RESUMEN
This is a case of a precarious thrombotic mass straddling a patent foramen ovale which had already embolised to the pulmonary circulation. The diagnosis was initially deceptive and management challenging. LEARNING POINTS: Echocardiography is mandated and can change management in haemodynamically unstable patients with pulmonary emboli.Pulmonary embolism can be life-threatening.The authors propose that urgent cardiac surgery is the safest treatment in the setting of highly mobile, large volume, intra-cardiac thrombus.
RESUMEN
BACKGROUND: Improving access to supermarkets has been shown to improve some dietary outcomes, yet there is little evidence for such effects on children. Relatedly, there is a dearth of research assessing the impact of a structural change (i.e. supermarket in a former food desert) on the home environment and its relationship with children's diet. OBJECTIVE: Assess the relative impact of the home environment on children's diet after the introduction of a new supermarket in a food desert. METHODS: Among a randomly selected cohort of households living in a food desert, parental diet was assessed before and after the opening of a full-service supermarket. The home environment and children's intake of fruits and vegetables was measured at one point - after the store's opening. Structural equation models were used to estimate the pathways between changes in parental dietary quality at follow-up and children's dietary intake through the home environment. RESULTS: Parental dietary improvement after the supermarket opened was associated with having a better home environment (ß = 0.45, p = 0.001) and with healthier children's dietary intake (ß = 0.46, p < 0.001) through higher family nutrition and physical activity scores (ß = 0.25, p = 0.02). CONCLUSIONS: Policy solutions designed to improve diet among low-resource communities should take into account the importance of the home environment.
RESUMEN
We describe the case of an 85 year old lady with symptomatic aortic stenosis (AS) with a history of previous coronary artery bypass grafting (CABG), who was referred for consideration of aortic valve replacement (AVR). Echocardiography revealed severe AS with peak gradient of 92 mmHg, orifice area of 0.6 cm2 and preserved left ventricular function. Computed tomography (CT) aortogram revealed a diffusely calcified aorta and an infrarenal abdominal aortic aneurysm (AAA) measuring 6.5 cm. For symptomatic and prognostic reasons she needed treatment of both the AAA and AS. Her calculated logistic EuroSCORE for AVR was 39%. Following discussion at a multidisciplinary forum, it was agreed that the best way to offer her treatment with the lowest risk was by using transcatheter techniques for both pathologies. She subsequently underwent transcatheter aortic valve implantation (TAVI) via the transapical approach to treat her AS, and 3 months later, endovascular stenting of her infrarenal AAA. She recovered well from both procedures. At 6 week follow up, her cardiac symptoms had improved considerably, and echocardiography revealed a mean AV gradient of 7 mmHg with good left ventricular function. Ultrasound of her abdomen revealed exclusion of the aneurysm sac with no endoleak. This is the first described case of TAVI and endovascular treatment of an AAA as a staged procedure.