Heart Institute Telemedicine and Telehealth Initiatives and Perspectives

This is a brief report of the telemedicine and telehealth initiatives developed at the Heart Institute (InCor HC FMUSP) since 2009. The challenges to develop, implement and make the service operational are described. Support was received from the Telemedicine University Network of the Ministry of Science, Technology and Innovation, the National Health Fund of Ministry of Health and a private donor to establish this Telemedicine and Telehealth Centre, making it possible for our students, professors and professionals to participate in activities at a distance, such as videoconferences, transmission of surgical procedures, web conferences and online courses. The Centre is also responsible for coordinating all local audio-visual resources available in our classrooms and amphitheatre, as well as producing videos.  Although the main focus of the Centre is education, the Centre provides support for the management of tele-ecg contracts, second opinion services and other opportunities for innovation in the field of telemedicine and telehealth. The current infrastructure has extended integration with other Services of the Institute, leading the acquisition of skills by health professionals, but the challenge remains of raising the awareness of collaborative work at a distance, implementing innovative healthcare services for remote monitoring of our patients with chronic conditions, and assessing their impact. It is mandatory to acquire and use new technologies to add value to patient care and, at the same time, get good return on investment

T-Wave alternans: desempeño clínico, limitaciones, metodologías de análisis

Reconhecer com precisão indivíduos com maior risco imediato de morte súbita cardíaca (MSC) ainda é uma questão em aberto. A natureza fortuita dos eventos cardiovasculares agudos não parece se adequar ao conhecido modelo de indução de taquicardia/fibrilação ventricular por um gatilho em sincronia a um substrato arritmogênico estático. Quanto ao mecanismo da MSC, uma instabilidade elétrica dinâmica explicaria melhor a raridade da associação simultânea de um gatilho certo a um substrato cardíaco apropriado. Diversos estudos tentaram medir essa instabilidade elétrica cardíaca (ou um equivalente válido) em uma sequência de batimentos cardíacos no ECG. Dentre os mecanismos possíveis podemos citar o prolongamento do QT, dispersão do QT, potenciais tardios, alternância de onda T ou T-wave alternans (TWA), e turbulência da frequência cardíaca. Este artigo se atém em particular ao papel da TWA no panorama atual da estratificação de risco cardíaco. Os achados sobre TWA ainda são heterogêneos, variando de um desempenho prognóstico muito bom até um quase nulo, dependendo da população clínica observada e protocolo clínico usado. Para preencher as atuais lacunas no conhecimento sobre TWA, profissionais médicos e pesquisadores devem explorar melhor as características técnicas das diversas tecnologias disponíveis para a avaliação de TWA e atentar ao fato de que os valores de TWA respondem a diversos outros fatores, além de medicamentos. Informações sobre mecanismos celulares e subcelulares da TWA estão fora do escopo deste artigo, mas são referenciados alguns dos principais trabalhos sobre este tópico, com o intuito de auxiliar no entendimento dos conceitos e fatos cobertos neste artigo. ______________________________________________________________________________________ ABSTRACTAccurate recognition of individuals at higher immediate risk of sudden cardiac death (SCD) is still an open question. The fortuitous nature of acute cardiovascular events just does not seem to fit the well-known model of ventricular tachycardia/fibrillation induction in a static arrhythmogenic substrate by a synchronous trigger. On the mechanism of SCD, a dynamical electrical instability would better explain the rarity of the simultaneous association of a correct trigger and an appropriate cardiac substrate. Several studies have been conducted trying to measure this cardiac electrical instability (or any valid surrogate) in an ECG beat stream. Among the current possible candidates we can number QT prolongation, QT dispersion, late potentials, T-wave alternans (TWA), and heart rate turbulence. This article reviews the particular role of TWA in the current cardiac risk stratification scenario. TWA findings are still heterogeneous, ranging from very good to nearly null prognostic performance depending on the clinical population observed and clinical protocol in use. To fill the current gaps in the TWA base of knowledge, practitioners, and researchers should better explore the technical features of the several technologies available for TWA evaluation and pay greater attention to the fact that TWA values are responsive to several factors other than medications. Information about the cellular and subcellular mechanisms of TWA is outside the scope of this article, but the reader is referred to some of the good papers available on this topic whenever this extra information could help the understanding of the concepts and facts covered herein. ______________________________________________________________________________________ RESUMENReconocer con precisión individuos con mayor riesgo inmediato de muerte súbita cardíaca (MSC) aun es una cuestión en abierto. La naturaleza fortuita de los eventos cardiovasculares agudos no parece adecuarse al conocido modelo de inducción de taquicardia/fibrilación ventricular por un gatillo en sincronía con un substrato arritmogénico estático. En cuanto al mecanismo de la MSC, una inestabilidad eléctrica dinámica explicaría mejor la rareza de la asociación simultánea de un gatillo correcto a un substrato cardíaco apropiado. Diversos estudios trataron de medir esa inestabilidad eléctrica cardíaca (o un equivalente válido) en una secuencia de latidos cardíacos en el ECG. Entre los mecanismos posibles podemos citar la prolongación del QT, dispersión del QT, potenciales tardíos, alternancia de onda T o T-wave alternans (TWA), y turbulencia de la frecuencia cardíaca. Este artículo se atiene en particular al papel de la TWA en el panorama actual de la estratificación de riesgo cardíaco. Los hallazgos sobre TWA aun son heterogéneos, variando de un desempeño pronóstico muy bueno hasta uno casi nulo, dependiendo de la población clínica observada y protocolo clínico usado. Para llenar las actuales lagunas en el conocimiento sobre TWA, profesionales médicos e investigadores deben explotar mejor las características técnicas de las diversas tecnologías disponibles para la evaluación de TWA y estar atento al hecho de que los valores de TWA responden a otros diversos factores, además de medicamentos. Informaciones sobre mecanismos celulares y subcelulares de la TWA están fuera del objetivo de este artículo, pero son referenciados algunos de los principales trabajos sobre este tópico, con el propósito de auxiliar en la comprensión de los conceptos y hechos cubiertos en este artículo

Improved relationship between left and right ventricular electrical activation after cardiac resynchronization therapy in heart failure patients can be quantified by body surface potential mapping

OBJECTIVES: Few studies have evaluated cardiac electrical activation dynamics after cardiac resynchronization therapy. Although this procedure reduces morbidity and mortality in heart failure patients, many approaches attempting to identify the responders have shown that 30% of patients do not attain clinical or functional improvement. This study sought to quantify and characterize the effect of resynchronization therapy on the ventricular electrical activation of patients using body surface potential mapping, a noninvasive tool. METHODS: This retrospective study included 91 resynchronization patients with a mean age of 61 years, left ventricle ejection fraction of 28%, mean QRS duration of 182 ms, and functional class III/IV (78%/22%); the patients underwent 87-lead body surface mapping with the resynchronization device on and off. Thirty-six patients were excluded. Body surface isochronal maps produced 87 maximal/mean global ventricular activation times with three regions identified. The regional activation times for right and left ventricles and their inter-regional right-to-left ventricle gradients were calculated from these results and analyzed. The Mann-Whitney U-test and Kruskall-Wallis test were used for comparisons, with the level of significance set at p≤0.05. RESULTS: During intrinsic rhythms, regional ventricular activation times were significantly different (54.5 ms vs. 95.9 ms in the right and left ventricle regions, respectively). Regarding cardiac resynchronization, the maximal global value was significantly reduced (138 ms to 131 ms), and a downward variation of 19.4% in regional-left and an upward variation of 44.8% in regional-right ventricular activation times resulted in a significantly reduced inter-regional gradient (43.8 ms to 17 ms). CONCLUSIONS: Body surface potential mapping in resynchronization patients yielded electrical ventricular activation times for two cardiac regions with significantly decreased global and regional-left values but significantly increased regional-right values, thus showing an attenuated inter-regional gradient after the cardiac resynchronization therapy

Purification of polyphenoloxidase (PPO) from ripe custard apple (Annona squamosa L.) pulp

The PPO (EC 1.10.3.2) extract of ripe custard apple (Annona squamosa L.) pulps, was partially purified by ammonium sulphate fractionation and purified 411 (Fraction I) and 118 (Fraction II) fold in an ion exchange column of DEAE-Toyopearl 650M, and 566 fold in a gel column of Toyopearl HW 55F. The enzyme of the most active fraction was characterized biochemically. The partially purified and purified enzyme used the o-diphenols as substrates and no activity towards monophenols was detected. With respect to the kinetic parameters, the purified enzyme presented values for Km and Vmax of 7.14 mM and 302.0 units/min/ml for catechol and 25.0 mM and 180.2 units/min/ml for L-dopa respectively, substrates which show greater specificity. The molecular weight was estimated as 90.700 daltons using gel filtration on Sephadex G-200. In the analysis of copper, the purified enzyme gave a value of 11ppm by weight of the liofilized sample. The amino acid composition of the custard apple fruit PPO, presented greater amounts of aspartic acid, glutamic acid and lysine and smaller amounts of methionine, arginine and tyrosine, with an absence of cysteine.A PFO (EC 1.10.3.2) extraída de polpa de pinha madura (Annona squamosa L.), foi parcialmente purificada por fracionamento em sulfato de amônio a 80% e purificada 411 (Fração I) e 118 (Fração II) vezes após cromatografia em coluna de troca iônica em DEAE-Toyopearl 650M, e 566 vezes em coluna de Toyopearl HW55F. A enzima da fração mais ativa foi caracterizada bioquimicamente. Quanto aos parâmetros cinéticos, a enzima apresentou valores de Km e Vmax de 7,14mM e 302,0 unidades/min/ml para catecol e 25,0mM e 180,2 unidades/min/ml para L-dopa respectivamente, substratos que demonstraram maior especificidade. O peso molecular foi estimado em 90.700 daltons através de filtração em gel Sephadex G-200. O teor de cobre da enzima purificada encontrado foi de 11ppm/peso da amostra liofilizada. Quanto à composição de aminoácidos, a PFO apresentou maiores teores de ácido aspártico, ácido glutâmico e lisina e menores teores de metionina, arginina e tirosina, com ausência de cisteína.9810

Avaliação Prognóstica da Microalternância da onda T na Cardiomiopatia Hipertrófica em um Seguimento Clínico de 9 anos

Resumo Fundamento: A morte súbita cardíaca (MSC), decorrente de arritmias ventriculares, é a principal complicação da cardiomiopatia hipertrófica (CMH). A microalternância da onda T (MAOT) está associada à ocorrência de arritmias ventriculares em diversas cardiopatias, mas seu papel na CMH permanece incerto. Objetivo: Avaliar associação da MAOT com a ocorrência de MSC ou arritmias ventriculares malignas em pacientes com CMH. Método: Pacientes com diagnóstico de CMH e classe funcional I-II (NYHA) foram selecionados de forma consecutiva. No início do seguimento os participantes realizaram a avaliação da MAOT pela metodologia da média móvel modificada no teste de esforço. Os resultados foram classificados em alterado ou normal. O desfecho foi composto por MSC, fibrilação ventricular, taquicardia ventricular sustentada (TVS) e terapia apropriada do cardioversor desfibrilador implantável (CDI). O nível de significância estatística foi de 5%. Resultados: Um total de 132 pacientes (idade média de 39,5±12,6 anos) foram incluídos, com tempo de seguimento médio de 9,5 anos. A MAOT foi alterada em 74 (56%) participantes e normal em 58 (44%). Durante o seguimento, nove (6,8%) desfechos ocorreram, com prevalência de 1,0%/ano, sendo seis casos de MSC, dois choques apropriados do CDI e um episódio de TVS. MAOT alterada foi associada à taquicardia ventricular não sustentada no Holter (p=0,016), espessura septal≥30 mm (p<0,001) e resposta inadequada da pressão arterial ao esforço (p=0,046). Cinco pacientes (7%) e quatro pacientes (7%) com MAOT alterada e normal, respectivamente, apresentaram desfecho primário [OR=0,85(IC95%: 0,21–3,35, p=0,83)]. Curvas de eventos de Kaplan-Meir não apresentaram diferenças entre MAOT normal e alterada. Conclusão: A MAOT alterada não foi associada à ocorrência de MSC ou arritmias ventriculares potencialmente fatais em pacientes com CMH, e a baixa taxa desses eventos em um seguimento em longo prazo sugere o bom prognóstico dessa cardiopatia

Desarrollar una propuesta de enseñanza aprendizaje de Matemáticas y su Didáctica para la formación de Docentes considerando la diversidad funcional asociada a la discapacidad intelectual, mediante la intervención en el Proyecto Liceo

Depto. de Didáctica de las Ciencias Experimentales , Sociales y MatemáticasFac. de EducaciónFALSEsubmitte

Event reconstruction for KM3NeT/ORCA using convolutional neural networks

The KM3NeT research infrastructure is currently under construction at two locations in the Mediterranean Sea. The KM3NeT/ORCA water-Cherenkov neutrino detector off the French coast will instrument several megatons of seawater with photosensors. Its main objective is the determination of the neutrino mass ordering. This work aims at demonstrating the general applicability of deep convolutional neural networks to neutrino telescopes, using simulated datasets for the KM3NeT/ORCA detector as an example. To this end, the networks are employed to achieve reconstruction and classification tasks that constitute an alternative to the analysis pipeline presented for KM3NeT/ORCA in the KM3NeT Letter of Intent. They are used to infer event reconstruction estimates for the energy, the direction, and the interaction point of incident neutrinos. The spatial distribution of Cherenkov light generated by charged particles induced in neutrino interactions is classified as shower- or track-like, and the main background processes associated with the detection of atmospheric neutrinos are recognized. Performance comparisons to machine-learning classification and maximum-likelihood reconstruction algorithms previously developed for KM3NeT/ORCA are provided. It is shown that this application of deep convolutional neural networks to simulated datasets for a large-volume neutrino telescope yields competitive reconstruction results and performance improvements with respect to classical approaches

Event reconstruction for KM3NeT/ORCA using convolutional neural networks

The KM3NeT research infrastructure is currently under construction at two locations in the Mediterranean Sea. The KM3NeT/ORCA water-Cherenkov neutrino de tector off the French coast will instrument several megatons of seawater with photosensors. Its main objective is the determination of the neutrino mass ordering. This work aims at demonstrating the general applicability of deep convolutional neural networks to neutrino telescopes, using simulated datasets for the KM3NeT/ORCA detector as an example. To this end, the networks are employed to achieve reconstruction and classification tasks that constitute an alternative to the analysis pipeline presented for KM3NeT/ORCA in the KM3NeT Letter of Intent. They are used to infer event reconstruction estimates for the energy, the direction, and the interaction point of incident neutrinos. The spatial distribution of Cherenkov light generated by charged particles induced in neutrino interactions is classified as shower-or track-like, and the main background processes associated with the detection of atmospheric neutrinos are recognized. Performance comparisons to machine-learning classification and maximum-likelihood reconstruction algorithms previously developed for KM3NeT/ORCA are provided. It is shown that this application of deep convolutional neural networks to simulated datasets for a large-volume neutrino telescope yields competitive reconstruction results and performance improvements with respect to classical approaches