Cardiac magnetic resonance imaging for the diagnosis of patients presenting with chest pain, raised troponin, and unobstructed coronary arteries

To evaluate the incremental diagnostic and prognostic value of cardiac magnetic resonance (CMR) in patients with chest pain, raised troponin and unobstructed coronary arteries, and to compare subsequent event rates between diagnostic groups. 130 patients (mean age: 54?±?17) presenting with troponin-positive acute chest pain and unobstructed coronary arteries were included. All patients were managed according to European Society of Cardiology guidelines, including echocardiography, and had CMR within 6.2?±?5.3?days of presentation. During follow-up, major adverse cardiovascular events (MACE) were recorded. CMR provided a diagnosis in 100 of 130 patients (76.9%), with the remaining 30 (23.1%) having a normal examination. CMR diagnosed 37 (28.5%) acute myocardial infarctions, 34 (26.1%) myocarditis, 28 (21.5%) apical ballooning syndromes and 1 (0.8%) hypertrophic cardiomyopathy. When a single diagnosis was suspected by the referring physician, CMR validated this diagnosis in 32 patients (76.2%). CMR provided a formal diagnosis in 61 patients (69.3%) in which the clinical diagnosis was uncertain between at least two possibilities. CMR corrected a wrong diagnosis in 10 patients (7.7%). CMR-suggested diagnosis led to a modification of therapy in 42 patients (32.3%). Median follow-up was 34?months (interquartile range 24–49) in 124 patients. Sixteen patients (12.9%) experienced MACE. MACE rate was not different between patients with a conclusive CMR and normal CMR. In patients with acute troponin-positive chest pain and unobstructed coronary arteries, early CMR has important diagnostic and therapeutic implications. However its association with occurrence of MACE during mid term follow-up was not obvious.     

The calcium paradox - What should we have to fear?

The calcium paradox was first mentioned in 1966 by Zimmerman et al. Thereafter gained great interest from the scientific community due to the fact of the absence of calcium ions in heart muscle cells produce damage similar to ischemia-reperfusion. Although not all known mechanisms involved in cellular injury in the calcium paradox intercellular connection maintained only by nexus seems to have a key role in cellular fragmentation. The addition of small concentrations of calcium, calcium channel blockers, and hyponatraemia hypothermia are important to prevent any cellular damage during reperfusion solutions with physiological concentration of calcium.     

Clínicas de anticoagulação,situação actual e perspectivas futuras

There are several modalities to monitor oral anticoagulant therapy, namely: monitoring by a secondary care specialist in the hospital setting; monitoring by the general practitioner/ family doctor in the primary care setting; monitoring by private laboratories of clinical analysis; self-monitoring with point-of-care devices. In Portugal, the most frequent modality is still the hospital monitoring/anticoagulation clinics, although monitoring in the primary care/routine medical care setting has began to be implemented in some areas of the country since five years ago. Anticoagulation clinics are still actually the organizations that optimize better the clinical and laboratorial follow up of the patients anticoagulated with warfarin. In 2011, anticoagulation control quality was evaluated, in the setting of an anticoagulation clinic (Santo António Hospital, Porto Hospital Center) by determining the proportion of INRs within the therapeutic range. The evaluation focused ambulatory patients, during a period of two months, corresponding to 1067 controls from 687 patients (mean age: 69 ± 13 years; 54%, n = 567, female gender). 71% of controls (n = 756) were within the therapeutic range. 27% of controls were outside the therapeutic range, after exclusion of patients with programmed surgery or invasive proceedings. 13.8% of controls were below the therapeutic range and 8.6% (n = 92) of the latter had INR ≤ 1.5. Above therapeutic range were 13.2% (n = 139), from which 4.4% (n = 46) had an INR between 5–8 and 0.3% (n = 4) an INR ≥ 8. The group of primary care Health Centers (Portuguese acronym ACES) of the Baixo Tâmega region conducted, also in 2011, an evaluation of the anticoagulant control quality, by determining the proportion of INRs within the therapeutic range. The results were similar to those found in the anticoagulation clinic of the Hospital de Santo António which shows that the quality of monitoring in the primary care setting can have the same quality of the anticoagulation clinics monitoring. The introduction of the new oral anticoagulants, that don’t require laboratorial monitoring constitutes a challenge. In Portugal, there is no experience yet to respond to the question if, in this new context, the anticoagulation clinics will be fundamental for the registration of patients, the evaluation of the hemorrhagic risk, the clinical follow up or the evaluation of the adherence to therapy.     

Determination of the appropriate b value and number of gradient directions for high‐angular‐resolution diffusion‐weighted imaging

High‐angular‐resolution diffusion‐weighted imaging (HARDI) is one of the most common MRI acquisition schemes for use with higher order models of diffusion. However, the optimal b value and number of diffusion‐weighted (DW) directions for HARDI are still undetermined, primarily as a result of the large number of available reconstruction methods and corresponding parameters, making it impossible to identify a single criterion by which to assess performance. In this study, we estimate the minimum number of DW directions and optimal b values required for HARDI by focusing on the angular frequency content of the DW signal itself. The spherical harmonic (SH) series provides the spherical analogue of the Fourier series, and can hence be used to examine the angular frequency content of the DW signal. Using high‐quality data acquired along 500 directions over a range of b values, we estimate that SH terms above l = 8 are negligible in practice for b values up to 5000 s/mm², implying that a minimum of 45 DW directions is sufficient to fully characterise the DW signal. l > 0 SH terms were found to increase as a function of b value, levelling off at b = 3000 s/mm², suggesting that this value already provides the highest achievable angular resolution. In practice, it is recommended to acquire more than the minimum of 45 DW directions to avoid issues with imperfections in the uniformity of the DW gradient directions and to meet signal‐to‐noise requirements of the intended reconstruction method. Copyright © 2013 John Wiley & Sons, Ltd.     

P50 sensory gating is a trait marker of the bipolar spectrum

Sensory gating deficit, assessed by a paired auditory stimulus paradigm (P50), has been reported as a stable marker of schizophrenia. The aim of this study was to explore if this neurophysiological disturbance also fulfilled stability criteria in the bipolar disorder (BD) spectrum bipolar, as state independence is one of the main points to be considered as a potential endophenotype of the illness. The P50 evoked potential was studied in 95 healthy controls and 126 bipolar euthymic patients. Euthymia was established according to Van Gorp's criteria. Bipolar I and II subtypes were analyzed separately. The influence of a lifetime history of psychoses was also evaluated in the clinical sample. P50 gating was deficitary in all the subsamples of patients relative to healthy comparison subjects. Bipolar I patients with and without a history of psychosis showed higher P50 ratios than the other subgroups of patients, although these differences were not significant. P50 alterations were mainly due to a deficit in the inhibition of the second wave (test wave or S2) amplitude. Conclusions: The findings suggest that this inhibitory deficit can be considered characteristic of the illness and that the intensity of the gating abnormality varies according to the severity of BD.     

Verletzungen und Überlastungsschäden im Motorrad-Enduro-Sport

According to public opinion, enduro- motorcycling is a dangerous sports. Little is known of accident mechanism during a competition and overuse injuries in enduro- motorcycling. Aim of this study is to evaluate accident and injury patterns as well as overuse syndromes.To detect overuse injuries volunteering athletes were examined immediately before and after each run. Six percent of all started riders sustained an accident. Two percent got injured of which 80% were of superficial kind. More then 50% of all examined riders presented overuse injuries with predominance at the forearm, the wrist and the hand. The transient carpal tunnel syndrome and the beginning compartment syndrome of the forearm flexors were established as diagnosis. Coolpacks and simple vibration blockers led to subjective improvement. Competitive enduro- motorcycling is an average risky sports. The incidence of overuse reactions is evident in more of 50% of all riders and is hence a relevant issue in sports medicine.