Soccer Team In The Shower

Medieval

Well, after a long time without putting anything on the blog, I decided to put a small sample of the photos I have of a market or medieval fairs I like best I've ever been.
I put diapos projection mode, otherwise would never end.

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Lung failure

The pulmonary valve incompetence is relatively common, particularly the physiological, which has become more evident since the introduction of Doppler techniques as conventional diagnostic tool in cardiology.

Etiology

The differentiation between primary or secondary valvular dysfunction is very important in the evaluation of tricuspid or pulmonary valve. In the adult, valvular disease of the right cavities, especially regurgitation is commonly a result of pulmonary hypertension secondary to heart disease left cavities, primary lung disease or pulmonary vascular disease, the toxic oil syndrome in Spain, has been the source of pulmonary hypertension and pulmonary insufficiency (PI).

The most common cause of IP is the expansion valve ring secondary to pulmonary hypertension of any etiology. Unlike pulmonary stenosis, the IP is rarely congenital in origin and can occur in idiopathic dilated pulmonary artery. It can also be caused by a connective, such as Marfan syndrome. Infective endocarditis can cause acute IP, especially in people addicted to intravenous drugs and is the second most prevalent after pulmonary hypertension. The iatrogenic due to surgical repair of the EP or balloon pulmonary valvuloplasty is another possible etiology, appearing in slight degree in 90% of the percutaneous technique 15. It is also a common finding after correction of tetralogy of Fallot. Often, the IP is a casual light in Doppler echocardiography. Other less common causes relate to rheumatic involvement, tuberculosis, chest trauma and carcinoid syndrome ^{4 , 19,} 20 , although less frequently than in PD (Table 5).

Pathophysiology

The difficulty for the normal closure of the pulmonary sigmoid ventricular diastole involves the backflow of blood volume pair you ejected into the pulmonary artery with subsequent volume overload of the right ventricle. Is well tolerated for a long time, unless it is complicated by pulmonary hypertension.

idiopathic dilatation of the pulmonary artery is a clinical condition that causes pulmonary regurgitation, with the following characteristics: marked dilatation of the pulmonary artery trunk and the pulmonary annulus, with a right ventricle and normal pulmonary valve obstruction and a gradient was not significant. This expansion may result from an abnormality of connective tissue. Hemodynamically there is a pressure gradient in pulmonary valve and a mild degree discrete elevated heart rate ^{7 ,} 21.

Clinic

Most patients with mild degrees experience a benign clinical course. When hypertension occurs pulmonary clinic accompanied by right ventricular systolic dysfunction, may appear syncope, fatigue or dyspnea.

IP Patients with infective endocarditis secondary to septic pulmonary embolism may occur, pulmonary hypertension and severe right ventricular dysfunction. However, the predominant symptoms for the disease that triggers pulmonary hypertension (most common cause). When the IP accompanies carcinoid syndrome spells are observed facial flushing, diarrhea and wheezing among other symptoms 22.

Exploration physical

On palpation can reveal a hyperdynamic right ventricle in left parasternal area, pulmonary artery systolic pulsations can cause prominent in the 2 nd intercostal space left and can be felt both systolic and diastolic thrills.

A cardiac auscultation and pulmonary hypertension is accentuated second heart sound, the pulmonary component. May be split wide of the second sound due to the prolongation of right ventricular ejection imposed by the increase in stroke volume. A systolic ejection click, nonvalvular due to the sudden expansion of the pulmonary artery for right ventricular stroke volume increased, preceding a mid-systolic murmur, second stage, in the 2 nd intercostal space. A third and fourth noise that increases with inspiration, right origin, are heard often at the 4 th left intercostal space. In the absence of pulmonary hypertension the diastolic regurgitant murmur is serious tone, with its epicenter in the third and fourth left intercostal space price. Ogy diamond morphology is brief, increases with inspiration and inhalation of amyl nitrite 21.

When systolic pressure pulmonary artery exceeds 60 mmHg, the pulmonary annulus dilatation causes a regurgitant jet speed as evidenced by auscultation in the left parasternal border, a diastolic murmur of acute tone, in decrescendo, beginning after the pulmonary component of second sound and that is the breath of Graham Stell called the IP, which increases with inspiration and decreases during the pressure of the Valsalva maneuver. This resembles the murmur of aortic regurgitation, but is accompanied by severe pulmonary hypertension symptomatology. Unlike the aortic valve rarely stenotic and regurgitant lesions coexist in the pulmonary valve due to rheumatic etiology of the unusual and low pulmonary artery pressure in relation to the aorta. Carcinoid syndrome is an exception to this, as it is very common in lung involvement are given both types of lesions (Table 6).

In idiopathic dilated pulmonary artery can find the following auscultatory findings: pulmonary ejection click, systolic ejection murmur at pulmonary focus area, as well as a wide splitting of second sound.

Electrocardiogram

In the IP in the absence of pulmonary hypertension can be seen in the electrocardiogram (ECG) pattern of right ventricular diastolic overload, rSr morphology 'or rsR' in right precordial leads. Regurgitation secondary to pulmonary hypertension shows a classic pattern of right ventricular hypertrophy. Likewise, alterations can be observed auriculograma for the underlying disease.

chest radiograph

Both the pulmonary artery and right ventricle appears enlarged in significant pulmonary insufficiency, but are totally nonspecific findings.

Echocardiography

The IP is the most common physiological regurgitation, ie without structural heart disease. In different series have described their presence by pulsed Doppler, continuous or color, in 60% to 100% of healthy subjects ^{23, 24} .

are common in advanced IP right ventricular dilatation and hypertrophy of the cavity if accompanied by pulmonary hypertension. Abnormal movement or paradoxical interventricular septum is characteristic of situations of volume overload of the right ventricle. In M, the pulmonary valve movement suggests the cause of regurgitation, so the absence of "a" wave and systolic notch in the posterior leaflet should suggest pulmonary hypertension. It is also possible to see the image of flapping or flutter the tricuspid valve. Both M-mode or two-dimensional echocardiography can observe the presence of vegetations in cases of endocarditis as a cause of lung failure. The pulsed Doppler is a very precise technique for the diagnosis of pulmonary insufficiency of any etiology, shows reversed flow in the artery lung ^{3 ,} 25. The color Doppler shows abnormal flow, regurgitant, which back in the outflow tract of right ventricle (Fig. 3).

Fig. 3. Color Doppler pulmonary insufficiency. Ao: aorta; AD: right atrium; IP: pulmonary insufficiency; AP: pulmonary artery.

The diagnosis of pulmonary regurgitation is often made by echocardiography, so it is recommended periodically repeat this technique in patients at risk to manifest, such as pulmonary stenosis corrected (either by surgery as mine valvuloto percutaneous) or corrected Fallot 12.

The echocardiogram is the main diagnosis of idiopathic dilated pulmonary artery. Some authors proposed for diagnostic confirmation of these two parameters:

1. Relationship of pulmonary artery bifurcation / aortic diameter of 2 cm behind the aortic valve equal to or greater than 1.4.

2. Value pulmonary artery / aortic diameter equal to or greater than 1.5 26 .

Cardiac Catheterization

is of little use in the diagnosis of IP. It is much more sensitive in diagnosis echocardiography, as this regurgitation is not easily demonstrated by angiography. However, it may be useful for calculating pulmonary vascular resistance in patients with pulmonary hypertension.

Natural History

Most patients with mild IP has a benign clinical course. By contrast, the moderate to severe shows an evolution towards chronic volume overload right ventricle with ventricular dilatation and systolic dysfunction. The evolution of cardiac lesions in the patient with carcinoid syndrome is very fast, leading to right heart failure, but death occurs in the systemic disease, rarely by the pulmonary valve 5.

Treatment

no specific therapy is usually required in the treatment of lung failure. It is essential to identify and address the specific etiology of regurgitation and selectively treat the disorder, either endocarditis, pulmonary hypertension or carcinoid syndrome. Conventional medical treatment with digitalis and diuretics are used in case of right heart failure.

Surgical treatment is reserved for severe regurgitation with evidence of progressive dilatation of the ventricular cavity or to the onset of right ventricular systolic dysfunction. A small number of patients operated for tetralogy of Fallot and residual IP importantly, is the most common indication for surgery in pulmonary regurgitation. In these cases it is preferable to the use of bioprosthesis by the lower risk of thrombosis. However, the outcome of valve replacement has not yet been validated in a sufficient evolutionary control. Some cases with pulmonary valve endocarditis may require valvulectomía.

References:

1. H. Plauth WH Pulmonary valve stenosis. In: JIMS. Current treatment of cardiovascular diseases. Philadelphia: Hurst JW, 1991, 118-123.
2. O'Rourke R, Rackley Ch, Edwards J, Karp R, Katz N. Tricuspid valve, pulmonic valve and multivessel disease. En: Alexander RW, Schlant R, Fuster V, eds. The heart. 9ª ed. New York: McGraw-Hill, 1998; 1.833-1.850.
3. Otto C. Right sided valve disease. En: Otto F, ed. Valvular heart disease. Philadelphia: WB Saunders, 1999; 362-379.
4. Moyssakis IE, Rallidis LS, Guida GF, Hihoyannopoulos PI. Incidence and evolution of carcinoide syndrome in the heart. J Heart Valve Dis 1997; 6 (6): 625-630.
5. Zarco P, Salmerón O. Soplos cardíacos. En: Zarco P. Clinical Examination of the heart. Madrid: Ed Alhambra, 1982, 93-154.
6. Mahra-Pour M, Whitney A, Liebman JF, G. Borkat Quantification of the Frank and Mac-Fee-Parungao octhogonal electrocardiogram in valvular pulmonic stenosis: Correlation with hemodynamic measurements. J Electrocardiol 1979, 12: 69-76. [Medline]
7. Libberthson RR. Congenital heart disease in children, adolescents and adults. Madrid: Ed Médica Panamericana, 1991, 1080-1271.
8. Gielen H, Daniels O, van Lier H. Natural history of congenital pulmonary valvar stenosis: an echo and doppler cardiographic study. Cardiol Young 1999; 9(2): 129-135.
9. Lange PE, Onnasch GW, Heintzen PH.V Valvular pulmonary stenosis: valvular pulmonary stenosis: natural history and right ventricular function in infants and children. Eur Heart J 1985; 6: 706.
10. Hayes CJ, Gersony WM, Driscoll DJ, Keane JF, Kidd L, O'Fallon WM, et al. Second natural history study of congenital heart defects: results of treatment of patients with pulmonary valvar stenosis. Circulation 1993; 87 (suppl I): 28-37.
11. Nadas AS. Report from the Joint study on the natural history of congenital heart defects. Clinical course: introduction. Circulation 1977; 56: 136-138. [Medline]
12. Bonow RO, Carabello B, de León AC Jr, Edmunds LH Jr, Fedderly BJ, Freed MD, et al. ACC/AHA Guidelines for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/ American Heart Association Task Force and Practice Guidelines (Commitee on management of patients with valvular heart disease). Circulation 1998; 98: 1.949-1.984.
13. Rao P, Galal O, Patnana M, Buck SH, Willson AD. Results of three to ten years follow up balloon dilatation of the pulmonary valve. Heart 1998; 80 (6): 591-595.
14. Ghannam R, Aouad A, Alami M, Fellat N, Bennani R, Haiten N, Benomar M. Percutaneous transluminal valvuloplasty in congenital pulmonary stenosis in adults. A propos of 34 cases. Arch Mal Coeur Vaiss. 1998; 91 (10): 1.249-1.254.
15. Hernández Cobeno MA, Bermúdez-Cañete R, Hernáiz I, Fernández Pineda L, Quero Jiménez C, Díaz García P. Percutaneous balloon pulmonary valvuloplasty: the medium-term results in a series of 100 consecutive pediatric patients. An Esp Pediatr 1998; 49 (3): 264-272.
16. Wang JK, Wu MH, Lee WL, Cheng CF, Lue HC. Balloon dilatation for critical pulmonary stenosis. Int J Cardiol 1999; 69 (1): 27-32.
17. Rao PS. Long term follow up results after balloon dilatation of pulmonic stenosis, aortic stenosis, and coarctation of the aorta: a review. Prog Cardiovasc Dis 1999; 42 (1): 59-74
18. Cheung YF, Leung MP, Lee JW, Chau AK, Yung TC. Evolving management for critical pulmonary stenosis in neonates and young infants. Cardiol Young 2000; 10 (3): 186-192.
19. Waller BF, Howard J, Fess S. Pathology of pulmonic valve stenosis and pure regurgitation. Clin Cardiol 1995; 18 (1): 45-50.
20. Pellikka PA, Tajik AJ, Khanderia BK, Seward JB, Callahan JA, Pitot HC, Kvols LK. Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 Patients. Circulation 1993, 87 (4): 1188-1196.
21. Burckardt D, J. Moppert Clinical Aspects and hemodynamic of idiopathic dilatation of pulmonary artery. Z Kardiol 1975; 64 (1): 57-68.
22. Braunwald E. Valvular heart disease. In: Treaty of Cardiology. 5 th ed. Philadelphia: Mc Graw Hill, 1997, 1095-1171.
23. Well H, García Fernández MA, Moreno M. Fisioílógicas valve regurgitation. In: Garcia Fernandez MA. Doppler principles and practices of heart. Madrid: Interamericana, McGraw Hill, 1995, 179-187.
24. Jobic Y, Slama M, Tribouilloy C, Lan Cheong Wah L, Choguet D, Boschat J, et al. Doppler evaluation of valve regurgitation achocardiographic in healthy Volunteers. Br Heart J 1993, 69 (2): 109-113.
25. Feigenbaum H. Pulmonary valve. In: Echocardiography. 4 th ed. Buenos Aires: Ed Panamericana, 1990, 332-333.
26. Boutin C, Davignon A, Fournier A, Houyel L, Van Doesburg N. Idiopathic dilatation of the pulmonary artery. Echocardiograpihc aspects. Arch Mal coeur Vaiss 1994; 86 (5): 663-666.

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Europride 2007. MADRID

Saturday 30 June.

March for Gay Pride Day, called this year Europride 2007 because Madrid was declared European Capital of gay pride.

Festive atmosphere, joy, some exhibitionism, left see, be seen, FIESTA, music ... but also and above all CLAIM.

Five days in which the center of Madrid, in particular the district of Chueca, has been the meeting place of thousands of gay and lesbian groups coming from all over the world to make a series of claims of rights and were also able to enjoy all sports and cultural activities and concerts have been organized through the streets of this neighborhood because of the Gay Pride Day.

Five days of fun that ended the protest march through the streets of our city.

Here some pics of the environment that could be experienced during this parade that went all audiences and made the streets they passed were completely crowded.

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La Cerdanya. The Cerdagne. Medieval markets

La Cerdanya, Catalonia region of the Pyrenees, consisting mainly of the upper valley of the Segre, which has certain distinctive qualities both geographical, historical and climate that give a special character, not indifferent to the visitors.

Protected by the mountains of Andorra to the north and the Sierra del Cadi south, is one of the most wide open valleys, because of his height, between 900 and 1300 meters. This feature along with its east-west valley makes the enjoyment of a particular climate and long hours of sunshine a year, more than 3000.

Inhabited since the Neolithic Ceretans by among others, as they knew the Romans to the people of this area, this is an area steeped in history.

In the seventh century was formed Cerdanya County, which along with other form Catalunya.

Puigcerdà With its capital, in the twelfth century has great economic and demographic boom, also due to its strategic location on the border with France, which always led to many clashes between the two countries.

clashes that eventually were resolved with the signing of the Treaty of the Pyrenees in 1659, which divided the region between the two countries.

This is called the English and French Cerdanya, La Cerdagne.

As a curiosity, noteworthy that Llívia, English people, is located within the French because when it became the allocation by some "administrative problems", was well as "English island" in French territory.

Despite all this, have always been closely linked livelihoods of people in one hand and the other, always walk from one side to the other and vice versa, no problems now thanks to the absence of the old boundaries but always doing as they could due to customs.

In fact you can hear people always tell how exitiosa smuggling from one area to another and how they did to avoid customs on the road ground instead of through roads, which often were guarded by police on both sides.

Among the wonderful landscapes that can be enjoyed, including forests, large meadows where you can watch the cattle grazing and even the Hispano-Breton horses bred in this area of \u200b\u200bthe Pyrenees, lakes and of course mountains with peaks over 2000 meters bordering the valley.

Another attraction for tourists in this area is the large number of resorts here are, in the Catalan as the French.

addition, due to its proximity to Barcelona, \u200b\u200bespecially since we have opened the Tunel del Cadi that lets you stay in BCN only about 2 hours, has made this area rather than escape of Barcelona, \u200b\u200bboth for weekends and holidays.

This influx of people has made the valley and long live mainly from tourism and this in turn has allowed the vast majority of the peoples of the area or have been restored conseven maintaining the traditional architectural style area, with stone houses and slate roofs, houses one for second homes and others to Rent For in the holiday seasons.

Here you can enjoy long nature walks and other activities such as the caving, horseback riding, quad biking, climbing, water activities in some of the lakes in summer, skiing, riding dogsled rides, snowmobile and snowshoe tours in winter. Probably some more that I leave unnamed.

Another thing for those who do not like so much of walking in the mountains or to engage in these activities is to visit villages that are dotted around the valley, where you can meet some of the many Romanesque churches there and enjoy the wide range of cuisine which is offered in restaurants in the area.

I was living and working there in the ski resort of La Molina, about five months ago two winters and I can assure you that walk through the valley, the villages and forests and mountains, both the French and the Catalan part is a pleasure, thanks to the sun almost always shines in the valley.

can find quiet and less quiet especially fine this week, but there is always something to do, something to do and if you want peace and tranquility, is located.

Even when it rains you can do things, because then can one come to Andorra and enjoy a day of shopping or a relaxing day in the famous spa or go to the French side which also can afford to relax in one of several hot springs there, where they can enjoy a hot outdoor bath while watching the mountains around you.