Evaluación de la anormalidad en la contractilidad ventricular y la respuesta a la terapia de resincronización cardiaca

La valoración de la sincronía de contracción cardiaca es uno de los elementos principales para el diagnóstico de sujetos con falla cardiaca, en los que es frecuente detectar anormalidades en el patrón de contracción causadas por diversas patologías que los llevan a ser candidatos a una terapia de resincronización. Para describir estas anormalidades se han desarrollado múltiples técnicas de imagen que permiten hacer una evaluación general de la condición del paciente. La Ventriculografía Radioisotópica en Equilibrio (VRIE) es una modalidad de imagen de medicina nuclear que ha demostrado ventajas en describir el patrón de contracción y la dinámica ventricular. El procesamiento digital de imágenes sobre estos estudios hasta la fecha ha logrado diferenciar entre sujetos sanos y sujetos con asincronía de la contracción mediante el análisis de fase y el análisis de factores de estructuras dinámicas (AFED), sin embargo la información aportada por estas técnicas es insuficiente para hacer una descripción detallada de las anormalidades en la contracción. Por ello, en este trabajo se propone graduar la severidad en la asincronía del patrón de contracción para sujetos con falla cardiaca, utilizando en conjunto información obtenida del análisis de factores e información de parámetros clínicos que se consideran relevantes en el diagnóstico, todo en un modelo de clasificación. Para graduar la severidad en la asincronía de la contracción se propuso un método basado en el análisis de las imágenes VRIE que brinda una medida de la asincronía en la que existen categorías de gravedad. Además se incluye una clasificación de la severidad propuesta por un cardiólogo experto en este tipo de imágenes ya que la experiencia profesional juega un papel fundamental en el diagnóstico de esas patologías. A partir de esta selección por el experto se construye un modelo de clasificación automático que permite ubicar a los sujetos en una categoría de gravedad. Este modelo se construye con la información obtenida del AFED y la información clínica relacionada. Para el proyecto se utilizaron estudios VRIE de 33 sujetos considerados normales y 42 sujetos con diagnóstico de asincronía de la contracción causada por diversos factores. Dentro del grupo de sujetos con anormalidades de la contracción tres fueron sometidos a una terapia de resincronización cardiaca (TRC) y fueron analizados seis meses después del procedimiento. Los resultados obtenidos muestran que existen regiones, de acuerdo a las categorías propuestas, en las que es posible clasificar a los pacientes, sin embargo las fronteras de decisión de las mismas no están del todo definidas. Esto implica que existen sujetos pertenecientes a distintos grupos que comparten características. Además sugieren que la incorporación de la información clínica al análisis de las imágenes permite una descripción más detallada de la condición de cada sujeto. Por otro lado permitieron observar las modificaciones causadas por la TRC y suponen que esta categorización puede ser utilizada en el diagnóstico de la asincronía y el pronóstico de respuesta a la TRC

Transdisciplinary experiential learning in biomedical engineering education for healthcare systems improvement

Background: The growing demand for more efficient, timely, and safer health services, together with insufficient resources, put unprecedented pressure on health systems worldwide. This challenge has motivated the application of principles and tools of operations management and lean systems to healthcare processes to maximize value while reducing waste. Consequently, there is an increasing need for professionals with the appropriate clinical experience and skills in systems and process engineering. Given their multidisciplinary education and training, biomedical engineering professionals are likely among the most suitable to assume this role. In this context, biomedical engineering education must prepare students for a transdisciplinary professional role by including concepts, methods, and tools that commonly belong to industrial engineering. This work aims to create relevant learning experiences for biomedical engineering education to expand transdisciplinary knowledge and skills in students to improve and optimize hospital and healthcare care processes. Methods: Healthcare processes were translated into specific learning experiences using the Analysis, Design, Development, Implementation, and Evaluation (ADDIE) model. This model allowed us to systematically identify the context where learning experiences were expected to occur, the new concepts and skills to be developed through these experiences, the stages of the student’s learning journey, the resources required to implement the learning experiences, and the assessment and evaluation methods. The learning journey was structured around Kolb’s experiential learning cycle, which considers four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation. Data on the student’s learning and experience were collected through formative and summative assessments and a student opinion survey. Results: The proposed learning experiences were implemented in a 16-week elective course on hospital management for last-year biomedical engineering undergraduate students. Students engaged in analyzing and redesigning healthcare operations for improvement and optimization. Namely, students observed a relevant healthcare process, identified a problem, and defined an improvement and deployment plan. These activities were carried out using tools drawn from industrial engineering, which expanded their traditional professional role. The fieldwork occurred in two large hospitals and a university medical service in Mexico. A transdisciplinary teaching team designed and implemented these learning experiences. Conclusions: This teaching-learning experience benefited students and faculty concerning public participation, transdisciplinarity, and situated learning. However, the time devoted to the proposed learning experience represented a challenge

Holter-determined arrhythmias in young elite athletes with suspected risk: Insights from a 20-year experience

PurposeWe assessed the occurrence of rhythm alterations in elite athletes with suspected risk using Holter monitoring, and the association of Holter-determined rhythm alterations with echocardiographic findings.MethodsA large cohort of Spanish elite athletes (N = 6,579, 34% female) underwent in-depth cardiological examination (including echocardiographic evaluation, and resting and exercise electrocardiogram [ECG]) between 01/02/1998 and 12/31/2018. Holter monitoring was performed in those reporting cardiovascular symptoms, with suspicion of cardiac structural abnormalities potentially associated with dangerous arrhythmias, or with resting/exercise ECG features prompting a closer examination. We assessed the occurrence of cardiac rhythm alterations, as well as the association between echocardiography-determined conditions and rhythm alterations.ResultsMost athletes (N = 5925) did not show any sign/symptom related to arrhythmia (including normal resting and exercise/post-exercise ECG results) whereas 9.9% (N = 654; 28% female; median age, 24 years [interquartile range 19–28]; competition experience [mean ± SD] 10±6 years) met the criteria to undergo Holter monitoring. Among the latter, sinus bradycardia was the most common finding (present in 96% of cases), yet with a relatively low proportion of severe (<30 bpm) bradycardia (12% of endurance athletes during night-time). Premature atrial and ventricular beats were also common (61.9 and 39.4%, respectively) but sinus pauses ≥3 s, high-grade atrioventricular blocks, and atrial fibrillation/flutter were rare (<1%). Polymorphic premature ventricular contractions (PVC, 1.4%) and idioventricular rhythm (0.005%) were also rare. PVC couplets were relatively prevalent (10.7%), but complex ventricular arrhythmias were not frequent (PVC triplets: 1.8%; sustained ventricular tachycardia: 0.0%; and nonsustained ventricular tachycardia: 1.5%). On the other hand, no associations were found between arrhythmias (including their different morphologies) and major cardiac structural alterations (including mitral prolapse). However, an association was found between mild mitral regurgitation and supraventricular (odds ratio 2.61; 95% confidence interval 1.08–6.32) and ventricular (2.80; 1.15–6.78; p = 0.02) arrhythmias, as well as between mild or moderate mitral regurgitation and ventricular arrhythmias (2.49; 1.03–6.01).ConclusionsIrrespective of the sports discipline, “dangerous” ventricular arrhythmias are overall infrequent even among young elite athletes who require Holter monitoring due to the presence of symptoms or abnormal echocardiographic/ECG findings, and do not seem to be associated with underlying serious cardiac structural pathologies

Vector competence for West Nile virus and St. Louis encephalitis virus (flavivirus) of three tick species of the genus Amblyomma (Acari: Ixodidae)

Many species of Amblyomma ticks are commonly found infesting wild birds in South America, where birds are important hosts for several arboviruses, such as West Nile virus (WNV) and St. Louis encephalitis virus (SLEV). In this study, WNV and SLEV transmission experiments were performed to evaluate the vector competence of three South American tick species: Amblyomma ovale, Amblyomma tigrinum, and Amblyomma tonelliae. Larval and nymphal ticks of each species were allowed to feed on chicks needle inoculated with WNV or SLEV. All three Amblyomma species acquired either WNV or SLEV through larval feeding, with infection rates varying from 3.1% to 100% for WNV and from 0% to 35.7% for SLEV in engorged larvae. Transstadial perpetuation of the viruses was demonstrated in the molted nymphs, with WNV infection rates varying from 0% to 33.7% and SLEV infection rates from 13.6% to 23.8%. Although nymphal ticks also acquired either virus through feeding, transstadial perpetuation to adult ticks was lower, with virus detection in only 3.2% of A. tigrinum and 11.5% of A. tonelliae unfed adult ticks. On the other hand, vector competence for nymphs (exposed to WNV or SLEV through larval feeding) and adult ticks (exposed to WNV or SLEV through larval or nymphal feeding) was null in all cases. Although our results indicate transstadial perpetuation of WNV or SLEV in the three tick species, the ticks were not competent to transmit these agents to susceptible hosts. The role of these ixodid tick species in the epidemiology of WNV and SLEV might be insignificant, even though at least A. ovale and A. tigrinum are frequent bird ticks in Latin America, so the virus could survive winter in the fed larvae. However, future studies are required to determine the implications that this could have, as well as analyze the vector competence of other common bird tick species in South America.Fil: Flores, Fernando Sebastián. Universidad Nacional de Córdoba. Facultad de Medicina; ArgentinaFil: Zanluca, Camila. Instituto Carlos Chagas, Curitiba;Fil: Guglielmone, Alberto Alejandro. Instituto Nacional de Tecnología Agropecuaria Eea, Rafaela; ArgentinaFil: Duarte dos Santos, Claudia N.. Instituto Carlos Chagas, Curitiba;Fil: Labruna, Marcelo B.. Universidade de Sao Paulo; BrasilFil: Diaz, Luis Adrian. Universidad Nacional de Córdoba. Facultad de Medicina; Argentina. Universidad Nacional de Córdoba; Argentin

Experiential Learning in Biomedical Engineering Education Using Wearable Devices: A Case Study in a Biomedical Signals and Systems Analysis Course

Biomedical engineering (BME) is one of the fastest-growing engineering fields worldwide. BME professionals are extensively employed in the health technology and healthcare industries. Hence, their education must prepare them to face the challenge of a rapidly evolving technological environment. Biomedical signals and systems analysis is essential to BME undergraduate education. Unfortunately, students often underestimate the importance of their courses as they do not perceive these courses’ practical applications in their future professional practice. In this study, we propose using blended learning spaces to develop new learning experiences in the context of a biomedical signals and systems analysis course to enhance students’ motivation and interest and the relevance of the materials learned. We created a learning experience based on wearable devices and cloud-based collaborative development environments such that the students turned daily-life scenarios into experiential learning spaces. Overall, our results suggest a positive impact on the students’ perceptions of their learning experience concerning relevance, motivation, and interest. Namely, the evidence shows a reduction in the variability of such perceptions. However, further research must confirm this potential impact. This confirmation is required given the monetary and time investment this pedagogical approach would require if it were to be implemented at a larger scale

Concepciones sobre Formación Ciudadana de Líderes Escolares de La Araucanía, Chile

Este artículo estudia las concepciones explícitas del equipo de gestión escolar sobre la educación cívica y su relación con el ejercicio del liderazgo escolar en las instalaciones educativas de la región de La Araucanía, Chile. La investigación se destaca por la promulgación de la Ley de Educación Cívica en las escuelas, y sigue un método cualitativo con un diseño exploratorio, que permite un primer acercamiento al objetivo del estudio, proporcionando evidencia en el campo de la educación cívica. Ejecutivos de diez instituciones educativas fueron entrevistados. Los resultados muestran diversos conceptos y enfoques de la educación cívica, que se centran en la comprensión de la construcción, la formación humana y su relación con la vida en sociedad, valores, territorio y cultura.El artículo indaga en las concepciones explícitas de los equipos directivos respecto de la formación ciudadana y su implicancia en el ejercicio del liderazgo escolar en centros educativos de la región de La Araucanía (Chile). La relevancia del estudio se enmarca en la promulgación de la Ley de Formación Ciudadana en los establecimientos educativos. La investigación adopta un enfoque cualitativo con un diseño exploratorio, que permite un primer acercamiento al objeto de estudio aportando evidencia al campo de la formación ciudadana. Se entrevistaron directivos de diez establecimientos educacionales. Los resultados muestran que existen diferentes concepciones y aproximaciones a la formación ciudadana y que estas se orientan en la comprensión del constructo, la formación de la persona y su relación con la convivencia en sociedad, los valores, el territorio y la cultura.This article studies the explicit conceptions of the school management team about civic education and its relation to the exercise of school leadership at educational facilities in the region of La Araucanía, Chile. The research is highlighted by the enactment of the Law on Civic Education at schools, and follows a qualitative method with an exploratory design, which allows a first approach to the objective of study, providing evidence to the field of civic education. Executives from ten educational institutions were interviewed. Results show diverse concepts and approaches to civic education, which focus on the construct understandings, the human training and their relationship with living in society, values, territory and culture

Disease-modifying treatments for patients with multiple sclerosis in Spain

[spa] La esclerosis múltiple es una enfermedad desmielinizante crónica del sistema nervioso central y discapacitante a largo plazo. Existen diferentes tratamientos modificadores de la enfermedad. Estos pacientes, a pesar de ser generalmente jóvenes, tienen una elevada comorbilidad y riesgo de polimedicación por su compleja sintomatología y discapacidad. Objetivo principal: determinar el tipo de tratamiento modificador de la enfermedad en los pacientes atendidos en servicios de farmacia de hospitales españoles. Objetivos secundarios: Conocer los tratamientos concomitantes, determinar la prevalencia de la polifarmacia, identificar la prevalencia de interacciones y analizar la complejidad farmacoterapéutica. Método: estudio observacional, transversal y multicéntrico. Se incluyeron todos los pacientes con diagnóstico de esclerosis múltiple y tratamiento modificador de la enfermedad activo a los que se atendió en las consultas de pacientes externos o en los hospitales de día durante la segunda semana de febrero 2021. Se recogieron: el tratamiento modificador, las comorbilidades y los tratamientos concomitantes para determinar el patrón de multimorbilidad, polifarmacia, complejidad farmacoterapéutica (Medication Regimen Complexity Index) e interacciones medicamentosas. Resultados: se incluyeron 1.407 pacientes de 57 centros de 15 Comunidades Autónomas. La forma de presentación de la enfermedad más frecuente fue la forma remitente recurrente (89,3%). El tratamiento modificador de la enfermedad más prescrito fue dimetilfumarato (19,1%), seguido de teriflunomida (14,0%). De los tratamientos modificadores parenterales, los 2 más prescritos fueron el acetato de glatiramero y el natalizumab con un 11,1 y 10,8% respectivamente. El 24,7% de los pacientes tenían una comorbilidad y el 39,8% al menos 2 comorbilidades. El 13,3% pertenecía al menos a uno de los patrones definidos de multimorbilidad y el 16,5% pertenecían a 2 o más patrones. Los tratamientos concomitantes prescritos fueron los psicofármacos (35,5%), los antiepilépticos (13,9%) y los antihipertensivos y fármacos para enfermedades cardiovasculares (12,4%). La presencia de la polifarmacia fue del 32,7% y de la polifarmacia extrema el 8,1%. La prevalencia de interacciones fue del 14,8%. La mediana de complejidad farmacoterapéutica fue de 8,0 (IQR: 3,3 – 15,0). Conclusiones: se ha descrito el tratamiento modificador de la enfermedad de los pacientes con esclerosis múltiple atendidos en los servicios de farmacia españoles y se ha caracterizado los tratamientos concomitantes, la prevalencia de polifarmacia, las interacciones, y su complejidad farmacoterapéutica[eng] Multiple sclerosis is a chronic demyelinating disease of the central nervous system and long-term disabling. Different disease-modifying treatments are available. These patients, despite being generally young, have high comorbidity and risk of polymedication due to their complex symptomatology and disability. Objective primary: To determine the type of disease-modifying treatment in patients seen in Spanish hospital pharmacy departments. Secondary objectives: To determine concomitant treatments, determine the prevalence of polypharmacy, identify the prevalence of interactions and analyse pharmacotherapeutic complexity. Method: Observational, cross-sectional, multicentre study. All patients with a diagnosis of multiple sclerosis and active disease-modifying treatment who were seen in outpatient clinics or day hospitals during the second week of February 2021 were included. Modifying treatment, comorbidities and concomitant treatments were collected to determine multimorbidity pattern, polypharmacy, pharmacotherapeutic complexity (Medication Regimen Complexity Index) and drug-drug interactions. Results: 1,407 patients from 57 centres in 15 autonomous communities were included. The most frequent form of disease presentation was the relapsing remitting form (89.3%). The most prescribed disease-modifying treat-ment was dimethyl fumarate (19.1%), followed by teriflunomide (14.0%). Of the parenteral disease-modifying treatments, the two most prescribed were glatiramer acetate and natalizumab with 11.1% and 10.8%. 24.7% of the patients had one comorbidity and 39.8% had at least 2 comorbidities. 13.3% belonged to at least one of the de-fined patterns of multimorbidity and 16.5% belonged to 2 or more patterns. The concomitant treatments pre-scribed were psychotropic drugs (35.5%); antiepileptic drugs (13.9%) and antihypertensive drugs and drugs for cardiovascular pathologies (12.4%). The presence of polypharmacy was 32.7% and extreme polypharmacy 8.1%. The prevalence of interactions was 14.8%. Median pharmacotherapeutic complexity was 8.0 (IQR: 3.3 - 15.0). Conclusions: We have described the disease-modifying treatment of patients with multiple sclerosis seen in Spanish pharmacy services and characterised concomitant treatments, the prevalence of polypharmacy, interac-tions, and their complexity

Measurement of the cosmic ray spectrum above 4×10184{\times}10^{18} eV using inclined events detected with the Pierre Auger Observatory

A measurement of the cosmic-ray spectrum for energies exceeding $4{\times}10^{18}$ eV is presented, which is based on the analysis of showers with zenith angles greater than $60^{\circ}$ detected with the Pierre Auger Observatory between 1 January 2004 and 31 December 2013. The measured spectrum confirms a flux suppression at the highest energies. Above $5.3{\times}10^{18}$ eV, the "ankle", the flux can be described by a power law $E^{-\gamma}$ with index $\gamma=2.70 \pm 0.02 \,\text{(stat)} \pm 0.1\,\text{(sys)}$ followed by a smooth suppression region. For the energy ($E_\text{s}$) at which the spectral flux has fallen to one-half of its extrapolated value in the absence of suppression, we find $E_\text{s}=(5.12\pm0.25\,\text{(stat)}^{+1.0}_{-1.2}\,\text{(sys)}){\times}10^{19}$ eV.Comment: Replaced with published version. Added journal reference and DO

Energy Estimation of Cosmic Rays with the Engineering Radio Array of the Pierre Auger Observatory

The Auger Engineering Radio Array (AERA) is part of the Pierre Auger Observatory and is used to detect the radio emission of cosmic-ray air showers. These observations are compared to the data of the surface detector stations of the Observatory, which provide well-calibrated information on the cosmic-ray energies and arrival directions. The response of the radio stations in the 30 to 80 MHz regime has been thoroughly calibrated to enable the reconstruction of the incoming electric field. For the latter, the energy deposit per area is determined from the radio pulses at each observer position and is interpolated using a two-dimensional function that takes into account signal asymmetries due to interference between the geomagnetic and charge-excess emission components. The spatial integral over the signal distribution gives a direct measurement of the energy transferred from the primary cosmic ray into radio emission in the AERA frequency range. We measure 15.8 MeV of radiation energy for a 1 EeV air shower arriving perpendicularly to the geomagnetic field. This radiation energy -- corrected for geometrical effects -- is used as a cosmic-ray energy estimator. Performing an absolute energy calibration against the surface-detector information, we observe that this radio-energy estimator scales quadratically with the cosmic-ray energy as expected for coherent emission. We find an energy resolution of the radio reconstruction of 22% for the data set and 17% for a high-quality subset containing only events with at least five radio stations with signal.Comment: Replaced with published version. Added journal reference and DO