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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In Portugal the incidence of HIV infection is increasing&#44; with more than 6000 new cases per year&#44; and mortality is decreasing &#40;less than 500 deaths&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> With greater longevity&#44; mostly due to newer and more effective antiretroviral therapies and antimicrobial prophylaxis&#44; mortality and morbidity have shifted from opportunistic illness toward a variety of other medical conditions&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> including cardiovascular disease&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;10</span></a> which occur later in the course of HIV infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiovascular disease in HIV infection is diverse&#46; Myocarditis&#44; pericarditis&#44; pleural effusion or neoplastic invasion may be due to opportunistic infections and tumors&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> directly dependent on immunological status&#46; On the other hand&#44; coronary artery disease has a complex and multifactorial pathogenesis&#44; and the role of HIV infection is less clear&#46; Possible mechanisms such as immune activation&#44; inflammation&#44; coagulation disturbances&#44; lipoprotein particle changes&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> antiretroviral toxicity&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and direct or immune-mediated damage of endothelial and myocardial cells&#44; are less well established and require validation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Ventricular filling abnormalities and diastolic dysfunction are the first manifestations of myocardial injury irrespective of the cause&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> and are widely reported in HIV-infected populations with and without antiretroviral treatment or without established cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is not known whether cardiac disease can be diagnosed in the early stages prior to established diastolic dysfunction&#46; Most myocardial pathologic processes are usually regional before becoming widespread&#44; and local ventricular mechanics can be accurately assessed using strain and strain rate &#40;SR&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to reveal abnormalities in cardiac function due to HIV infection using strain and strain rate analysis in infected subjects without cardiovascular disease&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Population and eligibility</span><p id="par0030" class="elsevierStylePara elsevierViewall">The enrolled population were HIV-infected individuals receiving routine care in the outpatient clinic&#46; Only patients without cardiovascular disease and aged 25&#8211;55 years were recruited&#44; to avoid possible confounding myocardial relaxation abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Both patients treated with antiretroviral drugs and untreated patients were included&#46; Pregnant women&#44; patients with diabetes&#44; hypertension&#44; dyslipidemia&#44; significant cardiac valve disease&#44; renal disease&#44; liver disease&#44; Centers for Disease Control and Prevention &#40;CDC&#41; class C patients&#44; and those with fever&#44; treated with interferon or corticoids&#44; and unable to read and sign the informed consent were excluded&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Initial assessment included a clinical questionnaire&#44; physical examination&#44; blood pressure measurement and a 12-lead electrocardiogram&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The control group were 20 healthy hospital workers&#44; frequency matched for gender and without cardiovascular risk factors&#44; who volunteered to undergo an echocardiogram and a physical exam&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our hospital&#39;s ethics committee approved the study protocol&#44; and all patients provided written informed consent&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Laboratory assessment</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients underwent laboratory tests&#44; including hemogram&#44; serum electrolytes&#44; blood glucose&#44; total cholesterol&#44; HDL cholesterol&#44; LDL cholesterol&#44; triglycerides&#44; viral load and CD4 count&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Detectable viral load was defined as more than 20 copies of HIV RNA&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Echocardiography</span><p id="par0060" class="elsevierStylePara elsevierViewall">Echocardiographic examinations were performed using a Vivid 7 digital ultrasound system with a 1&#46;5&#8211;5 MHz probe &#40;GE Medical Systems&#44; Horten&#44; Norway&#41; and analyzed in EchoPac &#40;GE Healthcare&#41;&#46; Three cardiac cycles were stored in cineloop format for offline analysis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Left ventricular and left atrial dimensions were measured according to the recommendations of the American Society of Echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Left ventricular ejection fraction was calculated by the change in ventricular volume percentages between systole and diastole in 2- and 4-chamber apical view using the modified Simpson&#39;s method &#40;mean of three measurements&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Left ventricular filling was assessed by spectral pulsed Doppler&#44; with the sample volume positioned over the flow immediately above the mitral leaflets&#46; Peak early diastolic flow velocity &#40;E&#41;&#44; peak atrial contraction flow velocity &#40;A&#41; and the E&#47;A ratio were obtained&#46; Pulsed tissue Doppler was used to assess longitudinal motion of the mitral annulus&#46; Particular care was taken to ensure that the ultrasound beam was aligned parallel to the direction of annular motion&#46; Peak septal and lateral wall velocities of the systolic wave S &#40;S&#8217;&#41;&#44; E wave &#40;E&#8217;&#41; and A wave &#40;A&#8217;&#41; were determined and the mean E&#47;E&#8217; ratio was calculated&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Diastolic function was evaluated and graded as recommended by the guidelines&#46; In preserved systolic function&#44; a left atrial volume less than 34 ml&#47;m<span class="elsevierStyleSup">2</span>&#44; lateral E&#8217; &#8805;10 m&#47;s and septal E&#8217; &#8805;8 m&#47;s confirmed that diastolic dynamics was normal&#46; An atrial volume of more than 34 ml&#47;m<span class="elsevierStyleSup">2</span>&#44; lateral E&#8217; &#60;10 m&#47;s with septal E&#8217; &#60;8 m&#47;s and mean E&#47;E&#8217; &#60;8 classified the diastolic dysfunction as grade I&#46; When mean E&#47;E&#8217; was &#62;8 and &#60;13 diastolic dysfunction was classified as grade II and as grade III when mean E&#47;E&#8217; was &#8805;13&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Strain rate measurements from the basal segments were obtained by color tissue Doppler &#40;&#62;140 fps&#41;&#46; The acquired velocity data allowed direct calculation of regional SR&#44; and the basal segments were chosen because angle deviations could be easily avoided&#44; making the assessment more reproducible&#46; Left outflow tract and transmitral flows were acquired to determine the timing of cardiac cycle events&#46; The angle of interrogation was kept as small as possible and aligned parallel to the region of interest&#44; in 4- and 2-chamber and apical long-axis views&#46; Systolic strain rate &#40;SR<span class="elsevierStyleInf">S</span>&#41;&#44; early diastolic strain rate &#40;SR<span class="elsevierStyleInf">E</span>&#41;&#44; and late diastolic strain rate &#40;SR<span class="elsevierStyleInf">A</span>&#41; were assessed offline from basal segments of the six walls&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The mean SR<span class="elsevierStyleInf">S</span>&#44; SR<span class="elsevierStyleInf">E</span>&#44; and SR<span class="elsevierStyleInf">A</span> correspond to the mean of the six basal segments&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Longitudinal&#44; radial and circumferential strain were obtained by 2D speckle tracking&#46; The frame rate was reduced to 58&#8211;85 fps in order to improve tracking quality and the angle was not so critical as the technique is angle-independent&#46; Longitudinal strain was assessed in apical view and circumferential and radial strain in parasternal short-axis view&#46; Global longitudinal strain was calculated by the mean longitudinal strain of the six walls &#40;basal&#44; mid and apical segments&#41; in apical view and mean circumferential and radial strain for the six mid left ventricular segments&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Images from 10 random patients were analyzed offline again and by a second blinded observer to assess intra- and inter-observer variability in strain and strain rate measurements&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">The control group was only frequency matched for gender&#46; Dichotomous data were expressed as number and percentage and compared with the chi-squared test&#46; Numerical variables were expressed as mean and standard deviation and were analyzed using the Student&#39;s t test for independent samples&#46; A multiple regression model was also applied&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Pearson&#39;s correlation analysis was used to evaluate the relationship between CD4 count&#44; viral load&#44; duration of infection and the various echocardiographic parameters&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In accordance with the CDC classification&#44; the population was divided in three groups &#40;CD4 &#60;200 cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; 200<span class="elsevierStyleSup">3</span> and CD4 &#62;500 cells&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#46; The echocardiographic findings were compared with one-way ANOVA and multivariate analysis was performed with MANOVA&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Intra- and inter-observer variability was tested by the Bland-Altman method&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> calculated as the absolute difference divided by the mean of the two observations&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A p value of less than 0&#46;05 was considered statistically significant&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Analysis was performed using SPSS software&#44; version 17&#46;0&#46;0 &#40;SPSS&#44; Inc&#46;&#44; Ill&#46;&#44; USA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0125" class="elsevierStylePara elsevierViewall">A total of 200 patients were screened in the outpatient clinic for study inclusion and 80 were potentially eligible&#46; Three were excluded because of hypertension at the clinical exam&#44; one had severe aortic stenosis&#44; and 26 refused to provide written informed consent&#46; Overall 50 patients were included&#44; mean age 41&#177;6 years&#44; 64&#37; male&#46; All the electrocardiograms were normal&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the characteristics of the HIV-infected population&#46; One patient has been infected for 30 years&#44; and another less than a year&#46; There was a high prevalence of smokers &#40;74&#37;&#44; 37 patients&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Seven &#40;14&#37;&#41; patients were not under active antiretroviral treatment&#58; four did not fulfill clinical or laboratory criteria to start drugs&#44; two were not compliant and the other presented an acute infection and started medication at the selection visit&#46; Patients were taking a mean of 3&#46;3 antiretroviral drugs&#44; 66&#37; were taking three&#44; 16&#37; four and 4&#37; five drugs&#46; Most were taking two antiretroviral classes&#44; except two who were taking three classes&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">CD4 count was 579&#177;285 cells&#47;mm<span class="elsevierStyleSup">3</span>&#59; maximum viral load was 463 000 copies and minimum was &#60;20 copies&#46; Fifteen patients &#40;30&#37;&#41; had detectable viral load&#44; of whom eight were under active treatment &#8211; six &#40;75&#37;&#41; with &#8216;blips&#8217; &#40;intermittent episodes of detectable low-level HIV1&#41;&#44; and two &#40;25&#37;&#41; were frequently non-compliant&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Comparing the HIV population to controls&#44; there were no differences in demographic and clinical data between groups except for diastolic blood pressure and smoking &#40;37 smokers in the HIV group and none in the control group&#44; p&#60;0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conventional echocardiographic parameters</span><p id="par0150" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; there were no differences in systolic or diastolic function parameters&#44; except for peak E-wave velocity&#44; which was higher in controls&#46; One HIV patient had diastolic dysfunction classified as grade I &#40;E&#47;E&#8217; &#60;8&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Strain and train rate analysis</span><p id="par0155" class="elsevierStylePara elsevierViewall">The 2D strain software achieved acceptable tracking in 97&#37; of cases in longitudinal strain&#44; 98&#37; in radial strain and 96&#37; in circumferential strain&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Global longitudinal strain&#44; mean radial and circumferential strain and mean SR<span class="elsevierStyleInf">S</span>&#44; SR<span class="elsevierStyleInf">E</span>&#44; and SR<span class="elsevierStyleInf">A</span> are reported in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Global longitudinal strain and SR<span class="elsevierStyleInf">S</span> and SR<span class="elsevierStyleInf">E</span> in the HIV group&#44; although in the normal range&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> were significantly lower than in the control group&#46; When analyzed in a multiple regression model including clinical and echocardiographic parameters&#44; only SR<span class="elsevierStyleInf">S</span> &#40;p&#61;0&#46;03&#44; 95&#37; CI 0&#46;036&#58;0&#46;671&#41; and SR<span class="elsevierStyleInf">E</span> &#40;p&#61;0&#46;001&#44; 95&#37; CI &#8722;0&#46;599&#58; &#8722;0&#46;168&#41; were different between groups&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Neither treatment &#40;also tested for the different drug classes and drug combinations&#58; nucleoside reverse transcriptase inhibitors and protease inhibitors or nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors&#41; nor detectable viral load had any impact on echocardiographic parameters&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Circumferential strain was different between CD4 categories &#40;CD4 &#60;200&#58; &#8722;16&#46;97&#177;3&#46;8&#37;&#59; 200&#8804;CD4 &#8804;500&#58; &#8722;16&#46;37&#177;2&#46;3&#37;&#59; CD4 &#62;500&#58; &#8722;19&#46;98&#177;3&#46;9&#37;&#59; p&#61;0&#46;049&#41; and was still different in multivariate analysis &#40;p&#61;0&#46;04&#46; 95&#37; CI &#8722;4&#46;59&#59; &#8722;0&#46;09&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The correlations obtained between disease duration and mean radial strain &#40;c&#61;&#8722;0&#46;31&#44; p&#61;0&#46;03&#41;&#44; and immunologic state and mean circumferential strain &#40;c&#61;&#8722;0&#46;4&#44; p&#61;0&#46;005&#41; were weak&#46; No clinical or laboratory data correlated with global longitudinal strain &#40;even when tested for the different coronary territories&#41;&#46; The same was observed for the strain rate parameters&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Intra-observer and inter-observer variability and reproducibility</span><p id="par0180" class="elsevierStylePara elsevierViewall">These are shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1&#8211;12</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><elsevierMultimedia ident="fig0055"></elsevierMultimedia><elsevierMultimedia ident="fig0060"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Our study excluded patients with comorbidities&#44; particularly established cardiovascular disease&#44; that could cause myocardial damage and abnormal cardiac mechanics&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Although there was a high prevalence of smokers&#44; the population was relatively healthy &#40;systolic blood pressure 122&#177;12 mmHg&#44; blood glucose 97&#177;13 mg&#47;dl&#44; LDL-cholesterol 115&#177;28 mg&#47;dl&#44; 90&#37; with CD4 count &#62;200 cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; only 32&#37; with detectable viral load&#44; and 86&#37; under antiretroviral treatment&#41;&#44; a representative sample of HIV-infected populations in developed countries&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> potentially achieving a normal life expectancy&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Previous echocardiographic studies in HIV-infected populations have focused on systolic and diastolic function assessed by 2D and spectral Doppler echocardiography&#44; only the most recent<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;19&#44;27&#44;28</span></a> using pulsed tissue Doppler&#44; but none had classified and graded diastolic dysfunction according to the current guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In our study there were no differences in systolic or diastolic function between groups when assessed with conventional echocardiography and pulsed tissue Doppler&#46; Previous studies also showed no systolic abnormalities&#44; but reported a high prevalence of diastolic dysfunction&#46; This difference can be explained by comparing the studied populations&#46; Our is a relatively healthy and young sample with no comorbidities&#44; unlike the larger sample &#40;689 patients&#41; studied by Reinsch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in the HIV-Heart Study&#44; who were older &#40;44&#177;10 years&#44; p&#61;0&#46;04&#41;&#44; 60&#37; had dyslipidemia&#44; 7&#37; had diabetes and one third had hypertension&#46; They used pulsed tissue Doppler and transmitral pulsed Doppler to assess diastolic dysfunction&#44; which was present in 48&#37; of the patients&#46; Blood pressure&#44; hyperlipidemia&#44; diabetes&#44; body mass index and age were different between groups with and without diastolic dysfunction&#44; but infection-related conditions were similar &#40;duration of infection&#44; CD4 count&#44; viral load and treatment&#41;&#46; Two other smaller studies using pulsed tissue Doppler<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;28&#44;29</span></a> came to the same conclusions concerning a high prevalence of relaxation abnormalities&#44; but again the classification and grading were not performed as recommended&#46; In a sub-analysis<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> of the SUN study with 659 patients&#44; diastolic dysfunction correlated with high-sensitivity C-reactive protein and the presence of hypertension&#46; Hsue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> obtained similar results&#44; the HIV-infected group having significantly more hypertension &#40;26&#37; vs&#46; 6&#37;&#41;&#44; and in multivariate analysis&#44; hypertension&#44; age and HIV infection increased the risk for diastolic dysfunction &#40;neither CD4 count&#44; viral load&#44; nor type of treatment increased the risk when adjusted for age and hypertension&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">To summarize&#44; our results&#44; which are not in agreement with previous studies&#44; can be explained by the fact that our HIV population were healthier compared with other&#44; more heterogeneous HIV populations&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The population studied by Oliviero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> was similar to ours in age and blood pressure but had a better metabolic status &#40;blood glucose&#44; p&#60;0&#46;001 and cholesterol&#44; p&#61;0&#46;001&#41;&#44; a shorter infection duration and were not under active antiretroviral therapy&#46; They reported an abnormal relaxation pattern in 30&#37; of patients&#44; but compared with our results there were no differences in diastolic parameters &#40;e&#8217; 0&#46;13&#177;0&#46;08 vs&#46; 0&#46;12&#177;0&#46;03&#44; p&#61;0&#46;4&#59; E&#47;e&#8217; 6&#46;6&#177;3&#46;5 vs&#46; 5&#46;7&#177;1&#46;8&#44; p&#61;0&#46;12&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Speckle tracking is a recent echocardiographic technology that analyzes motion by tracking natural acoustic reflections with relative angle independence&#44; less noise interference and substantially lower intra-observer and inter-observer variability&#46; Strain and strain rate are dimensionless measurements of deformation &#40;degree of shortening or stretching of fibers&#41;&#46; The degree of shearing increases toward the subendocardium&#46; The subendocardial region that is assessed by longitudinal strain is the most vulnerable component of left ventricular mechanics and therefore most sensitive to the presence of myocardial disease&#46; A transmural insult or progression of disease results in concomitant midmyocardial and subepicardial dysfunction&#44; leading to a reduction in circumferential and radial strain&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Our study was the first to assess strain and strain rate<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> in a HIV-infected population without established cardiovascular disease or risk factors&#46; Although the mean strain and strain rate obtained in the HIV group were in the normal range according to the latest ASE&#47;EAE Consensus Statement&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> global longitudinal strain&#44; SR<span class="elsevierStyleInf">S</span> and SR<span class="elsevierStyleInf">E</span> were statistically lower compared with the control group&#44; revealing early abnormalities&#46; It is important to note that diastolic dysfunction was not detected with conventional echocardiography but the presence of lower SR<span class="elsevierStyleInf">E</span> reveals abnormalities in myocardial relaxation&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In the present study viral load had no impact on myocardial performance&#44; probably because only 30&#37; had detectable virus in blood samples&#44; but circumferential strain differed according to immunological status &#40;more than half of the patients had CD4 &#62;500 cells&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; which is in agreement with the findings of previous studies that reported myocardial injury mediated by the non-myocyte pool&#44; especially in patients with low CD4 count&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Antiretroviral therapy is usually assumed to be toxic &#40;particularly protease inhibitors associated with lipodystrophy leading to metabolic disorders including insulin resistance and dyslipidemia<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;34&#44;35</span></a>&#41;&#44; but in our sample the drugs had no perceptible impact when studied individually or in combination&#44; probably because of the small number of patients enrolled&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Although we believe our data are relevant&#44; not only because they were obtained with strain and strain rate methodology&#44; but also because our population was healthy&#44; we do acknowledge some limitations&#44; including the small number of participants&#44; the fact that it was an observational study&#44; and the absence of biomarker assessment&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In conclusion&#44; diastolic dysfunction assessed as recommended by the latest guidelines is not prevalent in a relatively healthy HIV-infected population without cardiovascular disease or risk factors&#46; Although strain and strain rate are able to detect the first signs of myocardial mechanics abnormalities&#44; because these techniques are still in the research stage&#44; we consider it premature to recommend routine screening echocardiograms in HIV-infected adults without cardiovascular disease&#44; mostly because the prognostic impact of these findings is unknown&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical disclosures</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protection of human and animal subjects</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidentiality of data</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Right to privacy and informed consent</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Methods"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Population and eligibility"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Laboratory assessment"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Echocardiography"
            ]
            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Conventional echocardiographic parameters"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Strain and train rate analysis"
            ]
            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Intra-observer and inter-observer variability and reproducibility"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Discussion"
        ]
        8 => array:3 [
          "identificador" => "sec0060"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-03-18"
    "fechaAceptado" => "2013-12-20"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec352591"
          "palabras" => array:5 [
            0 => "HIV infection"
            1 => "Myocardial mechanics"
            2 => "Myocardium deformation"
            3 => "Speckle tracking"
            4 => "Color tissue Doppler"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec352592"
          "palabras" => array:5 [
            0 => "Infe&#231;&#227;o VIH"
            1 => "Mecanismos mioc&#225;rdicos"
            2 => "Deforma&#231;&#227;o mioc&#225;rdica"
            3 => "<span class="elsevierStyleItalic">Speckel tracking</span>"
            4 => "Doppler tecidular"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to detect abnormalities in left ventricular myocardial function due to HIV &#40;human immunodeficiency virus&#41; infection without established cardiovascular disease&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An echocardiogram was performed in 50 asymptomatic HIV-infected patients &#40;age 41&#177;6 years&#44; 64&#37; male&#41; and in 20 healthy individuals&#46; Conventional echocardiography and pulsed tissue Doppler imaging &#40;TDI&#41; were performed according to the guidelines&#46; The strain rate of the basal segments was obtained with color tissue Doppler and used to evaluate systolic strain rate &#40;SR<span class="elsevierStyleInf">S</span>&#41;&#44; early diastolic strain rate &#40;SR<span class="elsevierStyleInf">E</span>&#41; and late diastolic strain rate &#40;SR<span class="elsevierStyleInf">A</span>&#41;&#46; Longitudinal&#44; radial and circumferential strain were assessed by 2D speckle tracking&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean duration of HIV infection was 10&#177;5 years&#44; CD4 count was 579&#177;286 cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; 32&#37; had detectable viral load&#44; and 86&#37; were under treatment&#46; Of the HIV-infected patients&#44; one had grade 1 diastolic dysfunction&#46; The groups were not different except for E wave &#40;HIV 0&#46;72&#177;0&#46;17 m&#47;s vs&#46; control 0&#46;84&#177;0&#46;16 m&#47;s&#44; p&#61;0&#46;01&#41;&#44; longitudinal strain &#40;&#8722;19&#46;5&#177;1&#46;9&#37; vs&#46; &#8722;21&#177;2&#37;&#44; p&#61;0&#46;005&#41;&#44; SR<span class="elsevierStyleInf">S</span> &#40;&#8722;1&#46;1&#177;0&#46;28 s<span class="elsevierStyleSup">&#8722;1</span> vs&#46; &#8722;1&#46;3&#177;0&#46;28 s<span class="elsevierStyleSup">&#8722;1</span>&#44; p&#61;0&#46;02&#41; and SR<span class="elsevierStyleInf">E</span> &#40;1&#46;8&#177;0&#46;4 s<span class="elsevierStyleSup">&#8722;1</span> vs&#46; 2&#46;2&#177;0&#46;4 s<span class="elsevierStyleSup">&#8722;1</span>&#44; p&#60;0&#46;001&#41;&#44; but only SR<span class="elsevierStyleInf">S</span> &#40;p&#61;0&#46;03&#44; 95&#37; CI 0&#46;036&#59; 0&#46;67&#41; and SR<span class="elsevierStyleInf">E</span> &#40;p&#61;0&#46;001&#44; 95&#37; CI &#8722;0&#46;599&#59; &#8722;0&#46;168&#41; had independent value&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In an HIV-infected population without established cardiovascular disease&#44; myocardial deformation abnormalities can be detected with strain and strain rate&#44; revealing markers of myocardial injury&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar altera&#231;&#245;es na fun&#231;&#227;o mioc&#225;rdica secund&#225;rias &#224; infe&#231;&#227;o do v&#237;rus da imunodefici&#234;ncia humana &#40;VIH&#41; em doentes sem doen&#231;a cardiovascular estabelecida&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram realizados ecocardiogramas em 50 doentes com infe&#231;&#227;o VIH&#44; assintom&#225;ticos &#40;41&#177;6 anos&#44; 64&#37; homens&#41; e em 20 indiv&#237;duos saud&#225;veis&#46; O ecocardiograma convencional e o Doppler tecidular pulsado foram realizados e determinados segundo as &#250;ltimas recomenda&#231;&#245;es&#46; O <span class="elsevierStyleItalic">strain rate</span> dos segmentos basais foram determinados com o Doppler tecidular cor e avaliados o <span class="elsevierStyleItalic">strain rate</span> sist&#243;lico &#40;SRS&#41;&#44; o <span class="elsevierStyleItalic">strain rate</span> diast&#243;lico precoce &#40;SRE&#41; e o <span class="elsevierStyleItalic">strain rate</span> diast&#243;lico tardio &#40;SRA&#41;&#46; O <span class="elsevierStyleItalic">strain</span> longitudinal&#44; radial e circunferencial foi obtido a partir do 2D <span class="elsevierStyleItalic">speckle tracking</span>&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Na amostra a dura&#231;&#227;o da infe&#231;&#227;o era de 10&#177;5 anos&#44; com contagem de CD4 de 579&#177;286 c&#233;lulas&#47;mm<span class="elsevierStyleSup">3</span>&#44; 32&#37; tinham carga viral detet&#225;vel e 86&#37; estavam em terap&#234;utica ativa&#46; No grupo infetado&#44; um doente tinha disfun&#231;&#227;o diast&#243;lica de grau 1&#46; Os grupos eram semelhantes&#44; exceto para a onda E &#40;VIH 0&#44;72&#177;0&#44;17 m&#47;s <span class="elsevierStyleItalic">versus</span> control 0&#44;84&#177;0&#44;16 m&#47;s&#44; p&#61;0&#44;01&#41;&#44; <span class="elsevierStyleItalic">strain</span> longitudinal &#40;&#8211;19&#44;5&#177;1&#44;9&#37; <span class="elsevierStyleItalic">versus</span> &#8211;21&#177;2&#37;&#44; p&#61;0&#44;005&#41;&#44; SRS &#40;&#8211;1&#44;1&#177;0&#44;28 s-1 <span class="elsevierStyleItalic">versus</span> &#8211;1&#44;3&#177;0&#44;28 s-1&#44; p&#61;0&#44;02&#41; e SRE &#40;1&#44;8&#177;0&#44;4 s-1 <span class="elsevierStyleItalic">versus</span> 2&#44;2&#177;0&#44;4 s-1&#44; p&#60;0&#44;001&#41;&#44; mas s&#243; o SRS &#40;p&#61;0&#44;03&#44; 95&#37; CI 0&#44;036&#59; 0&#44;67&#41; e o SRE &#40;p&#61;0&#44;001&#44; 95&#37;CI &#8211;0&#44;599&#59; &#8211;0&#44;168&#41; foram diferentes na an&#225;lise multivariada&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Numa popula&#231;&#227;o infetada com o VIH&#44; mas sem doen&#231;a cardiovascular estabelecida&#44; as altera&#231;&#245;es na deforma&#231;&#227;o mioc&#225;rdica podem ser apercebidas atrav&#233;s do <span class="elsevierStyleItalic">strain</span> e do <span class="elsevierStyleItalic">strain rate</span>&#44; revelando poss&#237;veis marcadores de les&#227;o mioc&#225;rdica&#46;</p>"
      ]
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          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; CCR5rAs&#58; CCR5 receptor antagonists&#59; CS&#58; circumferential strain&#59; DBP&#58; diastolic blood pressure&#59; IIs&#58; integrase inhibitors&#59; LA&#58; left atrial&#59; LS&#58; global longitudinal strain&#59; LV&#58; left ventricular&#59; LVEDV&#58; left ventricular end-diastolic volume&#59; LVESV&#58; left ventricular end-systolic volume&#59; NNRTIs&#58; non-nucleoside reverse transcriptase inhibitors&#59; NRTIs&#58; nucleotide reverse transcriptase inhibitors&#59; PIs&#58; protease inhibitors&#59; RS&#58; radial strain&#59; SBP&#58; systolic blood pressure&#59; SR<span class="elsevierStyleInf">A</span>&#58; late diastolic strain rate&#59; SR<span class="elsevierStyleInf">E</span>&#58; early diastolic strain rate&#59; SR<span class="elsevierStyleInf">S</span>&#58; systolic strain rate&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Population &#40;n&#61;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">41&#177;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Caucasian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;96&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#177;4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Disease &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#177;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#177;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood glucose &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#177;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LDL cholesterol &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115&#177;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD4 &#62;500&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;54&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">200<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD4 &#60;200&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Viral load &#62;20 copies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;32&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NRTIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NNRTIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;68&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CCR5rAs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Under treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">43 &#40;86&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">LA volume &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">26&#177;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E wave &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&#177;0&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A wave &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;57&#177;0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E&#47;A ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;33&#177;0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean E&#8217; &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;12&#177;0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean E&#47;E&#8217;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&#46;7&#177;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean S&#8217; &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09&#177;0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ejection fraction &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#177;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVEDV &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55&#177;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVESV &#40;ml&#47;m<span class="elsevierStyleSup">2&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#177;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV mass &#40;g&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;19&#46;5&#177;1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#177;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CS &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;17&#46;8&#177;3&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR<span class="elsevierStyleInf">S</span> &#40;s<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;1&#46;1&#177;0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR<span class="elsevierStyleInf">E</span> &#40;s<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8&#177;0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SR<span class="elsevierStyleInf">A</span> &#40;s<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;2&#177;0&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Abbreviations as for <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p>"
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                0 => """
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Control group &#40;n&#61;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">HIV-infected population &#40;n&#61;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#177;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;60&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Caucasian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;96&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">117&#177;11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#177;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#177;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#177;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#177;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab565145.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of the HIV-infected population and the control group&#46;</p>"
        ]
      ]
      14 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0130" class="elsevierStyleSimplePara elsevierViewall">RA&#58; right atrial&#46; Other abbreviations as for <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Control group &#40;n&#61;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">HIV-infected population &#40;n&#61;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">p&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LV mass &#40;g&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#177;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#177;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LA volume &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#177;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#177;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RA volume &#40;cm<span class="elsevierStyleSup">2</span>&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;3&#177;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;6&#177;1&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E wave &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&#177;0&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&#177;0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E&#47;A ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&#177;0&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3&#177;0&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean E&#8217; &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;14&#177;0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;12&#177;0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean E&#47;E&#8217;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#177;1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#177;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ejection fraction &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#177;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#177;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean S&#8217; &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;1&#177;0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09&#177;0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab565146.png"
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Original Article
Impact of HIV infection on cardiac deformation
Impacto da infeção do vírus da imunodeficiência humana na deformação miocárdica
Lígia Mendesa,
Autor para correspondência
ligiamendes76@gmail.com

Corresponding author.
, Daniela Silvab, Carla Mirandaa, Joana Sác, Luís Duquec, Nelson Duartec, Paula Britoc, Leonel Bernardinoa, José Poçasc
a Cardiology Department, Hospital de São Bernardo, Setúbal, Portugal
b Cardiology Department, Hospital Militar, Lisboa, Portugal
c Infectious Disease Department, Hospital de São Bernardo, Setúbal, Portugal
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Bland-Altman plot of intra-observer variability in mean late diastolic strain rate&#46; x axis&#58; mean late diastolic strain rate&#59; y axis&#58; difference between observations&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In Portugal the incidence of HIV infection is increasing&#44; with more than 6000 new cases per year&#44; and mortality is decreasing &#40;less than 500 deaths&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> With greater longevity&#44; mostly due to newer and more effective antiretroviral therapies and antimicrobial prophylaxis&#44; mortality and morbidity have shifted from opportunistic illness toward a variety of other medical conditions&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> including cardiovascular disease&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;10</span></a> which occur later in the course of HIV infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiovascular disease in HIV infection is diverse&#46; Myocarditis&#44; pericarditis&#44; pleural effusion or neoplastic invasion may be due to opportunistic infections and tumors&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> directly dependent on immunological status&#46; On the other hand&#44; coronary artery disease has a complex and multifactorial pathogenesis&#44; and the role of HIV infection is less clear&#46; Possible mechanisms such as immune activation&#44; inflammation&#44; coagulation disturbances&#44; lipoprotein particle changes&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> antiretroviral toxicity&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and direct or immune-mediated damage of endothelial and myocardial cells&#44; are less well established and require validation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Ventricular filling abnormalities and diastolic dysfunction are the first manifestations of myocardial injury irrespective of the cause&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> and are widely reported in HIV-infected populations with and without antiretroviral treatment or without established cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">It is not known whether cardiac disease can be diagnosed in the early stages prior to established diastolic dysfunction&#46; Most myocardial pathologic processes are usually regional before becoming widespread&#44; and local ventricular mechanics can be accurately assessed using strain and strain rate &#40;SR&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to reveal abnormalities in cardiac function due to HIV infection using strain and strain rate analysis in infected subjects without cardiovascular disease&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Population and eligibility</span><p id="par0030" class="elsevierStylePara elsevierViewall">The enrolled population were HIV-infected individuals receiving routine care in the outpatient clinic&#46; Only patients without cardiovascular disease and aged 25&#8211;55 years were recruited&#44; to avoid possible confounding myocardial relaxation abnormalities&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Both patients treated with antiretroviral drugs and untreated patients were included&#46; Pregnant women&#44; patients with diabetes&#44; hypertension&#44; dyslipidemia&#44; significant cardiac valve disease&#44; renal disease&#44; liver disease&#44; Centers for Disease Control and Prevention &#40;CDC&#41; class C patients&#44; and those with fever&#44; treated with interferon or corticoids&#44; and unable to read and sign the informed consent were excluded&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Initial assessment included a clinical questionnaire&#44; physical examination&#44; blood pressure measurement and a 12-lead electrocardiogram&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The control group were 20 healthy hospital workers&#44; frequency matched for gender and without cardiovascular risk factors&#44; who volunteered to undergo an echocardiogram and a physical exam&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Our hospital&#39;s ethics committee approved the study protocol&#44; and all patients provided written informed consent&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Laboratory assessment</span><p id="par0050" class="elsevierStylePara elsevierViewall">All patients underwent laboratory tests&#44; including hemogram&#44; serum electrolytes&#44; blood glucose&#44; total cholesterol&#44; HDL cholesterol&#44; LDL cholesterol&#44; triglycerides&#44; viral load and CD4 count&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Detectable viral load was defined as more than 20 copies of HIV RNA&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Echocardiography</span><p id="par0060" class="elsevierStylePara elsevierViewall">Echocardiographic examinations were performed using a Vivid 7 digital ultrasound system with a 1&#46;5&#8211;5 MHz probe &#40;GE Medical Systems&#44; Horten&#44; Norway&#41; and analyzed in EchoPac &#40;GE Healthcare&#41;&#46; Three cardiac cycles were stored in cineloop format for offline analysis&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Left ventricular and left atrial dimensions were measured according to the recommendations of the American Society of Echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Left ventricular ejection fraction was calculated by the change in ventricular volume percentages between systole and diastole in 2- and 4-chamber apical view using the modified Simpson&#39;s method &#40;mean of three measurements&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Left ventricular filling was assessed by spectral pulsed Doppler&#44; with the sample volume positioned over the flow immediately above the mitral leaflets&#46; Peak early diastolic flow velocity &#40;E&#41;&#44; peak atrial contraction flow velocity &#40;A&#41; and the E&#47;A ratio were obtained&#46; Pulsed tissue Doppler was used to assess longitudinal motion of the mitral annulus&#46; Particular care was taken to ensure that the ultrasound beam was aligned parallel to the direction of annular motion&#46; Peak septal and lateral wall velocities of the systolic wave S &#40;S&#8217;&#41;&#44; E wave &#40;E&#8217;&#41; and A wave &#40;A&#8217;&#41; were determined and the mean E&#47;E&#8217; ratio was calculated&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Diastolic function was evaluated and graded as recommended by the guidelines&#46; In preserved systolic function&#44; a left atrial volume less than 34 ml&#47;m<span class="elsevierStyleSup">2</span>&#44; lateral E&#8217; &#8805;10 m&#47;s and septal E&#8217; &#8805;8 m&#47;s confirmed that diastolic dynamics was normal&#46; An atrial volume of more than 34 ml&#47;m<span class="elsevierStyleSup">2</span>&#44; lateral E&#8217; &#60;10 m&#47;s with septal E&#8217; &#60;8 m&#47;s and mean E&#47;E&#8217; &#60;8 classified the diastolic dysfunction as grade I&#46; When mean E&#47;E&#8217; was &#62;8 and &#60;13 diastolic dysfunction was classified as grade II and as grade III when mean E&#47;E&#8217; was &#8805;13&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Strain rate measurements from the basal segments were obtained by color tissue Doppler &#40;&#62;140 fps&#41;&#46; The acquired velocity data allowed direct calculation of regional SR&#44; and the basal segments were chosen because angle deviations could be easily avoided&#44; making the assessment more reproducible&#46; Left outflow tract and transmitral flows were acquired to determine the timing of cardiac cycle events&#46; The angle of interrogation was kept as small as possible and aligned parallel to the region of interest&#44; in 4- and 2-chamber and apical long-axis views&#46; Systolic strain rate &#40;SR<span class="elsevierStyleInf">S</span>&#41;&#44; early diastolic strain rate &#40;SR<span class="elsevierStyleInf">E</span>&#41;&#44; and late diastolic strain rate &#40;SR<span class="elsevierStyleInf">A</span>&#41; were assessed offline from basal segments of the six walls&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> The mean SR<span class="elsevierStyleInf">S</span>&#44; SR<span class="elsevierStyleInf">E</span>&#44; and SR<span class="elsevierStyleInf">A</span> correspond to the mean of the six basal segments&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Longitudinal&#44; radial and circumferential strain were obtained by 2D speckle tracking&#46; The frame rate was reduced to 58&#8211;85 fps in order to improve tracking quality and the angle was not so critical as the technique is angle-independent&#46; Longitudinal strain was assessed in apical view and circumferential and radial strain in parasternal short-axis view&#46; Global longitudinal strain was calculated by the mean longitudinal strain of the six walls &#40;basal&#44; mid and apical segments&#41; in apical view and mean circumferential and radial strain for the six mid left ventricular segments&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Images from 10 random patients were analyzed offline again and by a second blinded observer to assess intra- and inter-observer variability in strain and strain rate measurements&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0095" class="elsevierStylePara elsevierViewall">The control group was only frequency matched for gender&#46; Dichotomous data were expressed as number and percentage and compared with the chi-squared test&#46; Numerical variables were expressed as mean and standard deviation and were analyzed using the Student&#39;s t test for independent samples&#46; A multiple regression model was also applied&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Pearson&#39;s correlation analysis was used to evaluate the relationship between CD4 count&#44; viral load&#44; duration of infection and the various echocardiographic parameters&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In accordance with the CDC classification&#44; the population was divided in three groups &#40;CD4 &#60;200 cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; 200<span class="elsevierStyleSup">3</span> and CD4 &#62;500 cells&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#46; The echocardiographic findings were compared with one-way ANOVA and multivariate analysis was performed with MANOVA&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Intra- and inter-observer variability was tested by the Bland-Altman method&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> calculated as the absolute difference divided by the mean of the two observations&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A p value of less than 0&#46;05 was considered statistically significant&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Analysis was performed using SPSS software&#44; version 17&#46;0&#46;0 &#40;SPSS&#44; Inc&#46;&#44; Ill&#46;&#44; USA&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0125" class="elsevierStylePara elsevierViewall">A total of 200 patients were screened in the outpatient clinic for study inclusion and 80 were potentially eligible&#46; Three were excluded because of hypertension at the clinical exam&#44; one had severe aortic stenosis&#44; and 26 refused to provide written informed consent&#46; Overall 50 patients were included&#44; mean age 41&#177;6 years&#44; 64&#37; male&#46; All the electrocardiograms were normal&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the characteristics of the HIV-infected population&#46; One patient has been infected for 30 years&#44; and another less than a year&#46; There was a high prevalence of smokers &#40;74&#37;&#44; 37 patients&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Seven &#40;14&#37;&#41; patients were not under active antiretroviral treatment&#58; four did not fulfill clinical or laboratory criteria to start drugs&#44; two were not compliant and the other presented an acute infection and started medication at the selection visit&#46; Patients were taking a mean of 3&#46;3 antiretroviral drugs&#44; 66&#37; were taking three&#44; 16&#37; four and 4&#37; five drugs&#46; Most were taking two antiretroviral classes&#44; except two who were taking three classes&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">CD4 count was 579&#177;285 cells&#47;mm<span class="elsevierStyleSup">3</span>&#59; maximum viral load was 463 000 copies and minimum was &#60;20 copies&#46; Fifteen patients &#40;30&#37;&#41; had detectable viral load&#44; of whom eight were under active treatment &#8211; six &#40;75&#37;&#41; with &#8216;blips&#8217; &#40;intermittent episodes of detectable low-level HIV1&#41;&#44; and two &#40;25&#37;&#41; were frequently non-compliant&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Comparing the HIV population to controls&#44; there were no differences in demographic and clinical data between groups except for diastolic blood pressure and smoking &#40;37 smokers in the HIV group and none in the control group&#44; p&#60;0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conventional echocardiographic parameters</span><p id="par0150" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; there were no differences in systolic or diastolic function parameters&#44; except for peak E-wave velocity&#44; which was higher in controls&#46; One HIV patient had diastolic dysfunction classified as grade I &#40;E&#47;E&#8217; &#60;8&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Strain and train rate analysis</span><p id="par0155" class="elsevierStylePara elsevierViewall">The 2D strain software achieved acceptable tracking in 97&#37; of cases in longitudinal strain&#44; 98&#37; in radial strain and 96&#37; in circumferential strain&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Global longitudinal strain&#44; mean radial and circumferential strain and mean SR<span class="elsevierStyleInf">S</span>&#44; SR<span class="elsevierStyleInf">E</span>&#44; and SR<span class="elsevierStyleInf">A</span> are reported in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Global longitudinal strain and SR<span class="elsevierStyleInf">S</span> and SR<span class="elsevierStyleInf">E</span> in the HIV group&#44; although in the normal range&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> were significantly lower than in the control group&#46; When analyzed in a multiple regression model including clinical and echocardiographic parameters&#44; only SR<span class="elsevierStyleInf">S</span> &#40;p&#61;0&#46;03&#44; 95&#37; CI 0&#46;036&#58;0&#46;671&#41; and SR<span class="elsevierStyleInf">E</span> &#40;p&#61;0&#46;001&#44; 95&#37; CI &#8722;0&#46;599&#58; &#8722;0&#46;168&#41; were different between groups&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Neither treatment &#40;also tested for the different drug classes and drug combinations&#58; nucleoside reverse transcriptase inhibitors and protease inhibitors or nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors&#41; nor detectable viral load had any impact on echocardiographic parameters&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Circumferential strain was different between CD4 categories &#40;CD4 &#60;200&#58; &#8722;16&#46;97&#177;3&#46;8&#37;&#59; 200&#8804;CD4 &#8804;500&#58; &#8722;16&#46;37&#177;2&#46;3&#37;&#59; CD4 &#62;500&#58; &#8722;19&#46;98&#177;3&#46;9&#37;&#59; p&#61;0&#46;049&#41; and was still different in multivariate analysis &#40;p&#61;0&#46;04&#46; 95&#37; CI &#8722;4&#46;59&#59; &#8722;0&#46;09&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The correlations obtained between disease duration and mean radial strain &#40;c&#61;&#8722;0&#46;31&#44; p&#61;0&#46;03&#41;&#44; and immunologic state and mean circumferential strain &#40;c&#61;&#8722;0&#46;4&#44; p&#61;0&#46;005&#41; were weak&#46; No clinical or laboratory data correlated with global longitudinal strain &#40;even when tested for the different coronary territories&#41;&#46; The same was observed for the strain rate parameters&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Intra-observer and inter-observer variability and reproducibility</span><p id="par0180" class="elsevierStylePara elsevierViewall">These are shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1&#8211;12</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><elsevierMultimedia ident="fig0040"></elsevierMultimedia><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="fig0050"></elsevierMultimedia><elsevierMultimedia ident="fig0055"></elsevierMultimedia><elsevierMultimedia ident="fig0060"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Our study excluded patients with comorbidities&#44; particularly established cardiovascular disease&#44; that could cause myocardial damage and abnormal cardiac mechanics&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Although there was a high prevalence of smokers&#44; the population was relatively healthy &#40;systolic blood pressure 122&#177;12 mmHg&#44; blood glucose 97&#177;13 mg&#47;dl&#44; LDL-cholesterol 115&#177;28 mg&#47;dl&#44; 90&#37; with CD4 count &#62;200 cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; only 32&#37; with detectable viral load&#44; and 86&#37; under antiretroviral treatment&#41;&#44; a representative sample of HIV-infected populations in developed countries&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> potentially achieving a normal life expectancy&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Previous echocardiographic studies in HIV-infected populations have focused on systolic and diastolic function assessed by 2D and spectral Doppler echocardiography&#44; only the most recent<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;19&#44;27&#44;28</span></a> using pulsed tissue Doppler&#44; but none had classified and graded diastolic dysfunction according to the current guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In our study there were no differences in systolic or diastolic function between groups when assessed with conventional echocardiography and pulsed tissue Doppler&#46; Previous studies also showed no systolic abnormalities&#44; but reported a high prevalence of diastolic dysfunction&#46; This difference can be explained by comparing the studied populations&#46; Our is a relatively healthy and young sample with no comorbidities&#44; unlike the larger sample &#40;689 patients&#41; studied by Reinsch et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> in the HIV-Heart Study&#44; who were older &#40;44&#177;10 years&#44; p&#61;0&#46;04&#41;&#44; 60&#37; had dyslipidemia&#44; 7&#37; had diabetes and one third had hypertension&#46; They used pulsed tissue Doppler and transmitral pulsed Doppler to assess diastolic dysfunction&#44; which was present in 48&#37; of the patients&#46; Blood pressure&#44; hyperlipidemia&#44; diabetes&#44; body mass index and age were different between groups with and without diastolic dysfunction&#44; but infection-related conditions were similar &#40;duration of infection&#44; CD4 count&#44; viral load and treatment&#41;&#46; Two other smaller studies using pulsed tissue Doppler<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;28&#44;29</span></a> came to the same conclusions concerning a high prevalence of relaxation abnormalities&#44; but again the classification and grading were not performed as recommended&#46; In a sub-analysis<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> of the SUN study with 659 patients&#44; diastolic dysfunction correlated with high-sensitivity C-reactive protein and the presence of hypertension&#46; Hsue et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> obtained similar results&#44; the HIV-infected group having significantly more hypertension &#40;26&#37; vs&#46; 6&#37;&#41;&#44; and in multivariate analysis&#44; hypertension&#44; age and HIV infection increased the risk for diastolic dysfunction &#40;neither CD4 count&#44; viral load&#44; nor type of treatment increased the risk when adjusted for age and hypertension&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">To summarize&#44; our results&#44; which are not in agreement with previous studies&#44; can be explained by the fact that our HIV population were healthier compared with other&#44; more heterogeneous HIV populations&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The population studied by Oliviero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> was similar to ours in age and blood pressure but had a better metabolic status &#40;blood glucose&#44; p&#60;0&#46;001 and cholesterol&#44; p&#61;0&#46;001&#41;&#44; a shorter infection duration and were not under active antiretroviral therapy&#46; They reported an abnormal relaxation pattern in 30&#37; of patients&#44; but compared with our results there were no differences in diastolic parameters &#40;e&#8217; 0&#46;13&#177;0&#46;08 vs&#46; 0&#46;12&#177;0&#46;03&#44; p&#61;0&#46;4&#59; E&#47;e&#8217; 6&#46;6&#177;3&#46;5 vs&#46; 5&#46;7&#177;1&#46;8&#44; p&#61;0&#46;12&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Speckle tracking is a recent echocardiographic technology that analyzes motion by tracking natural acoustic reflections with relative angle independence&#44; less noise interference and substantially lower intra-observer and inter-observer variability&#46; Strain and strain rate are dimensionless measurements of deformation &#40;degree of shortening or stretching of fibers&#41;&#46; The degree of shearing increases toward the subendocardium&#46; The subendocardial region that is assessed by longitudinal strain is the most vulnerable component of left ventricular mechanics and therefore most sensitive to the presence of myocardial disease&#46; A transmural insult or progression of disease results in concomitant midmyocardial and subepicardial dysfunction&#44; leading to a reduction in circumferential and radial strain&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Our study was the first to assess strain and strain rate<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> in a HIV-infected population without established cardiovascular disease or risk factors&#46; Although the mean strain and strain rate obtained in the HIV group were in the normal range according to the latest ASE&#47;EAE Consensus Statement&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> global longitudinal strain&#44; SR<span class="elsevierStyleInf">S</span> and SR<span class="elsevierStyleInf">E</span> were statistically lower compared with the control group&#44; revealing early abnormalities&#46; It is important to note that diastolic dysfunction was not detected with conventional echocardiography but the presence of lower SR<span class="elsevierStyleInf">E</span> reveals abnormalities in myocardial relaxation&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In the present study viral load had no impact on myocardial performance&#44; probably because only 30&#37; had detectable virus in blood samples&#44; but circumferential strain differed according to immunological status &#40;more than half of the patients had CD4 &#62;500 cells&#47;mm<span class="elsevierStyleSup">3</span>&#41;&#44; which is in agreement with the findings of previous studies that reported myocardial injury mediated by the non-myocyte pool&#44; especially in patients with low CD4 count&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Antiretroviral therapy is usually assumed to be toxic &#40;particularly protease inhibitors associated with lipodystrophy leading to metabolic disorders including insulin resistance and dyslipidemia<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;34&#44;35</span></a>&#41;&#44; but in our sample the drugs had no perceptible impact when studied individually or in combination&#44; probably because of the small number of patients enrolled&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Although we believe our data are relevant&#44; not only because they were obtained with strain and strain rate methodology&#44; but also because our population was healthy&#44; we do acknowledge some limitations&#44; including the small number of participants&#44; the fact that it was an observational study&#44; and the absence of biomarker assessment&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In conclusion&#44; diastolic dysfunction assessed as recommended by the latest guidelines is not prevalent in a relatively healthy HIV-infected population without cardiovascular disease or risk factors&#46; Although strain and strain rate are able to detect the first signs of myocardial mechanics abnormalities&#44; because these techniques are still in the research stage&#44; we consider it premature to recommend routine screening echocardiograms in HIV-infected adults without cardiovascular disease&#44; mostly because the prognostic impact of these findings is unknown&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical disclosures</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protection of human and animal subjects</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidentiality of data</span><p id="par0250" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Right to privacy and informed consent</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => "Objetivo"
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            3 => "Resultados"
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              "titulo" => "Population and eligibility"
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              "titulo" => "Laboratory assessment"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Echocardiography"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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              "titulo" => "Conventional echocardiographic parameters"
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              "identificador" => "sec0045"
              "titulo" => "Strain and train rate analysis"
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              "identificador" => "sec0050"
              "titulo" => "Intra-observer and inter-observer variability and reproducibility"
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          "titulo" => "Discussion"
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              "titulo" => "Protection of human and animal subjects"
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              "titulo" => "Confidentiality of data"
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              "identificador" => "sec0075"
              "titulo" => "Right to privacy and informed consent"
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    "fechaRecibido" => "2013-03-18"
    "fechaAceptado" => "2013-12-20"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec352591"
          "palabras" => array:5 [
            0 => "HIV infection"
            1 => "Myocardial mechanics"
            2 => "Myocardium deformation"
            3 => "Speckle tracking"
            4 => "Color tissue Doppler"
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          "clase" => "keyword"
          "titulo" => "Palavras-chave"
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          "palabras" => array:5 [
            0 => "Infe&#231;&#227;o VIH"
            1 => "Mecanismos mioc&#225;rdicos"
            2 => "Deforma&#231;&#227;o mioc&#225;rdica"
            3 => "<span class="elsevierStyleItalic">Speckel tracking</span>"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The aim of this study was to detect abnormalities in left ventricular myocardial function due to HIV &#40;human immunodeficiency virus&#41; infection without established cardiovascular disease&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">An echocardiogram was performed in 50 asymptomatic HIV-infected patients &#40;age 41&#177;6 years&#44; 64&#37; male&#41; and in 20 healthy individuals&#46; Conventional echocardiography and pulsed tissue Doppler imaging &#40;TDI&#41; were performed according to the guidelines&#46; The strain rate of the basal segments was obtained with color tissue Doppler and used to evaluate systolic strain rate &#40;SR<span class="elsevierStyleInf">S</span>&#41;&#44; early diastolic strain rate &#40;SR<span class="elsevierStyleInf">E</span>&#41; and late diastolic strain rate &#40;SR<span class="elsevierStyleInf">A</span>&#41;&#46; Longitudinal&#44; radial and circumferential strain were assessed by 2D speckle tracking&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The mean duration of HIV infection was 10&#177;5 years&#44; CD4 count was 579&#177;286 cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; 32&#37; had detectable viral load&#44; and 86&#37; were under treatment&#46; Of the HIV-infected patients&#44; one had grade 1 diastolic dysfunction&#46; The groups were not different except for E wave &#40;HIV 0&#46;72&#177;0&#46;17 m&#47;s vs&#46; control 0&#46;84&#177;0&#46;16 m&#47;s&#44; p&#61;0&#46;01&#41;&#44; longitudinal strain &#40;&#8722;19&#46;5&#177;1&#46;9&#37; vs&#46; &#8722;21&#177;2&#37;&#44; p&#61;0&#46;005&#41;&#44; SR<span class="elsevierStyleInf">S</span> &#40;&#8722;1&#46;1&#177;0&#46;28 s<span class="elsevierStyleSup">&#8722;1</span> vs&#46; &#8722;1&#46;3&#177;0&#46;28 s<span class="elsevierStyleSup">&#8722;1</span>&#44; p&#61;0&#46;02&#41; and SR<span class="elsevierStyleInf">E</span> &#40;1&#46;8&#177;0&#46;4 s<span class="elsevierStyleSup">&#8722;1</span> vs&#46; 2&#46;2&#177;0&#46;4 s<span class="elsevierStyleSup">&#8722;1</span>&#44; p&#60;0&#46;001&#41;&#44; but only SR<span class="elsevierStyleInf">S</span> &#40;p&#61;0&#46;03&#44; 95&#37; CI 0&#46;036&#59; 0&#46;67&#41; and SR<span class="elsevierStyleInf">E</span> &#40;p&#61;0&#46;001&#44; 95&#37; CI &#8722;0&#46;599&#59; &#8722;0&#46;168&#41; had independent value&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In an HIV-infected population without established cardiovascular disease&#44; myocardial deformation abnormalities can be detected with strain and strain rate&#44; revealing markers of myocardial injury&#46;</p>"
      ]
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        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar altera&#231;&#245;es na fun&#231;&#227;o mioc&#225;rdica secund&#225;rias &#224; infe&#231;&#227;o do v&#237;rus da imunodefici&#234;ncia humana &#40;VIH&#41; em doentes sem doen&#231;a cardiovascular estabelecida&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram realizados ecocardiogramas em 50 doentes com infe&#231;&#227;o VIH&#44; assintom&#225;ticos &#40;41&#177;6 anos&#44; 64&#37; homens&#41; e em 20 indiv&#237;duos saud&#225;veis&#46; O ecocardiograma convencional e o Doppler tecidular pulsado foram realizados e determinados segundo as &#250;ltimas recomenda&#231;&#245;es&#46; O <span class="elsevierStyleItalic">strain rate</span> dos segmentos basais foram determinados com o Doppler tecidular cor e avaliados o <span class="elsevierStyleItalic">strain rate</span> sist&#243;lico &#40;SRS&#41;&#44; o <span class="elsevierStyleItalic">strain rate</span> diast&#243;lico precoce &#40;SRE&#41; e o <span class="elsevierStyleItalic">strain rate</span> diast&#243;lico tardio &#40;SRA&#41;&#46; O <span class="elsevierStyleItalic">strain</span> longitudinal&#44; radial e circunferencial foi obtido a partir do 2D <span class="elsevierStyleItalic">speckle tracking</span>&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Na amostra a dura&#231;&#227;o da infe&#231;&#227;o era de 10&#177;5 anos&#44; com contagem de CD4 de 579&#177;286 c&#233;lulas&#47;mm<span class="elsevierStyleSup">3</span>&#44; 32&#37; tinham carga viral detet&#225;vel e 86&#37; estavam em terap&#234;utica ativa&#46; No grupo infetado&#44; um doente tinha disfun&#231;&#227;o diast&#243;lica de grau 1&#46; Os grupos eram semelhantes&#44; exceto para a onda E &#40;VIH 0&#44;72&#177;0&#44;17 m&#47;s <span class="elsevierStyleItalic">versus</span> control 0&#44;84&#177;0&#44;16 m&#47;s&#44; p&#61;0&#44;01&#41;&#44; <span class="elsevierStyleItalic">strain</span> longitudinal &#40;&#8211;19&#44;5&#177;1&#44;9&#37; <span class="elsevierStyleItalic">versus</span> &#8211;21&#177;2&#37;&#44; p&#61;0&#44;005&#41;&#44; SRS &#40;&#8211;1&#44;1&#177;0&#44;28 s-1 <span class="elsevierStyleItalic">versus</span> &#8211;1&#44;3&#177;0&#44;28 s-1&#44; p&#61;0&#44;02&#41; e SRE &#40;1&#44;8&#177;0&#44;4 s-1 <span class="elsevierStyleItalic">versus</span> 2&#44;2&#177;0&#44;4 s-1&#44; p&#60;0&#44;001&#41;&#44; mas s&#243; o SRS &#40;p&#61;0&#44;03&#44; 95&#37; CI 0&#44;036&#59; 0&#44;67&#41; e o SRE &#40;p&#61;0&#44;001&#44; 95&#37;CI &#8211;0&#44;599&#59; &#8211;0&#44;168&#41; foram diferentes na an&#225;lise multivariada&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Numa popula&#231;&#227;o infetada com o VIH&#44; mas sem doen&#231;a cardiovascular estabelecida&#44; as altera&#231;&#245;es na deforma&#231;&#227;o mioc&#225;rdica podem ser apercebidas atrav&#233;s do <span class="elsevierStyleItalic">strain</span> e do <span class="elsevierStyleItalic">strain rate</span>&#44; revelando poss&#237;veis marcadores de les&#227;o mioc&#225;rdica&#46;</p>"
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            "Alto" => 1203
            "Ancho" => 1650
            "Tamanyo" => 82610
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Bland-Altman plot of inter-observer variability in mean radial strain&#46; x axis&#58; mean radial strain&#59; y axis&#58; difference between observations&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 1204
            "Ancho" => 1647
            "Tamanyo" => 82685
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Bland-Altman plot of inter-observer variability in mean circumferential strain&#46; x axis&#58; mean circumferential strain&#59; y axis&#58; difference between observations&#46;</p>"
        ]
      ]
      9 => array:7 [
        "identificador" => "fig0050"
        "etiqueta" => "Figure 10"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr10.jpeg"
            "Alto" => 1205
            "Ancho" => 1657
            "Tamanyo" => 84505
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Bland-Altman plot of inter-observer variability in mean systolic strain rate&#46; x axis&#58; mean systolic strain rate&#59; y axis&#58; difference between observations&#46;</p>"
        ]
      ]
      10 => array:7 [
        "identificador" => "fig0055"
        "etiqueta" => "Figure 11"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr11.jpeg"
            "Alto" => 1210
            "Ancho" => 1649
            "Tamanyo" => 82792
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Bland-Altman plot of inter-observer variability in mean early diastolic strain rate&#46; x axis&#58; mean early diastolic strain rate&#59; y axis&#58; difference between observations&#46;</p>"
        ]
      ]
      11 => array:7 [
        "identificador" => "fig0060"
        "etiqueta" => "Figure 12"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr12.jpeg"
            "Alto" => 1210
            "Ancho" => 1649
            "Tamanyo" => 88730
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Bland-Altman plot of inter-observer variability in mean late diastolic strain rate&#46; x axis&#58; mean late diastolic strain rate&#59; y axis&#58; difference between observations&#46;</p>"
        ]
      ]
      12 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; CCR5rAs&#58; CCR5 receptor antagonists&#59; CS&#58; circumferential strain&#59; DBP&#58; diastolic blood pressure&#59; IIs&#58; integrase inhibitors&#59; LA&#58; left atrial&#59; LS&#58; global longitudinal strain&#59; LV&#58; left ventricular&#59; LVEDV&#58; left ventricular end-diastolic volume&#59; LVESV&#58; left ventricular end-systolic volume&#59; NNRTIs&#58; non-nucleoside reverse transcriptase inhibitors&#59; NRTIs&#58; nucleotide reverse transcriptase inhibitors&#59; PIs&#58; protease inhibitors&#59; RS&#58; radial strain&#59; SBP&#58; systolic blood pressure&#59; SR<span class="elsevierStyleInf">A</span>&#58; late diastolic strain rate&#59; SR<span class="elsevierStyleInf">E</span>&#58; early diastolic strain rate&#59; SR<span class="elsevierStyleInf">S</span>&#58; systolic strain rate&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Population &#40;n&#61;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41&#177;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;64&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Caucasian&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48 &#40;96&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#177;4&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Disease &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#177;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">122&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DBP &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">78&#177;10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood glucose &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#177;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LDL cholesterol &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">115&#177;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD4 &#62;500&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27 &#40;54&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">200<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;36&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CD4 &#60;200&#47;mm<span class="elsevierStyleSup">3</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Viral load &#62;20 copies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;32&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NRTIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NNRTIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;68&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CCR5rAs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Under treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;86&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LA volume &#40;ml&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#177;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E wave &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;72&#177;0&#46;16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A wave &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;57&#177;0&#46;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">E&#47;A ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;33&#177;0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean E&#8217; &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;12&#177;0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean E&#47;E&#8217;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;7&#177;1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mean S&#8217; &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;09&#177;0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ejection fraction &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#177;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">E wave &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;84&#177;0&#46;16&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">E&#47;A ratio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;3&#177;0&#46;34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Mean E&#8217; &#40;m&#47;s&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;14&#177;0&#46;03&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;12&#177;0&#46;03&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Mean E&#47;E&#8217;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#177;1&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0135" class="elsevierStyleSimplePara elsevierViewall">Strain and strain rate parameters in the HIV-infected population and the control group&#46;</p>"
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      "titulo" => "References"
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              "identificador" => "bib0010"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changing spectrum of mortality due to human immunodeficiency virus&#58; analysis of 260 deaths during 1995&#8211;1999"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "H&#46; Valdez"
                            1 => "T&#46;K&#46; Chowdhry"
                            2 => "R&#46; Asaad"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1086/320164"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Infect Dis"
                        "fecha" => "2001"
                        "volumen" => "32"
                        "paginaInicial" => "1487"
                        "paginaFinal" => "1493"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11317251"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mortality in the highly active antiretroviral therapy era&#58; changing causes of death and disease in the HIV Outpatient Study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "F&#46;J&#46; Palella Jr&#46;"
                            1 => "R&#46;K&#46; Baker"
                            2 => "A&#46;C&#46; Moorman"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.qai.0000233310.90484.16"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Acquir Immune Defic Syndr"
                        "fecha" => "2006"
                        "volumen" => "43"
                        "paginaInicial" => "27"
                        "paginaFinal" => "34"
                        "link" => array:1 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparisons of causes of death and mortality rates among HIV-infected persons&#58; analysis of the pre-&#44; early&#44; and late HAART &#40;highly active antiretroviral therapy&#41; eras"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "N&#46;F&#46; Crum"
                            1 => "R&#46;H&#46; Riffenburgh"
                            2 => "S&#46; Wegner"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Acquir Immune Defic Syndr"
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                        "paginaFinal" => "200"
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ISSN: 08702551
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2015 Dezembro 47 8 55
2015 Novembro 42 15 57
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