Background: The use of cardiac computed tomography (cardiac CT) and the quantification of the Agatston score for the evaluation of calcium of the aortic valve (AVC) has increased in different clinical contexts for diagnostic and prognostic purposes. This study aims to evaluate the correlation between cardiac CT and histopathology for the quantification of AVC. Methods: Ninety patients diagnosed with severe aortic valve dysfunction, of any etiology and regardless of the predominant type of injury, were included. Before the surgical event, a Cardiac CT were performed with Agatston Score measurement. The removed native valve was evaluated by a Pathologist, who provided a qualitative and quantitative evaluation of valve calcium. Calcium density was also analyzed by quantifying the area in pixel units obtained from photomicrographs. Follow-up was performed for four years after the aortic valve replacement. Results: Ninety patients were analyzed. The degenerative etiology predominated 63.3% (57 patients). The calcium load was different for the gender (pi = 0.01) and type of valve injury (p = 0.0013). There was a positive correlation between the Agatston score, and the percentage of calcium reported by the pathologist in a conventional qualitative way (rs = 0.75, p < 0.001) and between the AVC and the Cote et al. score (rs = 0.77, p < 0.001). There was no difference in survival after aortic valve replacement concerning valve calcium load. Left ventricular dysfunction showed a significant difference in survival (p = 0.003, Log-rank). Conclusion: There is a moderately high correlation between the Agatston score quantified by Cardiac CT and the histopathological evaluation. The severity of the calcification did not prove to be a predictor of death in the postsurgical follow-up.

BACKGROUND:The evaluation of long-term inflammatory response and function in postoperative patients with aortic valve replacement (AVR) deserves special analysis because it is important to try to prevent reoperation and improve durability and functionality of the prostheses. It is our objective METHODS: In this study, we included a cohort of patients with aortic valve damage treated by AVR with mechanical prosthesis, bio prosthesis and we included a control group. RESULTS:We found that IL-4 and osteopontin levels were higher in patients with mechanical vs biological prostheses (p=0.01 and p=0.04, respectively), osteoprotegerin (OPG) levels were decreased (p=0.01), women had lower levels of ET-1 and IL-6, (p=0.02) (p=0.04), respectively. Patients older than 60 years had decreased levels of IL-1ß p<0.001) and a higher concentration of IL-4 p<0.05). IL-1ß, OPG and TNFα were higher in patients with less than 5 years of evolution vs more than 10 years (p=0.004, p=0.02 and p=0.03, respectively). Factors such as age, gender, prosthetic and elevated IL-1B and ET-1 levels are associated with valve dysfunction prosthetic. These results indicate that the inflammatory involvement present prior to valve replacement may be perpetuated by various factors in the long term. CONCLUSIONS:The findings provide us with the opportunity to effectively treat patients with AVR in the postoperative period, which could prolong the functionality of the bio prostheses. TRIAL REGISTRATION NUMBER:NCT04557345.

The initial evaluation of patients with COVID-19 represents a challenge to regulate a decision in preventive and timely management. There are various proposals as support tools that deserve to be evaluated. Aim . Evaluation of Chest CT Score performance and prognostic indices in COVID-19 patients to predict progress to critical illness. Methods . This was a retrospective study run from April to December 2020. Patients of any age and gender and who required hospitalization due to a confirmed diagnosis of COVID-19 by RT-PCR and Chest CT, were included. Demographic, characteristics prognosis indexes and laboratory were analyzed. Patients with acute coronary ischemic syndrome (ACS), acute heart failure, those who developed critical illness in the first 24 hours, and those with no RT-PCR result were excluded. Critical illness was defined by the need for supplemental oxygen and / or death during the hospitalization. Results . 109 patients were included. The mean age was 53.88 ± 13.51 years. In 75% of them, there was at least one comorbidity and 30% developed critical illness. In 49.5% there was a CORADS-5 on admission, and in 50% there was a peripheral distribution of the interstitial infiltrate in the left lower lobe. The risk factors were FiO2, CT Score> 18 and the NRL index. The combination of the High risk qCSI plus CT score> 18 indices was the best prediction index for development of a critical condition. Average mortality was 10%. Conclusion . The combined use of indices in patients infected with SARSCoV2 shows diagnostic accuracy and predicts severity.

Obesity, a chronic low-grade inflammation metabolic abnormality, is related to high proinflammatory cytokines concentrations. Epstein-Barr virus-induced gene 3 (EBI3) encodes for the EBI3 beta subunit that constitutes interleukin (IL) 27 and 35. Our objective was to assess the association of three EBI3 single nucleotide polymorphisms (SNPs) with the presence of central obesity in a group of Mexican subjects. The rs428253, rs4740, and rs4905 EBI3 SNPs were genotyped in 1323 individuals (1092 central obese and 231 non-central obese). We also analyzed IL-6, IL-27, and IL-35 concentrations. Under different models, the rs4740 (OR = 0.384, P-recessive = 0.010; OR = 0.404, P-codominant( 2) = 0.019) and rs4905 (OR = 0.380, P-recessive = 0.009; OR = 0.404, P-codominant( 2) = 0.018) were related with a low risk of central obesity. In central obese subjects, the SNPs were related to lower risk of hypoalphalipoproteinemia (rs4740) and with high IL-6 concentrations (rs428253, rs4740, and rs4905), whereas in non-central obese individuals, the rs428253 was related with low risk of increased visceral abdominal fat and hypertriglyceridemia. Interleukin-6, IL-27 and IL-35 concentrations were similar in both groups and no relation was noticed with the studied genotypes. Our results suggest an association of EBI3 SNPs with a low risk of central obesity and with a few risk factors for cardiovascular disease in individuals with and without central obesity.

Treatment of ascending aorta disease is surgical; however, some series have evaluated the effectiveness of endovascular treatment. We report the case of a patient with a ruptured pseudoaneurysm who underwent endovascular repair via the left common carotid artery. The clinical and neurological evolution was satisfactory during the in-hospital follow-up. (Level of Difficulty: Intermediate.)

Background Premature atherosclerosis has been recognized as a major cause of morbidity and mortality in SLE patients. Whether the effect of risk factors for cardiovascular disease in patients with lupus change over time is still unknown. We aimed to identify the incidence and risk factors for progression of coronary-artery calcification (CAC) in SLE patients. Methods Design: Inception Cohort. Since enrollment into the cohort, all patients had a standardized medical history, physical examination, and laboratory tests, including lipid profile, apoB, homocystein, high-sensitivity C-reactive protein (hs-CRP), serum complement (C3 and C4), and autoantibodies. Every 3–6 months, patients have been seen at the lupus clinic for medical care, and assessments of disease activity using the SLE disease activity scores, and medications usage. Every year, information has been updated, including irreversible damage accrual, any co-morbidities, traditional cardiovascular risk-factors, and a blood sample has been drawn. In 2008, 104 lupus patients from the cohort (93% females) was screened for coronary-artery calcifications using Multidetector Computed Tomography, after 5.1 years of follow-up. In 2018 a follow-up screening for CAC was carried-up. CAC was considered as positive if i) patients without CAC in 2008 were found with CAC +in the second screening or ii) patients with CAC positive in 2008 were found with any increase of their Calcium Score. Correlates for calcifications were analyzed. Cumulative incidence of CAC was calculated and risk factors for CAC progression were identified by multivariate analysis. Results At-enrollment into de cohort, lupus patients were 27.2+9.1 years of age and disease duration 5.4+3.8 months. On 2008 during the first screening, coronary-artery calcification were detected in 7.2% patients, since age 23 years, and from three years of diagnosis. At follow-up screening, progression of CAC was identified in 16.3% (IC95% 10.4–24.6). Cumulative incidence of CAC was observed in 9%. Earlier Risk factors associated with CAC were disease activity (p=0.03) and disease duration (p=0.03) while risk factors for progression of CAC were postmenopausal status (p=0.01), apoB levels (p=0.01). Conclusions Our findings suggest that in patients with SLE earlier CAC is associated with disease severity while in the progression of CAC, traditional risk factors for atherosclerosis were adding. Funding Source(s): None

INTRODUCTION:Pectus excavatum (PE) and carinatum (PC) are common in Marfan syndrome (SM) and similar syndromes (SS). Patients can evolve without symptoms. In some there is depression, social adjustment disorders, pulmonary and cardiovascular symptoms in which there is controversy about their relationship with the structural damage of the thorax.OBJECTIVE:To assess the prevalence of the type of thoracic deformity in patients with MS and SS in a historical and current cohort and to analyze the clinical, pulmonary and cardiovascular impact.METHOD:Prospective study. Subjects who met the Ghent criteria and who had a complete clinical record, an echocardiogram and/or magnetic resonance imaging, computed tomography and respiratory function tests were included.RESULTS:Of a total of 338 patients with MS and SS, 112 cases with thoracic deformity were detected, the prevalence of PE and PC in SM 13.6 and 12.4, respectively, was lower in SS. There is compression and displacement of lung and right cardiac cavities by PE and the correlation between the Haller Index and the increased PASP is 44 (p = 0.009).CONCLUSIONS:The prevalence of PE and PC in SM and SS is high, which impacts on lung function and cardiovascular damage, requires corrective management of the thoracic deformity and not only implies for aesthetic purposes.

Marfan syndrome (MS) is of the most common connective tissue disorders. Although most patients have mutations in the fibrillin-1 gene (FBN1) and more than 1,700 mutations have been described, there are no mutations in less than 10% of patients. Aortic dilation is the most important complication; it involves chronic inflammatory processes and endothelial dysfunction. Prospective study from March 2015 to January 2017, in a cohort of 32 patients of MS confirmed by Ghent criteria and 35 controls of both genders, with a median age of 26 years (18–56). Patients had no comorbidities such as diabetes, hypertension, and/or neoplasms. They were not being treated with statin, NSAIDs, calcium antagonists, oral nitrates, and/or beta-blockers during 7 days prior to the study and patients with smoking history in the last 4 years. Controls were matched by age and gender. We analyzed endothelial dysfunction by flow-mediated vasodilation in the brachial artery, determining the maximum peak flow in the reactive hyperemia phase with a Philips Envisor device with Doppler capability. Its correlation with serum levels of biological markers that could participate in endothelial dysfunction pathways such as NO3−/NO2− ratio, NO2−, citrulline, TNFα, IL-1, IL-6, IL-10, IL-8, osteopontin, ICAM, VCAM, and NO3−/NO2− was determined. Endothelial dysfunction was found in 21 MS patients (65%). The aortic annulus (AAo) was of 27 mm (22–40) and 24 mm (22–30) (p = 0.04) in MS patients with and without dysfunction. The level of NO3−/NO2− ratio, was of 108.95 ± 12.05 nM/ml in controls vs. 170.04 ± 18.76 nM/ml in MS (p = 0.002), NO2− was of 33.78 ± 3.41 vs. 43.95 ± 2.59 nM/ml (p = 0.03), citrulline 62.65 ± 3.46 vs. 72.81 ± 4.35 μMol/ml (p = 0.06). VCAM median was 39 pg/ml (0–86) vs. 32 pg/ml (11–66) (p = 0.03), respectively. The correlation of VCAM with triglycerides (TG) was of 0.62 (p = 0.005). There were no differences in TNFα, IL-1, IL-6, IL-8, IL-10, and osteopontin. MS endothelial dysfunction is related to aortic diameters, and increased levels of VCAM, L-citrulline and NO3−/NO2− ratio, NO2−. VCAM-1 has a significant correlation with TG and could play a significant role in endothelial dysfunction.

Background Real time sonoelastography (RTS) is a novel imaging option involving tissue stiffness assessment that might be a useful in primary Sjögren9s syndrome (PSS). Objectives To evaluate the stiffness of parotid and submandibular glands using RTS, and to correlate with a morphologic ultrasonographic (US) score, profibrotic chemokines and cytokines, and gland fibrosis among patients with PSS. Methods We included 26 PSS patients with salivary gland biopsy within 5 years previous the US evaluation. B-Mode US and RTS (ARFI technique) were performed by a trained radiologist. Parotid and submandibular glands were individually rated for parenchymal echogenicity, homogeneity, hypoechogenic areas, hyperechogenic reflections and clearness of borders using the Hocevar scale (Global B-mode sum score 0–48 points). RTS was conducted at both parotid and submandibular glands (8 areas of each gland to obtain a median value) and then reported a median global RTS score in m/seg. We assessed the ESSDAI, ESSPRI, non-stimulated whole salivary flow rate (NSWSF), C3 and C4 levels, RF, anti-Ro/La antibodies and salivary levels of CXCL14, CCL28, TRAIL and TGb measured by ELISA. We also evaluated the presence of fibrosis in biopsies with the Masson9s trichrome staining. Results The mean age was 51.1±11 years, median disease duration of 6.1 years, 92.8% were females and 92.8% had oral symptoms. The global B-mode score was 22.2 points (13–44) and the RTS global score 2.5 (1.64–3.28) m/seg. We found a correlation between the RTS global score and the global B-mode score (t=0.53, p=0.001), the RTS global score between both parotids (t=0.58, p=0.0001) and both submandibulars (t=0.50, p=0.0001); but not between parotids and submandibular glands. The RTS global score correlated with the NSWSF (t=-0.53, p=0.001), ESSDAI (t=0.31, p=0.03), glandular ESDDAI domain (t=0.36, p=0.02), C4 levels (t=-0.32, p=0.04), but not with the rest of serological variables, chemokines and cytokines levels. We found fibrosis in 7 patients (26.9%), and these patients were not different when compared to the group without it, regarding the RTS global score, B-mode global score, age and chemokine and cytokines levels, but tended to have a longer disease duration. At the linear regression analysis, the glandular ESSDAI domain (B=0.49, p=0.04), the C4 level (B=-0.02, p=0.05) and the disease duration (B=0.04, p=0.04) were associated with the RTS global score. Conclusions The elastrographic evaluation correlated with the US morphologic score and glandular activity but not with fibrosis. References Dejaco C, De Zordo T, Heber D, et al. Real-time sonoelastography of salivary glands for diagnosis and functional assessment of primary Sjögren9s syndrome. Ultrasound in Med & Biol 2014; 40:2759–67. Disclosure of Interest None declared

Dextrocardia, coartación aórtica y enfermedad arterial coronaria.Reporte de caso y revisión de la literatura Dextrocardia, aortic coarctation and coronary artery disease.A case report and review of the literature IntroducciónLa dextrocardia es una malposición en la cual el eje mayor del corazón está hacia la derecha y en dirección caudal, en este caso en situs solitus por encontrarse la aurícula izquierda al lado izquierdo del corazón así como la aurícula derecha en el lado derecho y las vísceras abdominales en concordancia 1 .La incidencia de malformaciones cardiacas adicionales a situs solitus en dextrocardia es del 90%, incluyendo drenaje anómalo de venas pulmonares, tetralogía de Fallot, defectos septales, estenosis pulmonar, coartación aórtica (CoAo) y transposición corregida de grandes vasos 1 .Reportamos un caso de CoAo y enfermedad arterial coronaria (EAC) en una paciente femenina con situs solitus en dextrocardia.La importancia de este artículo radica en la demostración de las herramientas semiológicas y de estudios complementarios para el diagnóstico de tan compleja asociación. Caso clínico

The prevalence of Myocardial Bridging (MB) has been found in 58% in Coronary Computed Tomography Angiography (CCTA), systolic compression and ischemia have been reported. The aim of this study was to describe the MB characteristics in CCTA and the presence of ischemia by Myocardial Perfusion Single

Objective. Premature atherosclerosis in patients with SLE is partially explained by traditional risk factors; therefore, we aimed to identify lupus-related risk factors for coronary artery calcifications.Methods. An inception cohort of 139 lupus patients (93% females) was screened for coronary artery calcifications using Multidetector CT, after 5.1 years of follow-up. Clinical and immunological variables and cardiovascular risk factors were assessed longitudinally. Also, 100 age-and sex-matched healthy subjects were studied. Correlates for calcifications were analysed in lupus patients, including levels of lipids and inflammatory molecules in samples obtained at enrolment, mid-term follow-up and at screening.Results. At enrolment, lupus patients were 27.2 (9.1) years of age and with a disease duration of 5.4 (3.8) months. Calcifications were detected in 7.2% of patients and 1% of controls [unadjusted odds ratio (OR) 7.7, 95% CI 1.05, 336.3, P = 0.02]. In lupus, calcifications were detected since the age of 23 years and from 3 years of diagnosis. Patients with calcifications were older, post-menopausal, and had higher levels of serum apolipoprotein B and Framingham risk scores (P<0.05). Lupus-related factors identified included age at diagnosis, IgG aCLs, cumulative lupus activity, length of moderate/severe activity and cumulative dose of prednisone and CYC (P<0.05). Use of anti-malarials was protective (P = 0.006). Logistic regression analysis showed as predictors of calcification: disease duration (OR 15.1, 95% CI 2.6, 87.2), age at enrolment (OR 8.5, 95% CI 1.7, 43.0) and SLEDAI 2000 update (SLEDAI-2K) mean area under the curve (OR 12.3, 95% CI 2.5, 61.8). Longitudinal analyses of lipids and inflammatory molecules did not differ between patients.Conclusions. Disease activity is a potentially modifiable risk factor for coronary artery calcifications in SLE. Therefore, management of traditional risk factors plus tight control of lupus activity, including the use of anti-malarials, is recommended.

Coccidioidomycosis is a systemic infection caused by the soil fungus Coccidioides immitis. It is endemic in northern Mexico and the southwest part of the United States. Radiologic manifestations are varied. Rupture of a coccidioidal pulmonary cavity with subsequent pneumothorax is a rare clinical event, even in endemic areas. We present a case with a brief review of this rare condition.

Question: A 43-year-old woman with history of breast cancer successfully treated with surgery and chemotherapy in 2003 was admitted because of hematochezia. The patient was well until 1 month ago, when she presented intermittent episodes of abdominal pain and vomiting. An abdominal mass in the right upper quadrant and in the pelvis was evident by palpation. Blood tests showed hemoglobin of 9 g/dL; white blood cells count and platelet count were within normal ranges.. Bilirubin and transaminases were also normal. Alkaline phosphatase was 216 IU/L; γ-glutamyltransferase, 323 IU/L; and albumin, 2.5 g/dL. Abdominal computed tomography showed centripetal-enhanced, hypodense tumors in the liver and ileum (Figure A). On colonoscopy, deformation of the ileocecal valve did not allow the evaluation of the ileum; therefore, surgery was performed. Grossly, there were a bleeding, dark-red tumor in the ileum and another 2 in the liver. Histologic analysis by hematoxylin and eosin (Figure B) showed a tumor with an angioformative appearance. Immunohistochemical staining (positivity for CD31 and CD34, and negativity for epithelial marker keratin) confirmed its vascular origin. Patient died after 1 month of follow-up. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Computed tomographic images suggested a vascular tumor of the intestine and liver. The diagnosis of hemangiosarcoma was made histologically. Microscopically, the tumor is characterized by sheets of polygonal cells and many spaces suggestive of vascular differentiation, with positive immunohistochemical staining for vimentin, factor VIII-related antigen and endothelial markers (UEA-I, CD31, CD34) and negative for epithelial marker keratin and epithelial membrane antigen. This is an extremely uncommon neoplasm of the gastrointestinal tract; until now, <20 cases have been reported to affect the small bowel.1Al Ali J. Ko H.H. Owen D. et al.Epithelioid angiosarcoma of the small bowel.Gastrointest Endosc. 2006; 64: 1018-1021Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 2Allison K.H. Yoder B.J. Bronner M.P. et al.Angiosarcoma involving the gastrointestinal tract: a series of primary and metastatic cases.Am J Surg Pathol. 2004; 28: 298-307Crossref PubMed Scopus (89) Google Scholar, 3Grewal J.S. Daniel A.R. Carson E.J. et al.Rapidly progressive metastatic multicentric epithelioid angiosarcoma of the small bowel: a case report and a review of literature.Int J Colorectal Dis. 2008; 23: 745-756Crossref PubMed Scopus (25) Google Scholar Few cases of extraintestinal angiosarcomas have been associated with breast cancer; however, the meaning of this relationship has not been elucidated. This is the first report of intestinal angiosarcoma in a patient with history of breast cancer. The prognosis of metastatic angiosarcoma is poor and most patients die within 6 months. Treatment usually involves operative resection of the bleeding lesion; unfortunately, because of its infiltrative and multifocal nature, complete operative excision is often not possible.3Grewal J.S. Daniel A.R. Carson E.J. et al.Rapidly progressive metastatic multicentric epithelioid angiosarcoma of the small bowel: a case report and a review of literature.Int J Colorectal Dis. 2008; 23: 745-756Crossref PubMed Scopus (25) Google Scholar The role of adjuvant radiation or chemotherapy in the treatment of this tumor remains unknown.

Barahona-Garrido, Josué MD1,2; Aguirre-Gutiérrez, Rubén MD3,4; Gutiérrez-Manjarrez, Juan I. MD5,6; Tellez-Ávila, Félix I. MD, MSc1,2; López-Arce, Gustavo MD1,2; Fomperoza-Torres, Angel MD2,7; Criales, Sergio MD2,8; Sánchez-Cortés, Eduardo MD9; Sarti, Helga M. MD2,10; Yamamoto-Furusho, Jesús K. MD, PhD1 Author Information

Barahona-Garrido, Josué MD; Aguirre-Gutiérrez, Rubén MD; Gutiérrez-Manjarrez, Juan I. MD; Tellez-Ávila, Félix I. MD, MSc; López-Arce, Gustavo MD; Fomperoza-Torres, Angel MD; Criales, Sergio MD; Sánchez-Cortés, Eduardo MD; Sarti, Helga M. MD; Yamamoto-Furusho, Jesús K. MD, PhD Author Information

A 56-year-old man presented with sudden-onset oropharyngeal dysphagia and vomiting of central etiology. Neurological evaluation showed uvula deviation to the left, paresis of the mid-right portion of the soft palate, lateralization of gaze to the right side, and dysphonia. Magnetic resonance imaging (MRI) showed an infarction in the left lateral medullary region, therefore the diagnosis of Wallenberg’s syndrome was established. The neurological issues along with the dysphagia gradually improved and the patient was discharged.