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OBJECTIVES: Dolutegravir is widely prescribed owing to its potent antiviral activity, high genetic barrier and good tolerability. The aim of this study was to characterize dolutegravir's pharmacokinetic profile and variability in a real-life setting and to identify individual factors and co-medications affecting dolutegravir disposition. METHODS: A population pharmacokinetic model was developed using NONMEM®. Relevant demographic factors, clinical factors and co-medications were tested as potential covariates. Simulations based on the final model served to compare expected dolutegravir concentrations under standard and alternative dosage regimens in the case of drug-drug interactions. RESULTS: A total of 620 dolutegravir plasma concentrations were collected from 521 HIV-infected individuals under steady-state conditions. A one-compartment model with first-order absorption and elimination best characterized dolutegravir pharmacokinetics. Typical dolutegravir apparent clearance (CL/F) was 0.93 L/h with 32% between-subject variability, the apparent volume of distribution was 20.2 L and the absorption rate constant was fixed to 2.24 h-1. Older age, higher body weight and current smoking were associated with higher CL/F. Atazanavir co-administration decreased dolutegravir CL/F by 38%, while darunavir modestly increased CL/F by 14%. Rifampicin co-administration showed the largest impact on CL/F. Simulations suggest that average dolutegravir trough concentrations are 63% lower after 50 mg/12h with rifampicin compared with a standard dosage of 50 mg/24h without rifampicin. Average trough concentrations after 100 mg/24h and 100 mg/12h with rifampicin are 92% and 25% lower than the standard dosage without rifampicin, respectively. CONCLUSIONS: Patients co-treated with dolutegravir and rifampicin might benefit from therapeutic drug monitoring and individualized dosage increase, up to 100 mg/12 h in some cases.
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Interacciones Farmacológicas , Inhibidores de Integrasa VIH/farmacocinética , Compuestos Heterocíclicos con 3 Anillos/farmacocinética , Modelos Teóricos , Adolescente , Adulto , Anciano , Antibióticos Antituberculosos/farmacología , Terapia Antirretroviral Altamente Activa/efectos adversos , Terapia Antirretroviral Altamente Activa/métodos , Estudios de Cohortes , Monitoreo de Drogas , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Oxazinas , Piperazinas , Piridonas , Adulto JovenRESUMEN
BACKGROUND: According to 2016 World Health Organization and United Nations Children's Fund country estimates, Eritrea has overall high vaccination coverage with immunization rates for three doses of diphtheria/tetanus/pertussis and polio vaccine of 95%, for two doses measles vaccine of 85% and for three doses hepatitis B vaccine of 85%. If confirmed, this could imply that routine basic vaccination of newly arrived Eritreans could be safely omitted. METHODS: We used stored serum samples from two cross-sectional studies that screened newly arrived Eritrean refugees for infectious diseases. Consenting refugees aged 16 years and older who registered in one of three neighbouring cantons in northwestern Switzerland were enrolled between January 2016 and December 2017. Antibody titers against the following vaccine-preventable diseases were measured (applied thresholds for seroprotection in brackets): diphtheria (>0.1 IU/ml), tetanus (>0.1 IU/ml), measles (>150 mIU/ml), rubella (only for women, >11 IU/ml), varicella (>50 mIU/ml), hepatitis B [hepatitis B surface antigen (HBsAg) Index >0.9, Hepatitis B core antibody (anti-HBc) Index >0.9 and antibodies to HBsAg (anti-HBs) >10 IE/L]. Differences between sex and age groups (≤25 and >25 years) were measured by Fisher's exact test. RESULTS: We analysed samples of 133 study participants (20 women, 15%) with a median age of 25 years (range 16-61). Rates of seropositivity were as follows for women/men, respectively: diphtheria 57.9%/74.8% (difference non-significant), tetanus 94.8%/41.1% (P < 0.001), measles 73.7%/76.6% (non-significant), rubella in women 78.9%, varicella 89.5%/95.3% (non-significant), anti-HBc 15.8%/26.2% (non-significant) and anti-HBs 15.8%/17.8% (non-significant). CONCLUSION: Seroprevalence for vaccine-preventable infections did not meet levels required to confer herd immunity in any of the human-to-human transmissible diseases that were studied. In general, the strategy proposed by the Federal Office of Public Health to offer basic immunization to all newly arrived refugees, including newly arriving Eritrean refugees, is justified.
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Anticuerpos Antivirales/sangre , Enfermedades Transmisibles Importadas/prevención & control , Refugiados/estadística & datos numéricos , Cobertura de Vacunación/estadística & datos numéricos , Adolescente , Adulto , Enfermedades Transmisibles Importadas/sangre , Enfermedades Transmisibles Importadas/inmunología , Estudios Transversales , Eritrea/etnología , Femenino , Humanos , Inmunidad Colectiva/inmunología , Masculino , Persona de Mediana Edad , Suiza , Vacunación/normas , Adulto JovenAsunto(s)
Derivación Gástrica , Inhibidores de Integrasa VIH/farmacocinética , Compuestos Heterocíclicos con 3 Anillos/farmacocinética , Plasma/química , Inhibidores de Integrasa VIH/administración & dosificación , Compuestos Heterocíclicos con 3 Anillos/administración & dosificación , Humanos , Oxazinas , Piperazinas , PiridonasRESUMEN
BACKGROUND: The aim of the present study was to develop a clinically relevant, accurate and usable risk assessment scoring system solely for colorectal cancer patients undergoing elective resection. METHODS: All colorectal resections for colorectal cancer 2006-2012 were identified from the American College of Surgeons Quality Improvement Program. Independent risk factors for 30-day mortality after elective surgery were identified using univariable and multivariable logistic regression. A points-calculator based on factors most strongly associated with mortality and accurately predicting risk of mortality was developed. RESULTS: Fifty-nine thousand nine hundred eighty-six patients underwent elective colorectal cancer surgery, and 1096 (1.8 %) died within 30 days. On multivariable analysis, the strongest risk factors for mortality were age ≥65 years [odds ratio (OR) 2.17, 95 % confidence interval (CI) 1.61-2.92], American Society of Anesthesiologists score ≥3 (OR 1.77, 95 % CI 1.29-2.42), renal failure (OR 3.15, 95 % CI 1.01-9.77), disseminated cancer (OR 2.56, 95 % CI 1.96-3.35), hypoalbuminemia (OR 2.84, 95 % CI 2.21-3.65), preoperative ascites (OR 3.17, 95 % CI 2.07-4.87), heart failure (OR 2.08, 95 % CI 1.35-3.20) and functional status (OR 2.05, 95 % CI 1.56-2.70). A model that accurately predicted risk of mortality was created using forward stepwise logistic regression and externally validated (area under the curve 0.826). This allowed for development of an eight-factor predictive score; maximum points conferred mortality of 96.1 % (p < 0.0001). CONCLUSIONS: A simple preoperative scoring system predicting 30-day mortality with good capability may allow better preoperative risk assessment, optimization and decision-making.
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Colectomía/mortalidad , Neoplasias Colorrectales/patología , Neoplasias Colorrectales/cirugía , Recto/cirugía , Factores de Edad , Anciano , Anciano de 80 o más Años , Ascitis/epidemiología , Colectomía/métodos , Procedimientos Quirúrgicos Electivos/mortalidad , Femenino , Estado de Salud , Insuficiencia Cardíaca/epidemiología , Humanos , Hipoalbuminemia/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Periodo Preoperatorio , Insuficiencia Renal/epidemiología , Medición de Riesgo/métodos , Factores de Riesgo , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Although most experts recommend empirical antibiotic treatment, covering also atypical bacteria, for patients admitted to an intensive care unit (ICU), the data are not clear for patients admitted to a general ward. European guidelines recommend starting empirical treatment with a beta-lactam antibiotic with or without a macrolide, but the with/without is not clarified. We investigated whether the use of antibiotic coverage for atypical pathogens was guided by clinical parameters. METHODS: We retrospectively analysed 300 patients hospitalised with community-acquired pneumonia. Four parameters for possible atypical pneumonia (age <55 years, abdominal symptoms, sodium <130 mmol/l, immunosuppression) and three for pneumonia severity (pneumonia severity index [PSI], ICU admission, pO2 <8 kPa (60 mm Hg) or O2 saturation <90%) were defined and correlated with the probability of coverage for atypical pathogens. Correlations were calculated using the chi-square test for 2 x 2 tables. RESULTS: Patients younger than 55 years significantly more likely to receive coverage for atypical pathogens than older patients (odds ratio [OR] 2.68; 95% confidence interval [CI] 1.3-5.5, p = 0.009). In patients with a PSI >III the proportion receiving coverage for atypical bacteria was even smaller than in patients with less severe pneumonia (OR 0.77; 95% CI 0.60-0.99, p = 0.03), but no difference was found for PSI >IV compared with PSI ≤IV (OR = 1.03; 95% CI 0.61-1.74, p = 0.9). The other clinical parameters had no effect on antibiotic coverage: ICU admission (OR =1.39; 95% CI 0.87-2.4, p = 0.15); pO2 >8 kPa or O2-Saturation >90% (OR 1.36; 95% CI 0.85-2.17, p = 0.19); abdominal symptoms (OR 1.06; 95% CI 0.51-2.25, p = 0.88); sodium <130 mmol/l (OR 0.63; 95% CI 0.29-1.36, p = 0.2) or immunosuppression (OR 1.007; 95% CI 0.462-44, p = 1). There was also no correlation between the number of clinical parameters present and the coverage of atypical pathogens (r = 0.48). Mortality was no different between patients in whom atypical pathogens were covered compared with those with beta-lactam therapy alone (OR 1.2; 95% CI 0.66-2.25, p = 0.43). CONCLUSION: Physicians have difficulties deciding when to cover atypical pathogens in hospitalised patients with community-acquired pneumonia. Guidelines should clarify under what circumstances combination therapy is warranted.
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Antibacterianos/uso terapéutico , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Adhesión a Directriz/estadística & datos numéricos , Macrólidos/uso terapéutico , Neumonía Bacteriana/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , beta-Lactamas/uso terapéutico , Adulto , Factores de Edad , Anciano , Neumonía por Clamidia/tratamiento farmacológico , Claritromicina/uso terapéutico , Infecciones Comunitarias Adquiridas/inmunología , Quimioterapia Combinada/estadística & datos numéricos , Hospitalización , Humanos , Huésped Inmunocomprometido , Enfermedad de los Legionarios/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Neumonía Bacteriana/inmunología , Neumonía por Mycoplasma/tratamiento farmacológico , Neumonía Neumocócica/tratamiento farmacológico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
Current evolutions and substantial amendments of the German health care system in combination with distinguished progress in cardiac surgery over the past years require both a reflection of principles in patient-centered care and an update of basic standard requirements for a department of cardiac surgery in Germany. In due consideration of the data from the voluntary registry of the German Society for Thoracic and Cardiovascular Surgery, this article accurately defines core requirements for a cardiac surgical department (cardiac surgery on-site), subdivided into facilities, staff and processes. If based on these standards, one may anticipate that cardiac surgical care is performed under appropriate conditions leading to an intrinsic benefit for patients.
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Procedimientos Quirúrgicos Cardíacos/normas , Servicio de Cardiología en Hospital/normas , Atención a la Salud/normas , Evaluación de Procesos y Resultados en Atención de Salud/normas , Garantía de la Calidad de Atención de Salud/normas , Servicio de Cardiología en Hospital/organización & administración , Atención a la Salud/organización & administración , Alemania , Adhesión a Directriz/normas , Personal de Salud/normas , Humanos , Evaluación de Procesos y Resultados en Atención de Salud/organización & administración , Seguridad del Paciente/normas , Guías de Práctica Clínica como Asunto/normas , Garantía de la Calidad de Atención de Salud/organización & administración , Resultado del TratamientoRESUMEN
In multilayer white organic light-emitting diodes the electronic processes in the various layers--injection and motion of charges as well as generation, diffusion and radiative decay of excitons--should be concerted such that efficient, stable and colour-balanced electroluminescence can occur. Here we show that it is feasible to carry out Monte Carlo simulations including all of these molecular-scale processes for a hybrid multilayer organic light-emitting diode combining red and green phosphorescent layers with a blue fluorescent layer. The simulated current density and emission profile are shown to agree well with experiment. The experimental emission profile was obtained with nanometre resolution from the measured angle- and polarization-dependent emission spectra. The simulations elucidate the crucial role of exciton transfer from green to red and the efficiency loss due to excitons generated in the interlayer between the green and blue layers. The perpendicular and lateral confinement of the exciton generation to regions of molecular-scale dimensions revealed by this study demonstrate the necessity of molecular-scale instead of conventional continuum simulation.
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We studied the efficacy of propafenone in preventing atrial tachyarrhythmias after cardiac surgery, and the possible relationships between CYP2D6 polymorphism and the efficacy, pharmacokinetics, and tolerability of propafenone. One hundred and sixty patients were randomized (double blind) to receive propafenone (n= 78) or placebo (n= 82) for 1 week after cardiac surgery. The patients who were assigned to the propafenone group received 1 mg/kg infused in 1 h, followed by a continuous infusion at a rate of 4 mg/kg/24 h until the following morning, and subsequently 450 mg/day orally until the sixth postoperative day. Thirty-seven patients completed the trial in the propafenone group and 45 in the placebo group. The frequency of occurrence of atrial tachyarrhythmia was lower in the propafenone group than in the placebo group (29.7% vs. 53.3%, P< 0.05; relative risk, 0.56). Plasma propafenone concentrations were markedly influenced by CYP2D6 genotype-derived phenotype.
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Antiarrítmicos/uso terapéutico , Fibrilación Atrial/prevención & control , Propafenona/uso terapéutico , Taquicardia/prevención & control , Cirugía Torácica , Anciano , Antiarrítmicos/sangre , Fibrilación Atrial/enzimología , Fibrilación Atrial/genética , Citocromo P-450 CYP2D6/genética , Citocromo P-450 CYP2D6/metabolismo , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Polimorfismo Genético/genética , Complicaciones Posoperatorias/enzimología , Complicaciones Posoperatorias/prevención & control , Propafenona/sangre , Taquicardia/enzimología , Taquicardia/genéticaRESUMEN
Starting in November 1999, we performed a left atrial radiofrequency ablation procedure concomitantly to a variety of cardiac surgical procedures. By January 2001, this ablation procedure had been performed on 100 patients (age 65.7 +/- 10.4 years, 53 % male, 47 % female, left atrium 51.0 +/- 7.5 mm) suffering either from chronic or paroxysmal atrial fibrillation. Primary cardiac pathology was mitral valve disease in most cases (43), aortic valve disease (28) or coronary heart disease (27). After bilateral pulmonary veins isolation, an additional ablation line was directed from the left pulmonary veins to the mitral valve annulus (Thermaline probe, Boston Scientific Corporation, USA). Finally, the left atrial appendage was resected. Surgical success was evaluated in the immediate postoperative course, 3 and 6 months postoperatively (ECG and echocardiography), and every year after that. Operative time was 229.7 +/- 56.5 min, ablation time 18.8 +/- 6.9 min. Follow-up is 95 % complete at the time of writing. Mean follow-up time was 7.3 months, ranging from 3 to 23 months. Success (sinus rhythm and atrial contraction) was proven in 72 out of 90 patients (80.0 %) (75.0 % mitral valve surgery, 84.0 % other cardiac surgery). The reported results support a broad spectrum of indications for this left atrial ablation procedure.
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Fibrilación Atrial/cirugía , Ablación por Catéter , Anciano , Apéndice Atrial/cirugía , Estudios de Casos y Controles , Femenino , Estudios de Seguimiento , Atrios Cardíacos/cirugía , Humanos , Masculino , Válvula Mitral/cirugía , Factores de TiempoRESUMEN
BACKGROUND: In this report we address the question whether the Ross operation can be recommended in combined and complicated cardiac procedures. METHODS: From February 1995 to July 2000, we performed 203 Ross operations, 129 with ideal clinical presentation (group 1: mean age 41 +/- 13 years, male 105). In 74 patients, the clinical presentation was complex (group 2: mean age 35 +/- 17 years, male 57), defined as previous aortic or cardiac operations in 32, active endocarditis in 8 or combined procedures in 40 patients. Follow-up is 95 % complete. RESULTS: Neither early mortality nor thromboembolic events were observed. Complications in group 1 vs. group 2 were prolonged ventilation in 1 vs. 1, pacemaker insertion in 1 vs. 2, minor myocardial infarction in none vs. 2 and postoperative bleeds in 2 vs. 3 patients. In group 1, one patient died of hemoptysis at 25 months, and in group 2 one sudden death occurred at 5 months. In the long term, two patients required reoperation for autograft failure in group 1, and one on group 2. Pulmonary stenosis required surgical treatment in one patient of group 2. Echocardiography revealed physiological gradients across the autograft with no significant regurgitation in either group. CONCLUSION: The Ross operation has excellent mid-term results and is a safe and attractive therapeutic approach, both in combined procedures and complex clinical presentations.
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Endocarditis/etiología , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Infecciones Relacionadas con Prótesis/etiología , Estenosis de la Válvula Pulmonar/etiología , Adolescente , Adulto , Anciano , Niño , Preescolar , Terapia Combinada , Ecocardiografía , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Falla de Prótesis , Estenosis de la Válvula Pulmonar/cirugía , Reoperación , Medición de Riesgo , Trasplante Autólogo , Trasplante Homólogo , Resultado del TratamientoRESUMEN
With the introduction of the maze operation Cox was able to show that the surgical treatment of atrial fibrillation (AF) is feasible. However, the maze operation remains surgically demanding and time-consuming as it requires multiple incisions in both atria. This has led to the development of various modifications. With new ablative technology and the acceptable results of an exclusively left atrial maze procedure in combination with mitral valve surgery, it has become possible to simplify the maze operation radically. Thirty-one patients ( mean age 62.3 years) with chronic or intermittent AF underwent a modified radiofrequency procedure in combination with some other cardiac surgical operation. Mitral valve disease coexisted in 17 patients, aortic valve disease in 9, coronary heart disease in 4 patients and 1 had an atrial septal defect (ASD). After left atriotomy and with the use of the Thermaline radiofrequency ablator probe, bilateral pulmonary vein isolation was carried out. An additional ablation line was directed from the left pulmonary veins to the posterior mitral valve annulus, and finally the left atrial appendage was resected. The complete procedure added an average of only 18.2 minutes to the operation. In the early postoperative course AF or atrial flutter recurred in 12 patients but at discharge only 8 patients (24%) still had an arrhythmia. We concentrated on the first 26 patients of our series who had received a follow-up examination 3 months postoperatively. At discharge 18 of the 26 patients were in sinus rhythm (69,2%), and at 3 months after surgery 23 of 26 patients were in sinus rhythm (88.5%), with recovery of atrial contraction confirmed echocardiographically. Only 4 patients still required medication for arrhythmias. The modified radiofrequency ablation procedure of the left atrium proved to be simple to perform, quick and reliable. It offers the possibility of a surgical cure for AF when performed together with another cardiac operation, and the early results indicate a high rate of success for this simple procedure.
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Procedimientos Quirúrgicos Cardíacos , Ablación por Catéter/métodos , Atrios Cardíacos/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/cirugía , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
BACKGROUND: The Ross operation approaches the ideal aortic valve replacement. Between February 1995 and February 2000 we performed 186 procedures. This article reviews modifications introduced reflecting our experience. METHODS: In all patients the Ross operation was performed as root replacement. Echocardiographic follow-up was complete in 94% of patients. RESULTS: No operative death or early mortality occurred, nor did thromboembolic or hemorrhagic events. One patient died at 25 months from hemoptysis with pulmonary valve vegetations. Three patients required reoperation for autograft insufficiency. In 1 patient a tethered cusp was repairable and in 2 patients progressive autograft dilatation required autograft replacement. After routinely incorporating support into the aortic annulus and replacing all dilated ascending aorta, autograft dilatation did not recur. For the pulmonary homograft, one outflow patch was placed to relieve a symptomatic gradient. Nine patients with elevated gradients were under observation. Echocardiography revealed autograft median peak systolic gradients of 4.6+/-2.8 mm Hg, pulmonary homograft gradients of 14.8+/-9.6 mm Hg, and nil or insignificant regurgitation. CONCLUSIONS: The aortic annulus must be supported and the dilated ascending aorta replaced. Root replacement with a short autograft allows consistent results. Pulmonary homograft dysfunction is rare but unpredictable.
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Válvula Aórtica/cirugía , Válvulas Cardíacas/trasplante , Complicaciones Posoperatorias/diagnóstico por imagen , Adolescente , Adulto , Válvula Aórtica/diagnóstico por imagen , Niño , Preescolar , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Trasplante Autólogo , Trasplante Homólogo , Resultado del TratamientoRESUMEN
BACKGROUND: Parental knowledge of their child's heart disease, while often overlooked, contributes to compliance and reduces anxiety. Prior studies have shown that 36% of parental diagnostic descriptions are incorrect. OBJECTIVES: To assess parental knowledge and attitudes among outpatients at a hospital pediatric cardiology clinic. METHODS: Seventy-four families completed a questionnaire in which they described their child's condition and stated their attitude towards dental hygiene and future prenatal diagnosis. RESULTS: Eighteen percent of the parents failed to describe their child's malformation correctly. We found that parental understanding of the heart defect correlated with parental education. Future prenatal diagnosis was considered by 88% of families, and termination of pregnancy by 40%. Only 40% of children were aware of their heart problem. Children of parents who were ignorant about the condition tended to lack knowledge themselves. An additional finding was that 68% of Jewish families turn to non-medical personnel for medical advice--an interesting finding not hitherto addressed. CONCLUSIONS: Ignorance of their child's problem did not correlate with its severity or complexity but rather with parental background: the less educated the parent, the more likely was the problem perceived incorrectly.
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Actitud Frente a la Salud , Conocimientos, Actitudes y Práctica en Salud , Cardiopatías/congénito , Padres/educación , Padres/psicología , Aborto Terapéutico , Adolescente , Adulto , Análisis de Varianza , Ansiedad/etiología , Ansiedad/prevención & control , Niño , Preescolar , Femenino , Cardiopatías/diagnóstico , Humanos , Lactante , Recién Nacido , Israel , Judíos/educación , Judíos/psicología , Masculino , Persona de Mediana Edad , Evaluación de Necesidades , Cooperación del Paciente/psicología , Cooperación del Paciente/estadística & datos numéricos , Embarazo , Diagnóstico Prenatal , Pronóstico , Factores Socioeconómicos , Encuestas y CuestionariosRESUMEN
The prevalence of sleep-disordered breathing has not been well studied in women, especially in terms of the effects of age, body mass index (BMI), and menopause. We evaluated this question using a two-phase random sample from the general population. In Phase I, 12,219 women and 4,364 men ranging in age from 20 to 100 yr were interviewed; and in Phase II, 1,000 women and 741 men of the Phase I subjects were selected for one night of sleep laboratory evaluation. The results of our study indicated that, for clinically defined sleep apnea (apnea/hypopnea index > or = 10 and daytime symptoms), men had a prevalence of 3.9% and women 1.2%, resulting in an overall ratio of sleep apnea for men to women of 3.3:1 (p = 0.0006). The prevalence of sleep apnea was quite low in premenopausal women (0.6%) as well as postmenopausal women with hormone replacement therapy (HRT) (0.5%). Further, in these women the presence of sleep apnea appeared to be associated exclusively with obesity (BMI > or = 32.3 kg/m2). Postmenopausal women without HRT had a prevalence of sleep apnea that was significantly higher than the prevalence in premenopausal women with HRT (2.7 versus 0.6%, p = 0.02) and was more similar to the prevalence in men (3.9%), although it remained significantly less when controlling for age and BMI (p = 0.001). These data combined indicate that menopause is a significant risk factor for sleep apnea in women and that hormone replacement appears to be associated with reduced risk.
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Síndromes de la Apnea del Sueño/epidemiología , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Índice de Masa Corporal , Terapia de Reemplazo de Hormonas , Humanos , Masculino , Menopausia , Persona de Mediana Edad , Análisis Multivariante , Prevalencia , Factores SexualesRESUMEN
A 3-year-old boy with early rupture of an aortic aneurysm due to infantile Marfan's syndrome is presented. In an emergency operation we prepared a composite graft using a 17-mm St. Jude prosthesis with an 18-mm vascular conduit. The postoperative period was complicated by pneumothoraces, transient bilateral phrenic nerve paralysis, cerebral convulsion, and supraventricular tachycardia. Four months postop the composite graft was replaced with an aortic homograft due to severe stenosis. His condition after 12 months is excellent.
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Rotura de la Aorta/etiología , Síndrome de Marfan/complicaciones , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Preescolar , Humanos , Masculino , UltrasonografíaRESUMEN
BACKGROUND AND AIM OF THE STUDY: The Ross operation, introduced more than 30 years ago, has recently undergone several modifications to improve both technical feasibility and results. At the authors' institution, the Ross operation, performed as root replacement in all cases, was commenced in February 1995. METHODS: A total of 225 patients (177 males, 48 females; mean age 39+/-15 years; range: 2 to 67 years) were operated on up to December 2000. Aortic regurgitation was present in 80 patients, stenosis in 69, and combined disease in 73; prostheses were replaced in three patients. Combined procedures were performed in 51 patients. Nine patients had active endocarditis. Follow up was 98% complete and totaled 471 patient-years. RESULTS: There was no early mortality, and no thromboembolic or hemorrhagic events. Complications included prolonged ventilation in two patients, perioperative myocardial infarction in three, pacemaker implants in three and perioperative bleeding in six. One patient died at 25 months from hemoptysis, and one at five months of unknown cause. In the long term, four patients required reoperation due to autograft regurgitation (one autograft repair, three autograft replacements). Routine aortic annulus support, a lowered threshold in replacing all dilated ascending aorta and keeping the autograft short to the level of the sinotubular junction seems to have prevented further autograft failure. Pulmonary homograft stenosis led to reoperation in one patient. Six patients with elevated gradients are currently under observation. Echocardiography revealed autograft median peak gradients of 5.1+/-2.8 mmHg, pulmonary homograft gradients of 14.2+/-11.5 mmHg, and no significant regurgitation, except in one additional patient with recently diagnosed aortic insufficiency (grade >2). CONCLUSION: Mid-term excellent hemodynamic results, low morbidity and reoperation requirement support the evolved root replacement technique and justify its further utilization.
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Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/cirugía , Válvula Pulmonar/trasplante , Adolescente , Adulto , Válvula Aórtica/fisiopatología , Niño , Preescolar , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/fisiopatología , Hemodinámica/fisiología , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Tasa de Supervivencia , Factores de Tiempo , Trasplante Autólogo , Resultado del TratamientoRESUMEN
BACKGROUND: The excellent results of the Cox-Maze-III operation showed that a surgical treatment of atrial fibrillation is possible. The maze operation is surgically demanding and time-consuming. This fact led to the development of simplified modifications. Due to the good results of an exclusive left atrial maze procedure in combination with mitral valve surgery and new technologies of ablation, it seems reasonable to perform these techniques concomitant to cardiac surgery on a large number of patients.¶ METHODS: From November 1999 until June 2000 a modified maze procedure concomitant to a cardiac surgical intervention was performed on 42 patients, with a mean age of 62.2 years, suffering from chronic or intermittent atrial fibrillation. Primary cardiac disease was mainly cardiac valve disease (mitral valve disease 19 patients, aortic valve disease 10 patients) or coronary heart disease (8 patients). After left atriotomy and with the use of the Thermaline probe (Boston Scientific, Corporation, San Jose, California, USA) a bilateral pulmonary veins isolation was carried out by radiofrequency ablation. An additional ablation line was directed from the left pulmonary veins to the posterior mitral valve anulus. Finally, the left atrial appendage was resected. An evaluation of the therapeutic success was carried out in the immediate postoperative course and 3 months after surgery, at that point of time operation-related influences on the refractory period of the atrial myocardium were negligible.¶ RESULTS: At the time of discharge 32 patients (76.2%) showed a regular supraventricular rhythm. Twenty-one patients have already undergone the 3-month follow-up examination. At the time of discharge 13 out of these 21 patients (61.9%) were in sinus rhythm and at 3 months after surgery 18 out of these 21 patients (85.7%) showed a sinus rhythm with a restoration of atrial transport function echocardiographically determined. Three patients were still receiving antiarrhythmic medication.¶ CONCLUSION: The modified maze procedure in combination with cardiac surgical interventions proved to be easy, quick and reliable to perform. The early results suggest a high success rate of this technique. The long-term results have to be verified with further, regular follow-up examinations of the patients.
RESUMEN
Emergency medicine (EM) program directors have expressed a desire for more evaluative data to be included in application materials. This is consistent with frustrations expressed by program directors of multiple specialties, but mostly by those in specialties with more competitive matches. Some of the concerns about traditional narrative letters of recommendation included lack of uniform information, lack of relative value given for interval grading, and a perception of ambiguity with regard to terminology. The Council of Emergency Medicine Residency Directors established a task force in 1995 that created a standardized letter of recommendation form. This form, to be completed by EM faculty, requests that objective, comparative, and narrative information be reported regarding the residency applicant.
Asunto(s)
Correspondencia como Asunto , Medicina de Emergencia/educación , Guías como Asunto , Internado y Residencia , Solicitud de Empleo , Evaluación Educacional , Humanos , Estados UnidosRESUMEN
HISTORY AND ADMISSION FINDINGS: A few days after uneventful surgical reconstruction of the mitral valve a 43-year-old man was found to have a systolic murmur due to prolapse of the posterior leaflet, suggesting renewed mitral regurgitation. INVESTIGATIONS: Echocardiography revealed haemodynamically significant left ventricular outflow tract obstruction (LVOT) with a left ventricle to aorta systolic gradient of 83 mm Hg. In addition there was moderately severe mitral regurgitation as well as a pericardial effusion but no signs of tamponade. TREATMENT AND COURSE: The obstruction was at first treated with verapamil, later with sotalol. The pericardial effusion was interpreted as part of a postcardiotomy syndrome. The effusion regressed under steroid administration, and the LVOT and mitral regurgitation also decreased. A provocation test five months postoperatively no longer brought about an outflow gradient. The good results were still present 12 months postoperatively. CONCLUSION: The described, rarely seen form of LVOT was probably caused by a combination of a very large anterior mitral leaflet, postoperative pericardial effusion and pharmacological effects. If the obstruction first occurs postoperatively, appropriate medication may improve the cardiac status and reoperation may be avoided. Echocardiography is an important method of diagnosis and serial monitoring.