable recurrent lead dislocation. Electrode parameters were all within normal limits. Although lead dislocation could not be demonstrated macroscopically, sensing and pacing parameters were found to have changed 6 months to 1 year after implantation, with a marked elevation in impedance. Laboratory analysis showed deformation and fracture of the coil electrodes as well as deterioration of the insulation coating. In conclusion, our experience shows that the retained guidewire technique should not be used because delayed electrode damage can occur.

Introduction and objectives Occasionally, implanting a left ventricular pacing electrode for cardiac resynchronization therapy via the coronary sinus may be complicated by the presence of anatomical structures that obstruct the access to the target vein. Our objective was to report on experience using a double-wire technique for implanting left ventricular venous leads gained at the Dr Negrin Hospital in Gran Canaria, Spain. Methods In 20 (12%) of 170 consecutive patients (67 ± 9 years, 72%male)undergoing implantation of a cardiac resynchronization device, a second parallel hydrophilic guidewire had to be used during lead implantation in the target vein as implantation was impossible without using this technique. Results Implantation using a conventional approach was impossible because there was severe tortuosity at the vessel entrance in 5 patients (25%), a sharp angle at the entrance to the target vein in 7 (35%), a venous valve at the vessel entrance in 8 (40%), and, finally, poor support for the guiding catheter in four (20%), due to the presence of either a fenestrated Thebesian valve (2 patients) or a restrictive Vieussens valve (2 patients) that blocked passage of the guiding catheter or electrode. In 4 patients (20%), there was more than 1 factor. In all these cases, implantation was achieved in the target vein without complications after passage of a second hydrophilic guidewire. Conclusions The use of a second parallel guidewire (ie, the double-wire technique) provides a safe and effective way of implanting left ventricular venous pacing electrodes in patients with anatomical complications.

Patients affected by chronic fatigue syndrome (CFS) characteristically show easy and unexplained fatigue after minimal exertion that does not resolve with rest and is associated with specific symptoms lasting for more than six months. Cardiopulmonary exercise testing is a valid procedure for determining functional capacity in patients with CFS. We compare cardioventilatory adaptation to exercise between a group of eighty-five consecutive women patients affected by CFS and a group of fifteen healthy women extremely sedentary individuals, with the use of maximum incremental exercise testing on a cycle ergometer and arm ergometer, assessing possible differences. The majority of values achieved at peak exhaustive exercise were significantly lower in CFS patients than controls, including the percentage of maximum oxygen uptake in arm physical test (37.4±10.0% in CFS vs. 58.9± 15.8% in controls) and leg physical test (53.4±15.0% in CFS patients vs. 76.2 ± 18.0%in controls).In conclusion, the CFS group s...

Myxoma is the most common primary tumor of the heart. It is uncommon for these tumors to become infected and, at times, clinical presentation is no different from that of an uninfected myxoma. We describe the case of a 58-year-old woman with a previous pharyngeal infection that developed into infection of a left atrial myxoma and which was complicated by systemic embolism affecting the lower limbs. Streptococcus oralis was identified in blood cultures and embolic material. The tumor was resected and the patient's subsequent clinical evolution was uneventful. The incidence of infected myxoma is very low. A review of the literature based on individual case reports is presented.

Methods commonly used in regional geological analysis were employed to study the visual landscapes of the Sigüenza–Molina de Aragón area (Spain). Landscape data were compiled to produce a landscape map and a photograph catalogue. Lithological composition, tectonic structure and recent erosive processes are the main factors controlling the visual landscapes. Territorial properties, such as colours and agricultural capacities, are controlled by these geological characteristics. The landscape map and the photographic catalogue is the main contribution of this paper. The first level of landscape classification distinguishes zones with dominance of either flat, concave or convex areas. Other parts of the territory are, however, composed of concave and convex combinations that originate hybrid orographic structures. In a second level of classification, several subdivisions for each of these types are established.

The landscapes of a territory are the consequence of its history; overlapped geological, vegetable and cultural histories usually exist on a landscape. At the Mediterranean domain, however, a translucent vegetation exists, and its history is closely related to the geologic and cultural histories, because low-technology agricultural uses on a different hardness rock background control vegetation. Thus, in areas like the Guadalajara province, the geologic composition and the human activities can be considered the primary conditions for landscape configuration. Both condition the typologies, distribution and relative importance of the geotic, biotic and anthropogenic components of landscapes. A complex network of interrelations among all them exists but, in the base of which lie the geology of the territory, included relief, because it has amore independent influence since man cannot modify the geologic factors; such as the colour of the rocks, the size and distribution of rock bodies, the palaeogeographic domains and the tectonic structure all which control landscape development and configuration. Moreover, geology influences conditions and even limit, the presence, typologies and development of the biotic and anthropogenic elements. These factors also have a major relevance for environmental management, educational and economic policy, and, in some cases, for environmental impact assessment.

Chronic fatigue syndrome (CFS) is a disabling illness of unknown etiology that is characterized by fatigue associated with a reduced ability to work, lasting for more than 6 months, and accompanied by a specific set of symptoms. The diagnosis remains difficult because of the absence of laboratory tests and is, therefore, made largely on the basis of the symptoms reported by the patient. The aim of this study was to analyze differences in blood nitrate levels in CFS patients and a matched control group after a physical exercise test.Forty-four consecutive female patients with CFS and 25 healthy women performed an exercise test using a cycle ergometer with monitoring of cardiopulmonary response. Blood samples were obtained for biochemical analyses of glucose, lactate, and nitrates at the beginning (under resting conditions) and after the maximal and supramaximal tests.Plasma nitrates differed between the groups, with higher values in the CFS group (F = 6.93, p = 0.003). Nitrate concentration increased in relation to workload and reached higher values in the CFS group, the maximum difference with respect to the control group being 295% (t = 4.88, p0.001).The main result of the present study is that nitric oxide (NO) metabolites (nitrates) showed a much higher increase after a maximal physical test in CFS patients than in a group of matched subjects. This combination (exercise plus NO response evaluation) may be useful in the assessment of CFS.