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Background: Leishmania is the parasitic protozoan responsible for leishmaniases, a disease that can cause a range of cutaneous, mucosal, and visceral infections. Two subgenera L. Viannia and L. Leishmania are known to infect humans in the tropics and subtropics of the Americas. The aim of the present study was to develop a new pair of primers for the two subgenera and test in clinical samples. Methods: We designed two new pairs of primers for a PCR method from two conserved genes, cysteine proteinase B (cpb) and N-acetylglucosamine-6-phosfate deacetylase-like protein (nagA), as specific markers for those two respective subgenera. Primers were tested with 16 microscopical positive clinical samples from the Amazon region of Ecuador obtained in 2010-2020 period. Results: The cpb presented a band of 172 bp and the nagA a band of 300 bp, thus clearly differentiating L. viannia from L. leishmania. Additionally, primers identified and differentiated the clinical samples in the two subgenera. Conclusion: The new primers targeting different two genes and standardized in a PCR assay could identified and differentiated Leishmania parasites at subgenus level. This protocol could be used for Leishmania genus identification and diagnosis at the subgenus level and for determining the parasite's geographical distribution where different Leishmania subgenera are found in the same area.
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Objective: The study objective was to evaluate the safety and clinical and echocardiographic outcomes of a new surgical technique in adult patients diagnosed with a giant left atrium. Methods: We analyzed a cohort of patients who underwent left atrium reduction surgery between January 2016 and June 2020 performed by a specialized surgical team in 2 national reference centers in Lima, Peru. We assessed the major adverse valvular-related events and the New York Heart Association functional class as primary clinical outcomes. Also, our primary echocardiographic endings were the diameter, area, and volume of the left atrium. We assessed these variables at 3 time periods: baseline (t0), perioperative period (t1), and extended follow-up (t2: 12 ± 3.4 months). We carried out descriptive and bivariate exploratory statistical analysis for dependent measures. Results: We included 17 patients, 70.6% of whom were women. Rheumatic mitral valve disease (76.5%) was the main etiology. We performed 14 (82.4%) mitral valve replacements and 3 repairs. Major adverse valvular-related events occurred in 1 patient (5.9%) (hemorrhagic stroke) at t1. A significant reduction in the size of the left atrium was observed: diameter (77 mm vs 48 mm, P < .001), area (75 cm2 vs 31 cm2, P < .001), and volume (332 cm3 vs 90 cm3, P < .001). Compared with t0 and t1, these echocardiographic findings remained without significant changes during t2. Conclusions: Our surgical left atrium reduction technique was associated with improved clinical functionality and reduced left atrium measures in patients with a giant left atrium undergoing mitral valve surgery.
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Background: Fibroid is the most prevalent benign tumor of the female genital tract. Intravenous and intracardiac leiomyomatosis (IVL and ICLM, respectively) are rare complications that present with symptoms of pulmonary thromboembolism and heart failure and whose etiology, despite controversial, is a direct vascular invasion by a primary uterine leiomyoma. Case presentation: We present the case of a 31-year-old female patient with a previous history of pelvic pain and dysmenorrhea, whose ultrasound showed an enlarged and heterogeneous uterus. Complete hysterectomy was performed, and the anatomopathological examination showed leiomyomas without evidence of malignancy. One month later, the patient manifested dyspnea and chest pain. A neoplastic thrombus was identified, extending from the inferior vena cava to the right atrium, for which we proceeded with cavo-atrial thrombectomy under Normothermic Cardiopulmonary Bypass (CPB) with Warm Blood Cardioplegia (WBC). A metastatic lung injury of non-malignant histology was also detected. Discussion: Uterine leiomyoma is a very common benign tumor of the female genital tract. IVL with ICLM are rare and difficult-to-treat complications, whose etiology is a direct vascular invasion by a primary uterine leiomyoma, although it is still controversial. The incidence of ICLM is 10 to 30% of IVL cases. The main symptoms of ICLM are dyspnea, syncope, edema of the lower extremities and palpitations. Treatment is based on complete surgical removal of the tumor thrombus. Studies demonstrated that the one-stage procedure is safer from the patient's perspective and that CPB with WBC reduced intraoperative blood loss and total operative time, ensuring a less traumatic postoperative. Conclusions: Most patients with uterine leiomyoma are asymptomatic and acute complications are rare. In ICLM clinical manifestations are related to heart failure and flow obstruction. Because of the severity of the condition and the curative potential of treatment, surgery is morbid but highly recommended. The use of CPB with WBC improved the postoperative period and increased the patient's quality of life.
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Abstract Introduction: Halting ventilation during cardiopulmonary bypass (CPB) is implemented to operate in a less bleeding setting. It sustains a better visualization of the operation area and helps to perform the operation much more comfortably. On the other hand, it may lead to a series of postoperative lung complications such as atelectasis and pleural effusion. In this study, we investigated the effects of low tidal volume ventilation on inflammatory cytokines during CPB. Methods: Twenty-eight patients undergoing cardiovascular surgery were included in the study. Operation standards and ventilation protocols were determined and patients were divided into two groups: patients ventilated with low tidal volume and non-ventilated patients. Plasma samples were taken from patients preoperatively, perioperatively from the coronary sinus and postoperatively after CPB. IL-6, IL-8, TNF-α and C5a levels in serum samples were studied with enzyme-linked immunosorbent assay (ELISA) kits. Results: C5a, IL-6, IL-8 and TNF-α were similar when compared to the low tidal volume ventilated and non-ventilated groups (P>0.05) Comparing the groups by variables, IL-6 levels were increased during CPB in both groups (P=0.021 and P=0.001), and IL-8 levels decreased in the ventilation group during CPB (P=0.018). Conclusion: Our findings suggest that low tidal volume ventilation may reduce the inflammatory response during CPB. Although the benefit of low tidal volume ventilation in CPB has been shown to decrease postoperative lung complications such as pleural effusion, atelectasis and pneumonia, we still lack more definitive and clear proofs of inflammatory cytokines encountered during CPB.
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INTRODUCTION: Halting ventilation during cardiopulmonary bypass (CPB) is implemented to operate in a less bleeding setting. It sustains a better visualization of the operation area and helps to perform the operation much more comfortably. On the other hand, it may lead to a series of postoperative lung complications such as atelectasis and pleural effusion. In this study, we investigated the effects of low tidal volume ventilation on inflammatory cytokines during CPB. METHODS: Twenty-eight patients undergoing cardiovascular surgery were included in the study. Operation standards and ventilation protocols were determined and patients were divided into two groups: patients ventilated with low tidal volume and non-ventilated patients. Plasma samples were taken from patients preoperatively, perioperatively from the coronary sinus and postoperatively after CPB. IL-6, IL-8, TNF-α and C5a levels in serum samples were studied with enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: C5a, IL-6, IL-8 and TNF-α levels were similar when compared to the low tidal in volume ventilated and non-ventilated groups (P>0.05). Comparing the groups by variables, IL-6 levels were increased during CPB in both groups (P=0.021 and P=0.001), and IL-8 levels decreased in the ventilation group during CPB (P=0.018). CONCLUSION: Our findings suggest that low tidal volume ventilation may reduce the inflammatory response during CPB. Although the benefit of low tidal volume ventilation in CPB has been shown to decrease postoperative lung complications such as pleural effusion, atelectasis and pneumonia, we still lack more definitive and clear proofs of inflammatory cytokines encountered during CPB.
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Derrame Pleural , Atelectasia Pulmonar , Humanos , Puente Cardiopulmonar , Volumen de Ventilación Pulmonar , Citocinas , Factor de Necrosis Tumoral alfa , Interleucina-6 , Puente de Arteria Coronaria , Interleucina-8 , Pulmón , Complicaciones Posoperatorias/prevención & controlRESUMEN
Primary cardiac sarcomas are very aggressive, being a challenge to cardio-oncology specialty. Surgical planning and innovative techniques have enhanced the possibility of resection. We have described a case of recurrent primary left atrium angiosarcoma, successfully resected with a modified partial autotransplantation technique, planned using a 3-dimensional model created from computed tomography. (Level of Difficulty: Intermediate.).
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Objective: Temperature during cardiopulmonary bypass (CPB) for cardiac surgery has been controversial. The aim of the current study is to compare the outcomes for patients with mild hypothermia versus normothermic CPB temperatures. Methods: All patients who underwent cardiac surgery with CPB and temperatures ≥32°C from 2011 to 2018 were included, which consisted of mild hypothermia (32°C-35°C) and normothermia (>35°C) cohorts. Propensity matching (1:1) was performed for risk adjustment. Primary outcomes included operative and long-term survival. Secondary outcomes included postoperative complications. Results: A total of 6525 patients comprised 2 cohorts: mild hypothermia (32°C-35°C; n = 3148) versus normothermia (>35°C; n = 3377). Following adjustment for surgeon preference, there were 1601 propensity-matched patients who had similar baseline characteristics (standard mean difference, ≤0.10), including CPB time, crossclamp time, and intra-aortic balloon pump placement. Kaplan-Meier analysis showed no difference in long-term survival (82.6% vs 81.6%; P = .81). Over a median follow-up of 4.4 years, there were no differences in overall mortality (18.1% vs 18.1%; P = 1.1) or readmission (50.3% vs 48.3%; P = .2). Acute renal failure (3.7% vs 2.4%; P = .03) and intensive care unit hours (46.5 vs 45.1; P = .04) were significantly higher with hypothermia. There was no difference between cohorts for postoperative stroke (2.0% vs 2.0%; P = 1.0), reoperation (5.9% vs 6.0%; P = .9), or operative intra-aortic balloon pump placement (1.7% vs 1.8%; P = .9). Conclusions: Patients with mild hypothermia during CPB had increased postoperative renal failure and length of intensive care unit stay. Although there was no difference in long-term survival, mild hypothermia does not appear to offer patients appreciable benefits, compared with normothermia.
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BACKGROUND: Acute Kidney Injury is a complication in children with heart disease undergoing cardiac surgery with cardiopulmonary bypass. The aim of this study is to describe the behavior of KIM-1 (Kidney Injury Molecule) and NGAL (Neutrophil Gelatinase Associated Lipocalin) as early predictors of renal damage, comparing them with serum creatinine and creatinine clearance, in neonates undergoing cardiac surgery. METHODS: Twenty-one (21) neonates, under 4 kg, with complex congenital heart diseases, RACHS-1 > 3, without preoperative renal failure, were studied. Serum creatinine and creatinine clearance were measured preoperatively and at 24, 48, 72, 96 hours postoperatively. Urinary samples of KIM-1(pg/ml) and NGAL (ng/ml) were collected after induction of anesthesia at 24 and 48 hours post-operatively. RESULTS: nRIFLE criteria were used to divide cohorts in "NO AKI" (12 patients) and "AKI" (nine patients). In the AKI group, serum creatinine increased significantly and creatinine clearance decreased significantly at 24, 48, and 72 hours compared with their respective baseline values. There was no difference in KIM-1 and NGAL values between patients who developed AKI and those who did not at any measured time. CONCLUSIONS: The deterioration of renal function continues to be one of the most frequent complications in this population. In our study, biomarkers did not show any correlation with the appearance of AKI. It remains to be seen whether this behavior of the biomarkers is linked with the non-consistent release of these types of molecules in immature kidneys. It is likely that a larger panel of biomarkers together with other glomerular filtration rate assessment methods will provide more information about AKI diagnosis.
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Lesión Renal Aguda , Procedimientos Quirúrgicos Cardíacos , Lesión Renal Aguda/diagnóstico , Lesión Renal Aguda/etiología , Proteínas de Fase Aguda , Biomarcadores , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Niño , Creatinina , Humanos , Recién Nacido , Riñón/fisiología , Lipocalina 2 , Valor Predictivo de las Pruebas , Proteínas Proto-OncogénicasRESUMEN
Unlike other HCP metals such as titanium and magnesium, the behavior of zinc alloys has only been modeled in the literature. For the low Zn-Cu-Ti alloy sheet studied in this work, the anisotropy is clearly seen on the stress-strain curves and Lankford coefficients. These features impose a rigorous characterization and an adequate selection of the constitutive model to obtain an accurate representation of the material behavior in metal forming simulations. To describe the elastoplastic behavior of the alloy, this paper focuses on the material characterization through the application of the advanced Cazacu-Plunket-Barlat 2006 (CPB-06 for short) yield function combined with the well-known Hollomon hardening law. To this end, a two-stage methodology is proposed. Firstly, the material characterization is performed via tensile test measurements on sheet samples cut along the rolling, diagonal and transverse directions in order to fit the parameters involved in the associate CPB-06/Hollomon constitutive model. Secondly, these material parameters are assessed and validated in the simulation of the bulge test using different dies. The results obtained with the CPB-06/Hollomon model show a good agreement with the experimental data reported in the literature. Therefore, it is concluded that this model represents a consistent approach to estimate the behavior of Zn-Cu-Ti sheets under different forming conditions.
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OBJECTIVE: The goal of the present study was to compare the myocardial protection obtained with histidine-tryptophan-ketoglutarate (HTK) cardioplegic solution (Custodiol®) and with intermittent hypothermic blood solution. METHODS: Two homogenous groups of 25 children with acyanotic congenital heart disease who underwent total correction with mean aortic clamping time of 60 minutes were evaluated in this randomized study. Troponin and creatine kinase-MB curves, vasoactive-inotropic score, and left ventricular function were obtained by echocardiogram in each group. The values were correlated and presented through graphs and tables after adequate statistical treatment. RESULTS: It was observed that values of all the studied variables varied over time, but there was no difference between the groups. CONCLUSION: We conclude that in patients with acyanotic congenital cardiopathies submitted to total surgical correction, mean aortic clamping time around one hour, and cardiopulmonary bypass with moderate hypothermia, the HTK crystalloid cardioplegic solution offers the same myocardial protection as the cold-blood hyperkalemic cardioplegic solution analyzed, according to the variables considered in our study model.
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Soluciones Cardiopléjicas/uso terapéutico , Cardiopatías Congénitas/cirugía , Análisis de Varianza , Forma MB de la Creatina-Quinasa/análisis , Método Doble Ciego , Ecocardiografía , Femenino , Glucosa/uso terapéutico , Cardiopatías Congénitas/fisiopatología , Humanos , Lactante , Recién Nacido , Masculino , Manitol/uso terapéutico , Tempo Operativo , Cloruro de Potasio/uso terapéutico , Procaína/uso terapéutico , Estudios Prospectivos , Sustancias Protectoras/uso terapéutico , Valores de Referencia , Reproducibilidad de los Resultados , Estadísticas no Paramétricas , Factores de Tiempo , Resultado del Tratamiento , Troponina/análisis , Función Ventricular IzquierdaRESUMEN
Abstract Objective: The goal of the present study was to compare the myocardial protection obtained with histidine-tryptophan-ketoglutarate (HTK) cardioplegic solution (Custodiol®) and with intermittent hypothermic blood solution. Methods: Two homogenous groups of 25 children with acyanotic congenital heart disease who underwent total correction with mean aortic clamping time of 60 minutes were evaluated in this randomized study. Troponin and creatine kinase-MB curves, vasoactive-inotropic score, and left ventricular function were obtained by echocardiogram in each group. The values were correlated and presented through graphs and tables after adequate statistical treatment. Results: It was observed that values of all the studied variables varied over time, but there was no difference between the groups. Conclusion: We conclude that in patients with acyanotic congenital cardiopathies submitted to total surgical correction, mean aortic clamping time around one hour, and cardiopulmonary bypass with moderate hypothermia, the HTK crystalloid cardioplegic solution offers the same myocardial protection as the cold-blood hyperkalemic cardioplegic solution analyzed, according to the variables considered in our study model.
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Humanos , Masculino , Femenino , Recién Nacido , Lactante , Soluciones Cardiopléjicas/uso terapéutico , Cardiopatías Congénitas/cirugía , Cloruro de Potasio/uso terapéutico , Procaína/uso terapéutico , Valores de Referencia , Factores de Tiempo , Troponina/análisis , Ecocardiografía , Método Doble Ciego , Estudios Prospectivos , Reproducibilidad de los Resultados , Análisis de Varianza , Función Ventricular Izquierda , Resultado del Tratamiento , Estadísticas no Paramétricas , Sustancias Protectoras/uso terapéutico , Forma MB de la Creatina-Quinasa/análisis , Tempo Operativo , Glucosa/uso terapéutico , Cardiopatías Congénitas/fisiopatología , Manitol/uso terapéuticoAsunto(s)
Puente Cardiopulmonar , Ultrafiltración , Procedimientos Quirúrgicos Cardíacos , Niño , Corazón , HumanosRESUMEN
Doenças causadas por agentes infecciosos e parasitários são chamadas negligenciadas por não despertarem interesse das indústrias farmacêuticas para o desenvolvimento de novas alternativas terapêuticas. Essas doenças são responsáveis por levar milhões de pessoas à morte todos os anos e afetam principalmente os países pobres e em desenvolvimento. Dentre estas, a doença de Chagas e as leishmanioses, parasitoses causadas por parasitas flagelados pertencentes à família Trypanosomatidae, T. cruzi e Leishmaina sp., respectivamente, se apresentam como um sério problema de saúde pública mundial. Endêmicas em vários países e causando milhões de mortes anualmente, ainda hoje não existem fármacos eficientes e seguros para o tratamento dessas doenças. Este panorama torna eminente a necessidade de pesquisa e desenvolvimento de novos fármacos para essas parasitoses. A busca por agentes quimioterápicos envolve a seleção de vias metabólicas essenciais à sobrevivência dos parasitas. Dentre estas, destacamse cisteíno-proteases presentes nesses tripanossomatídeos, deste modo a cruzaína no T. cruzi, e a CPB2.8 na Leishmania mexicana, se mostram como alvos bioquímicos promissores. A disponibilidade de estruturas cristalográficas da cruzaína e do sequenciamento genômico da CPB2.8, nos permite utilizar estratégias de planejamento de fármacos baseado no receptor (SBDD) na identificação de candidatos a fármacos para essas doenças. Entre as técnicas modernas de SBDD utilizadas, a triagem virtual possibilita identificar promissores candidatos a novos fármacos. Assim neste trabalho, obteve-se por meio da técnica de modelagem comparativa o modelo da enzima CPB2.8 de L. mexicana, visto a indisponibilidade da estrutura cristalográfica no Protein Data Bank (PDB). De modo a refinar o modelo construído realizou-se a simulação por dinâmica molecular de 100ns, apresentando estabilização a partir de 80ns. A simulação por dinâmica molecular foi validada por meio do gráfico de Ramachandran, gráfico de raio de giro, RMSD, gráfico de superfície hidrofóbica. Foram calculados os mapas de interação molecular no programa GRID das seguintes proteínas: cruzaína, CPB2.8, catepsina B e catepsina L, e, posteriormente, foi construído um modelo farmacofórico baseado no sítio ativo das enzimas cruzaína e CPB2.8. O modelo farmacofórico da cruzaína foi validado por curva ROC apresentando valor de AUC 61%. A triagem virtual foi realizada para ambas as proteínas e foram obtidos 369 compostos para a cuzaína e 225 compostos para a CPB2.8. Foi realizado o ancoramento molecular desses compostos obtidos pela triagem virtual a fim de diminuir a quantidade de compostos a serem avaliados experimentalmente
Neglected diseases are caused by parasites and infectious agents and affect mainly people in poor areas being prevalent in 149 countries and causing 534,000 deaths per year. Among neglected diseases we can highlight Chagas Disease and Leishmaniasis, both have a high rate of morbidity and mortality and both are addressed in this project in the search of new drugs against a NTD. Nowadays, the search for new drugs involves the selection of biological pathways essential for parasite survival, in this class of parasites we can suggest the cysteine proteases, a proteases family present in Trypanosoma cruzi and and Leishmania ssp. In order to obtain a new agent against Neglected Disease in this work was obtained the model of the enzyme CPB2.8 of L. mexicana using the comparative modeling technique, due to the unavailability of the crystallographic structure in the Protein Data Bank (PDB). In order to refine the constructed model was performed the molecular dynamics simulation of 100ns, stabilization was achieved from 80ns. Molecular dynamics simulation was validated using the Ramachandran graph, radius of rotation graph, RMSD, hydrophobic surface area graph. The molecular interaction fields were calculated in the GRID program to cruzain, CPB2.8, cathepsin B and cathepsin L. Based on molecular interaction fields generated pharmacophoric models were constructed using information about the active site of the enzymes cruzain and CPB2.8. The pharmacophoric model of cruzain was validated by ROC curve presenting AUC value of 61%. Virtual screening was performed for both proteins and 369 compounds were obtained for cuzain and 225 compounds for CPB2.8. Docking studies of these compounds was performed in order to decrease the amount of compounds to be evaluated experimentally
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Trypanosoma cruzi/clasificación , Triaje , Proteasas de Cisteína/análisis , Enfermedades Desatendidas/prevención & control , Preparaciones Farmacéuticas , Trypanosomatina/clasificación , Descubrimiento de Drogas , Leishmania/clasificaciónRESUMEN
OBJECTIVE: To identify preoperative predictors of extracorporeal support in patients with pulmonary hypertension (PH) undergoing bilateral sequential lung transplantation (LTx), and to examine outcomes associated with the use of extracorporeal support. DESIGN: Retrospective, observational study. SETTING: Single organ transplantation and tertiary care university medical center. PARTICIPANTS: Adults with PH (preoperative mean pulmonary artery pressure (mPAP)≥25 mmHg) who underwent primary bilateral sequential LTx during 2007 to 2013. MEASUREMENTS AND MAIN RESULTS: Of 262 patients with PH undergoing LTx, extracorporeal support was initiated intraoperatively in 149 (57%). Preoperative severe right ventricle (RV) dysfunction and moderate or severe tricuspid regurgitation (TR) were associated with extracorporeal support. In the remaining 208 patients without those factors, increasing preoperative oxygen requirement (odds ratio [OR] 1.30 per 1 L/min, 95% confidence intervals [CI] 1.11-1.52, p = 0.001), presence of RV dilation (OR 2.77, 95% CI 1.28-6.02, p = 0.010), and mPAP (OR 1.33 per 5-mmHg increase in mPAP, 95% CI 1.04-1.70, p = 0.021) were associated independently with extracorporeal support in the multivariable model. Analysis of 49 propensity-matched pairs showed longer intensive care unit (5 v 14 days, p = 0.006) and hospital stays (27 v 39 days, p = 0.016) and increased need for tracheostomy (16% v 41%, p = 0.017) in patients exposed to extracorporeal support but no differences in 30-day mortality, stroke, myocardial infarction, or dialysis. CONCLUSIONS: Severity of RV dysfunction, TR, RV dilatation, increasing oxygen requirement, and increasing mPAP showed significant associations with the need for extracorporeal support during LTX in patients with PH. Extracorporeal support was associated with increased length of stay and tracheostomy but not with mortality or other complications. © 2016 Elsevier Inc. All rights reserved.
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Hipertensión Pulmonar/cirugía , Tiempo de Internación/tendencias , Trasplante de Pulmón/tendencias , Diálisis Renal/tendencias , Anciano , Femenino , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/epidemiología , Trasplante de Pulmón/efectos adversos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Diálisis Renal/métodos , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Disfunción Ventricular Derecha/diagnóstico , Disfunción Ventricular Derecha/epidemiología , Disfunción Ventricular Derecha/cirugíaRESUMEN
"New Breeding Techniques" (NBTs) are a group of recent innovations in plant breeding using molecular biology tools. It is becoming evident that NBTs can introduce advantageous traits for agriculture that could be commercially available very soon However, there is still a need of clarifying its regulatory status, particularly in regards to worldwide regulations on Genetically Modified Organisms (GMOs). This article reviews the meaning of the NBTs concept, performs an overall regulatory analysis of these technologies and reports the first regulation in the world that is applied to these technologies, which was issued by the Argentine Government.
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Agricultura/legislación & jurisprudencia , Cruzamiento/legislación & jurisprudencia , Ingeniería Genética/legislación & jurisprudencia , Organismos Modificados Genéticamente , Agricultura/métodos , Agricultura/tendencias , Argentina , Cruzamiento/métodos , Ingeniería Genética/métodos , Variación Genética , Regulación Gubernamental , SeguridadRESUMEN
OBJECTIVES: The technical difficulty in the revascularization of the circumflex artery territory with off-pump surgery may compromise the outcome of this method in clinical follow-up. We aimed to evaluate cardiac events in patients with stable coronary artery disease and severe obstruction of the circumflex system, undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass. METHODS: MASS III was a single-centre study that evaluated 308 patients with multivessel coronary artery disease randomized to on-pump (153) or off-pump (155) CABG. Of this total, 260 (84.4%) patients had, on coronary angiography, at least one 70% obstruction in the circumflex territory (141 on-pump and 119 off-pump). The combined outcome was death, myocardial infarction, target vessel revascularization (angioplasty or surgery) or hospitalization for cardiac causes. Variables with possible associations (P < 0.1) were included in the multivariate analysis. RESULTS: The two groups were well matched for demographics and clinical and angiographic characteristics. After 5 years of follow-up, off-pump CABG had higher combined events than on-pump had: 25 (21%) vs 17 (12%), hazard ratio 1.88, 95% confidence interval 1.02-3.48, P = 0.041. In the multivariate model with the inclusion of the following variables: age (P = 0.09) and complete revascularization (P = 0.68), off-pump surgery remained as a predictor of combined events in 5 years, P = 0.03. CONCLUSIONS: In patients with multivessel coronary artery disease and severe lesions in the circumflex territory, off-pump coronary artery bypass surgery resulted in a higher incidence of cardiac events at 5-year follow-up. CLINICAL TRIAL REGISTRATION NUMBER: ISRCTN59539154 (http://www.controlled-trials.com).
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Puente de Arteria Coronaria Off-Pump/métodos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Anciano , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Complicaciones PosoperatoriasRESUMEN
OBJECTIVES: Cardiovascular complications are a major cause of morbidity and mortality among renal transplant recipients. This study assessed perioperative risk factors for mortality and long-term outcomes in renal transplant recipients who underwent cardiac surgery. METHODS: From 1999 to 2010, 92 renal transplant recipients with a functioning allograft underwent cardiac surgery at our institution. Cardiac procedures included coronary artery bypass grafting (43 patients, 46%), isolated valve surgery (17 patients, 18%), combined coronary artery bypass grafting and valve surgery (18 patients, 19%), and aortic procedures (7 patients, 7%). RESULTS: Transient renal failure requiring dialysis occurred in 20 of 92 patients (21%), with 3 not recovering renal function and returning to a permanent dialysis regimen while in the hospital. After cardiac surgery 30-day, 1-year, 5-year, and 8-year survival rates were 89%, 72%, 47%, and 30%, respectively. Freedom from dialysis was 90% after 1 year, 66% after 5 years, and 49% after 8 years. Risk factors for 30-day mortality were age > 65 years, left ventricle ejection fraction < 35%, and a combined cardiac procedure. Pulmonary hypertension and diabetes were risk factors for death from a cardiac cause after discharge. Diabetes, dyslipidemia, preoperative use of an intra-aortic balloon pump, postoperative creatinine > 2 mg/dL, and transient renal failure requiring dialysis were associated with a permanent dialysis requirement after cardiac surgery. CONCLUSIONS: Cardiac surgery in patients receiving renal transplant who have functioning allograft has acceptable outcomes. If combined procedures are required, patients should be carefully considered. Transient postoperative renal impairment, even if resolved at discharge, increases the risk for allograft failure during long-term follow-up.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Supervivencia de Injerto , Trasplante de Riñón/efectos adversos , Insuficiencia Renal/etiología , Anciano , Procedimientos Quirúrgicos Cardíacos/mortalidad , Femenino , Tasa de Filtración Glomerular , Supervivencia de Injerto/efectos de los fármacos , Humanos , Inmunosupresores/uso terapéutico , Estimación de Kaplan-Meier , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Análisis Multivariante , Selección de Paciente , Modelos de Riesgos Proporcionales , Recuperación de la Función , Diálisis Renal , Insuficiencia Renal/mortalidad , Insuficiencia Renal/fisiopatología , Insuficiencia Renal/terapia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The objective of this study was to determine the association between preoperative nutritional status and postoperative outcomes in children undergoing surgery for congenital heart defects (CHD). METHODS: Seventy-one patients with CHD were enrolled in a prospective, 2-center cohort study. We adjusted for baseline risk differences using a standardized risk adjustment score for surgery for CHD. We assigned a World Health Organization z score for each subject's preoperative triceps skin-fold measurement, an assessment of total body fat mass. We obtained preoperative plasma concentrations of markers of nutritional status (prealbumin, albumin) and myocardial stress (B-type natriuretic peptide [BNP]). Associations between indices of preoperative nutritional status and clinical outcomes were sought. RESULTS: Subjects had a median (interquartile range [IQR]) age of 10.2 (33) months. In the University of California at San Francisco (UCSF) cohort, duration of mechanical ventilation (median, 19 hours; IQR, 29 hours), length of intensive care unit stay (median, 5 days; IQR 5 days), duration of any continuous inotropic infusion (median, 66 hours; IQR 72 hours), and preoperative BNP levels (median, 30 pg/mL; IQR, 75 pg/mL) were associated with a lower preoperative triceps skin-fold z score (P < .05). Longer duration of any continuous inotropic infusion and higher preoperative BNP levels were also associated with lower preoperative prealbumin (12.1 ± 0.5 mg/dL) and albumin (3.2 ± 0.1; P < .05) levels. CONCLUSIONS: Lower total body fat mass and acute and chronic malnourishment are associated with worse clinical outcomes in children undergoing surgery for CHD at UCSF, a resource-abundant institution. There is an inverse correlation between total body fat mass and BNP levels. Duration of inotropic support and BNP increase concomitantly as measures of nutritional status decrease, supporting the hypothesis that malnourishment is associated with decreased myocardial function.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Trastornos de la Nutrición del Niño/complicaciones , Fenómenos Fisiológicos Nutricionales Infantiles , Cardiopatías Congénitas/cirugía , Trastornos de la Nutrición del Lactante/complicaciones , Desnutrición/complicaciones , Estado Nutricional , Complicaciones Posoperatorias/etiología , Adiposidad , Biomarcadores/sangre , Procedimientos Quirúrgicos Cardíacos/mortalidad , Cardiotónicos/uso terapéutico , Trastornos de la Nutrición del Niño/diagnóstico , Trastornos de la Nutrición del Niño/mortalidad , Trastornos de la Nutrición del Niño/fisiopatología , Preescolar , Femenino , Guatemala , Cardiopatías Congénitas/complicaciones , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/fisiopatología , Humanos , Lactante , Trastornos de la Nutrición del Lactante/diagnóstico , Trastornos de la Nutrición del Lactante/mortalidad , Trastornos de la Nutrición del Lactante/fisiopatología , Recién Nacido , Tiempo de Internación , Modelos Lineales , Modelos Logísticos , Masculino , Desnutrición/diagnóstico , Desnutrición/mortalidad , Desnutrición/fisiopatología , Análisis Multivariante , Péptido Natriurético Encefálico/sangre , Proyectos Piloto , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Prealbúmina/análisis , Estudios Prospectivos , Respiración Artificial , Factores de Riesgo , San Francisco , Albúmina Sérica/análisis , Albúmina Sérica Humana , Grosor de los Pliegues Cutáneos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: To describe the off-label use of antithrombin concentrate in tertiary care pediatric hospitals across the US. STUDY DESIGN: This is a retrospective, multicenter, cohort study of 4210 admissions of children younger than 18 years of age who received antithrombin concentrate between 2002 and 2011 within the Pediatric Health Information System administrative database. An on-label admission was defined as an admission with an International Classification of Diseases diagnostic code for a primary hypercoagulable state; admissions without this code were classified as off-label. RESULTS: During the 10-year study period, off-label use of antithrombin concentrate increased 5-fold. Overall, 97% of study subjects received antithrombin off-label. Neonates younger than 30 days of age comprised the largest age group (45.7%) of use; 87% of patients had at least one complex chronic condition, with congenital heart/lung defects being the most prevalent primary diagnosis (36.3%). Extracorporeal membrane oxygenation was the most common procedure associated with antithrombin use (43.7%). CONCLUSIONS: The off-label use of antithrombin concentrate is increasing rapidly, particularly in critically ill children receiving extracorporeal membrane oxygenation, with few parallel studies to substantiate its safety or efficacy. Further preclinical and controlled clinical studies are critical to expanding our knowledge of this drug. In the meantime, antithrombin concentrate should be used judiciously by clinicians and following guidelines instated by hospitals.
Asunto(s)
Antitrombinas/uso terapéutico , Uso Fuera de lo Indicado , Adolescente , Niño , Preescolar , Estudios de Cohortes , Femenino , Cardiopatías Congénitas/tratamiento farmacológico , Hospitales Pediátricos , Humanos , Lactante , Recién Nacido , Enfermedades Pulmonares/congénito , Enfermedades Pulmonares/tratamiento farmacológico , Masculino , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
OBJECTIVE: Although hyperlactatemia after cardiac surgery is common, the implications of raised levels remain controversial. The aim of this study was to evaluate whether high lactate levels after cardiac surgery are predictors of major complications including mortality. PATIENTS AND METHODS: This was a substudy of TRACS (Transfusion Requirements After Cardiac Surgery), which was designed as a prospective, randomized, controlled trial evaluating the effects of a transfusion strategy on morbidity and mortality. RESULTS: Of the 502 patients enrolled, 52 (10%) had at least 1 major complication. Patients with complications were older, had a higher EuroSCORE, lower left ventricular ejection fraction, lower preoperative hemoglobin, a higher prevalence of renal disease, and received more blood transfusions than the group without complications. Lactate levels were higher in the group with complications at the end of surgery (3.6 mmol/L [2.8-5.1] vs 3.3 mmol/L [2.2-4.8]; P = .018), immediately after intensive care unit (ICU) admission (0 hour) (4.4 mmol/L [3.1-8.4] vs 4 mmol/L [2.6-6.4]; P = .048); 6 hours (4 mmol/L [2.7-5.8] vs 2.6 mmol/L [2-3.6], P < .001), and 12 hours after admission (2.3 mmol/L [1.8-3.2] vs 1.7 mmol/L [1.3-2]; P < .001). In a multivariate model, higher age (odds ratio [OR], 1.048, 95% confidence interval [CI], 1.011-1.086; P = .010), left ventricular ejection fraction (LVEF) lower than 40% (OR, 3.03; 95% CI, 1.200-7.510; P = .019 compared with LVEF of 40%-59%; OR, 3.571; 95% CI, 1.503-8.196; P = .004 compared with LVEF higher than 60%), higher EuroSCORE (OR, 1.138; 95% CI; 1.007-1.285; P = .038), red blood cell transfusion (OR, 1.230; 95% CI, 1.086-1.393; P = .001), and lactate levels 6 hours after ICU admission (OR, 3.28, 95% CI; 1.61-6.69; P = .001) are predictors of major complications. CONCLUSIONS: Hyperlactatemia 6 hours after ICU admission is an independent risk factor for worse outcomes in adult patients after cardiac surgery.