RESUMO
BACKGROUND: COPD exacerbations have negative impact on patients' survival. Several risk factors for grave outcomes of such exacerbations have been descried. Muscle dysfunction and mass loss were shown to impact negatively on prognosis and survival. Low activity of the enzyme ALT (Alanine amino-transferase) in the blood is a known indicator for sarcopenia and frailty, however, no previous studies addressed the association of low ALT amongst patients hospitalized due to COPD exacerbation and long-term survival. METHODS: This is a historic prospective cohort study of patients hospitalized due to acute COPD exacerbation. RESULTS: Included were 232 consecutive COPD exacerbation patients. The median time of follow-up was 34.9 months (IQR 23.13-41.73 months). During this period 104 (44.8%) patients died. All patients were grouped to quartiles according to blood ALT levels (after exclusion of cases considered to have hepatic tissue damage (ALT > 40 IU)). The risk of long-term mortality increased, in a statistically significant manner, amongst patients with low ALT values: the median survival of patients with ALT < 11 IU was 18.5 months only while the median survival for the rest of the study group was not reached. For ALT < 11 IU; 12-16 IU; 17-20 IU and > 21 IU the mortality rates were 69%; 40.9%; 36.3 and 25% respectively (p < 0.001 for comparison of lower quartile with upper three quartiles). The crude hazard ratio for mortality amongst patients with ALT levels lower than 11 IU was 2.37 (95% CI; 1.6-3.5). This increased risk of mortality remained significant after adjustment for age, weight, creatinine, albumin concentration and cardiovascular diseases (HR = 1.83; 95% CI 1.08-3.1, p < 0.05). CONCLUSIONS: Low ALT values, a biomarker of sarcopenia and frailty, are associated with poor long-term survival amongst patients hospitalized due to COPD exacerbation.
Assuntos
Alanina Transaminase/sangue , Fragilidade/enzimologia , Doença Pulmonar Obstrutiva Crônica/enzimologia , Sarcopenia/enzimologia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Progressão da Doença , Feminino , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Mortalidade , Prognóstico , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/mortalidade , Fatores de Risco , Análise de SobrevidaRESUMO
OBJECTIVES: The aim was to compare the burden of environmental shedding of toxigenic Clostridioides difficile among asymptomatic carriers, C. difficile-infected (CDI) patients and non-carriers in an inpatient non-epidemic setting. METHODS: C. difficile carriage was determined by positive toxin-B PCR from rectal swabs of asymptomatic patients. Active CDI was defined as a positive two-step enzyme immunoassay/polymerase chain reaction (EIA/PCR) test in patients with more than three unformed stools/24 hr. C. difficile environmental contamination was assessed by obtaining specimens from ten sites in the patients' rooms. Toxigenic strains were identified by PCR. We created a contamination scale to define the overall level of room contamination that ranged from clean to heavy contamination. RESULTS: One hundred and seventeen rooms were screened: 70 rooms inhabited by C. difficile carriers, 30 rooms by active CDI patients and 17 rooms by non C. difficile -carriers (control). In the carrier rooms 29 (41%) had more than residual contamination, from which 17 (24%) were heavily contaminated. In the CDI rooms 12 (40%) had more than residual contamination from which three (10%) were heavily contaminated, while in the control rooms, one room (6%) had more than residual contamination and none were heavily contaminated. In a multivariate analysis, the contamination score of rooms inhabited by carriers did not differ from rooms of CDI patients, yet both were significantly more contaminated than those of non-carriers odd ratio 12.23 and 11.16 (95% confidence interval 1.5-99.96 p 0.0195, and 1.19-104.49 p 0.035), respectively. DISCUSSION: Here we show that the rooms of C. difficile carriers are as contaminated as those of patients with active CDI and significantly more than those of non-carriers.
Assuntos
Proteínas de Bactérias/genética , Toxinas Bacterianas/genética , Portador Sadio/diagnóstico , Clostridioides difficile/fisiologia , Infecções por Clostridium/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Derrame de Bactérias , Portador Sadio/microbiologia , Clostridioides difficile/genética , Clostridioides difficile/isolamento & purificação , Infecções por Clostridium/microbiologia , Microbiologia Ambiental , Fezes/microbiologia , Feminino , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Drug prescription errors are made, worldwide, on a daily basis, resulting in a high burden of morbidity and mortality. Existing rule-based systems for prevention of such errors are unsuccessful and associated with substantial burden of false alerts. OBJECTIVE: In this prospective study, we evaluated the accuracy, validity, and clinical usefulness of medication error alerts generated by a novel system using outlier detection screening algorithms, used on top of a legacy standard system, in a real-life inpatient setting. MATERIALS AND METHODS: We integrated a novel outlier system into an existing electronic medical record system, in a single medical ward in a tertiary medical center. The system monitored all drug prescriptions written during 16 months. The department's staff assessed all alerts for accuracy, clinical validity, and usefulness. We recorded all physician's real-time responses to alerts generated. RESULTS: The alert burden generated by the system was low, with alerts generated for 0.4% of all medication orders. Sixty percent of the alerts were flagged after the medication was already dispensed following changes in patients' status which necessitated medication changes (eg, changes in vital signs). Eighty-five percent of the alerts were confirmed clinically valid, and 80% were considered clinically useful. Forty-three percent of the alerts caused changes in subsequent medical orders. CONCLUSION: A clinical decision support system that used a probabilistic, machine-learning approach based on statistically derived outliers to detect medication errors generated clinically useful alerts. The system had high accuracy, low alert burden and low false-positive rate, and led to changes in subsequent orders.
Assuntos
Sistemas de Apoio a Decisões Clínicas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Aprendizado de Máquina , Sistemas de Registro de Ordens Médicas , Erros de Medicação/prevenção & controle , Centros Médicos Acadêmicos , Algoritmos , Quimioterapia Assistida por Computador , Humanos , Israel , Sistemas de Medicação no Hospital , Segurança do Paciente , Estudos ProspectivosRESUMO
A severe staphylococcal septicemia originating from an unknown focus occurred in a 17-year-old patient who had undergone a Rastelli-Ross operation 5 years earlier. The clinical course was complicated by extensive bilateral pneumonia, diffuse intravascular coagulation, and glomerulonephritis. After 4 weeks of intensive conservative treatment, including a daily regimen of 16 Gm. of cloxacillin, the patient was operated upon for a rapidly progressive false aneurysm, which had resulted from dehiscence of the anastomosis between the prosthesis and ventricle. The excised prosthesis proved to be sterile. The postoperative course was uneventful. Cloxacillin treatment was continued for 6 months, initially parenterally and later orally. After discontinuation of therapy, no signs of infection have occurred. Right-sided intracardiac or intravascular prosthetic material may be particularly susceptible to infections originating from the body surface.
Assuntos
Prótese Vascular/efeitos adversos , Endocardite Bacteriana/tratamento farmacológico , Infecções Estafilocócicas/tratamento farmacológico , Tetralogia de Fallot/cirurgia , Aneurisma Infectado/cirurgia , Criança , Cloxacilina/uso terapêutico , Endocardite Bacteriana/complicações , Endocardite Bacteriana/diagnóstico por imagem , Aneurisma Cardíaco/cirurgia , Humanos , Masculino , Resistência às Penicilinas , Pneumonia Estafilocócica/diagnóstico por imagem , Polietilenotereftalatos/efeitos adversos , Radiografia , Sepse/tratamento farmacológico , Infecções Estafilocócicas/complicações , Infecções Estafilocócicas/diagnóstico por imagemRESUMO
Muscular subaortic stenosis associated with ventricular septal defect (VSD) is a rare but important anomaly. Two types of left ventricular outflow tract (LVOT) obstruction should be distinguished on the basis of morphologic as well as hemodynamic differences, depending on whether the stenosis is localized above (Type I) or below (Type II) the defect. The five cases presented are all in the latter category. In the first two cases the correct diagnosis was not made until after repair of the VSD. Two patients had previously undergone banding of the pulmonary artery (PAB). Marked carotid shudder and a vertical QRS axis in the frontal plane were presented in all cases. For the diagnosis to be established by catheterization, the catheter tip must be maneuvered into the apical part of the left ventricular cavity in order to detect the stenosis on the withdrawal curve. It is difficult to visualize the stenosis by angiography. The surgical approach through the VSD via a right atriotomy is highly recommended for Type II subaortic stenosis.
Assuntos
Cardiopatias Congênitas , Comunicação Interventricular/complicações , Angiocardiografia , Cateterismo Cardíaco , Criança , Pré-Escolar , Eletrocardiografia , Feminino , Seguimentos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/cirurgia , Comunicação Interventricular/fisiopatologia , Comunicação Interventricular/cirurgia , Humanos , Lactente , MasculinoRESUMO
Few data exists on the differences in long-term outcome between Mustard and Senning operations. We reviewed available data of all hospital survivors of these operations and assessed risk factors for late death and sinus node dysfunction. Of those patients undergoing the Mustard operation, 60 were hospital survivors (46 simple transposition, 14 complex); of those patients undergoing the Senning operation, 62 were hospital survivors (43 simple, 19 complex). Median duration of follow-up was 16 years (maximum 25 years) for Mustard operation, 11 years (maximum 20 years) for Senning operation. No reoperations were done, except for pacemaker implantation. No differences were found between the two groups with regard to baffle-associated problems, right ventricular failure, sudden death (6% in both groups), and functional status at final follow-up (New York Heart Association class I or II, except for four patients). For patients undergoing the Mustard operation, survival at 16-year follow-up was 91% with simple transposition and 60% with complex transposition (p = 0.027); for both groups of patients undergoing the Senning operation, survival at 16-year follow-up was 78%. Survival in the absence of rhythm disturbance at 16-year follow-up was 18% for Mustard operation and 53% for Senning operation (p < 0.001). In multivariate analysis, significant independent risk factors for late death turned out to be complex transposition (versus simple) and active arrhythmias. The only significant risk factor for the occurrence of sinus node dysfunction was the Mustard operation. We conclude that apart from the difference in the loss of sinus rhythm, no differences were found in the long-term clinical results of the two types of operations.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Complicações Pós-Operatórias/epidemiologia , Transposição dos Grandes Vasos/cirurgia , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Criança , Pré-Escolar , Feminino , Seguimentos , Átrios do Coração/cirurgia , Humanos , Lactente , Masculino , Análise Multivariada , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Análise de SobrevidaRESUMO
An anatomic study of 28 heart specimens with tricuspid atresia showed 15 hearts with ventriculoarterial concordance and a right-sided anterior outlet chamber. Of these 15 hearts, 12 showed evidence of restricted pulmonary blood flow. In eight of these 12 specimens, an anterior deviation of the outlet septum, relative to the primary septum, was present. This deviation caused a narrowing inside the outlet chamber and functioned as infundibular pulmonary stenosis. The outlet chambers of the 15 hearts with ventriculoarterial concordance were compared with those of 13 hearts with tricuspid atresia and ventriculoarterial discordance and also a right-sided anterior outlet chamber. In the latter group of 13 hearts, five showed evidence of restricted pulmonary blood flow, at least partially caused by posterior deviation of the outlet septum relative to the primary septum. A clear difference in outlet chamber morphology was found without exception between specimens with and without ventriculoarterial concordance. Clinical data in three long-term survivors of the Fontan procedure demonstrate that the special morphology of the outlet chamber can pose surgical problems. Especially in patients with ventriculoarterial concordance, when the outlet chamber is incorporated into the pulmonary circuit, the surgeon must give special attention to the specific morphology to prevent undesirable sequelae.
Assuntos
Circulação Pulmonar , Valva Tricúspide/anormalidades , Adolescente , Criança , Pré-Escolar , Feminino , Seguimentos , Átrios do Coração/cirurgia , Septos Cardíacos/patologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/patologia , Humanos , Artéria Pulmonar/cirurgia , Estenose da Valva Pulmonar/diagnóstico por imagem , Estenose da Valva Pulmonar/etiologia , Radiografia , Valva Tricúspide/cirurgiaRESUMO
The influence of growth of an aorta-coronary anastomosis, comparable to the coronary translocation anastomosis during the arterial switch operation, was studied in pigs. The anastomosis between the right coronary artery and the aorta did not grow, and this lack of growth may result in stenosis. With another technique, by which the coronary artery was excised with a cuff of aortic wall, the effects caused by absence of growth were circumvented and a normal-sized coronary ostium was present after growth. However, when no cuff was used, stenosis occurred at the suture line and caused growth retardation of the animal as well as histologic damage to the right ventricle.
Assuntos
Aorta/crescimento & desenvolvimento , Ponte de Artéria Coronária , Suínos/fisiologia , Animais , Aorta/patologia , Vasos Coronários/patologia , Feminino , Masculino , Seio Aórtico/crescimento & desenvolvimentoRESUMO
Sixty-six patients (23 neonates with transposition of the great arteries and intact ventricular septum, 33 infants and children with transposition and a large ventricular septal defect, and 10 with double-outlet right ventricle with a subpulmonary ventricular septal defect have received an arterial switch repair since 1977. Eight (one with transposition and intact ventricular septum, six with transposition and ventricular septal defect, and one with double-outlet right ventricle with subpulmonary ventricular septal defect) died in the hospital. All other patients have had follow-up as of June, 1985. Including the hospital deaths, the 11 month actuarial survival rate for the entire group was 81%, and no deaths have occurred among the 33 patients alive at that time and traced as long as 8 years. The hazard function for death has only a single early phase, and its 70% confidence limits overlap the hazard function of a matched general population by 12 months after the operation. Incremental risk factors for death included low birth weight (but not weight or age at operation), transposition of the great arteries with large ventricular septal defect, double-outlet right ventricle with subpulmonary ventricular septal defect, and presence of a patent ductus arteriosus. Coronary artery morphology and position of the great arteries were not risk factors. Long aortic cross-clamp time was possibly (p = 0.11) a risk factor. Early date of operation was a risk factor (p = 0.004); thus, predicted 1 year survival rate, including hospital deaths, after the arterial switch operation in 1985 is 99.9% (70% confidence limits 99.0%-100%) for neonates with transposition and intact ventricular septum and 99.7% (98.4%-99.9%) for those with transposition and a large ventricular septal defect or double-outlet right ventricle. The late functional status was excellent, and the rhythm was sinus in 96% of the 55 surviving patients. A formal comparison with the results of the atrial switch repair indicates that the arterial switch repair is superior.
Assuntos
Aorta/cirurgia , Vasos Coronários/cirurgia , Artéria Pulmonar/cirurgia , Transposição dos Grandes Vasos/cirurgia , Pressão Sanguínea , Circulação Coronária , Humanos , Lactente , Recém-Nascido , Métodos , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/mortalidade , ReoperaçãoRESUMO
The trousers-shaped baffle has been found very useful in intraatrial correction of transposition of the great arteries. Reasons are given to explain the particular form of the patch, and details of the operative technique are described.
Assuntos
Septos Cardíacos/cirurgia , Próteses e Implantes , Transposição dos Grandes Vasos/cirurgia , Pré-Escolar , Humanos , Lactente , Pericárdio , Polietilenotereftalatos , Politetrafluoretileno , Veias CavasRESUMO
Takedown and reconstruction of a previous Glenn anastomosis at the time of repair was performed in 1 child with pulmonary atresia and ventricular septal defect and in 3 children with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis. All 4 survived and showed excellent clinical results. The surgical technique and postoperative hemodynamic and lung scintigraphic data are presented.
Assuntos
Artéria Pulmonar/cirurgia , Veia Cava Superior/cirurgia , Adolescente , Ponte Cardiopulmonar , Criança , Feminino , Defeitos dos Septos Cardíacos/cirurgia , Humanos , Pulmão , Masculino , Artéria Pulmonar/anormalidades , Circulação Pulmonar , Cintilografia , Transposição dos Grandes Vasos/cirurgiaRESUMO
Usual techniques in open-heart operations leave a vertical median skin scar. Especially for women this is rather embarassing since it looks ugly. The use of horizontal submammary skin incision for access to the heart is described here. Although obtaining the usual midsternal exposure takes some extra time, long-term results have shown the value of this approach and its benefit to the patient. The surgical technique is simple, and wound healing, in the long run, is unimpaired.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Esterno/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Cicatriz , Comportamento do Consumidor , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , CicatrizaçãoRESUMO
This paper presents the case history of an 8-year-old girl who had total situs inversus and double-outlet right ventricle with pulmonary stenosis and severe tricuspid insufficiency in the presence of dextrocardia with ventricular discordance. A successful repair was performed using the Rastelli technique in conjunction with replacement of the tricuspid valve with a Bjork-Shiley prosthesis. The postoperative course was uneventful, and follow-up catheterization revealed a good operative result. However, the patient died suddenly during an emotionally upsetting period about two months after the operation. Postmortem examination revealed only signs of moderately severe cardiac decompensation. Some anatomical and embryological comments are made.
Assuntos
Aorta/anormalidades , Cardiomiopatia Hipertrófica/cirurgia , Dextrocardia/complicações , Comunicação Interventricular/cirurgia , Estenose Subvalvar Pulmonar/cirurgia , Insuficiência da Valva Tricúspide/cirurgia , Aorta/transplante , Cateterismo Cardíaco , Criança , Feminino , Coração/fisiopatologia , Comunicação Interatrial/cirurgia , Comunicação Interventricular/fisiopatologia , Próteses Valvulares Cardíacas , Ventrículos do Coração/anormalidades , Ventrículos do Coração/cirurgia , Humanos , Métodos , Estenose Subvalvar Pulmonar/complicações , Estenose Subvalvar Pulmonar/congênito , Situs Inversus/complicações , Transplante Autólogo , Insuficiência da Valva Tricúspide/congênito , Insuficiência da Valva Tricúspide/fisiopatologiaRESUMO
Atrioventricular valve development is described as following the general principle of junctional invagination and myocardial undermining. We have added considerations of the topographic relations of the developing mitral valve to these principles. Two groups of malformations are then distinguished: the first comprises disturbances of the general principle, the second is related to topographic abnormalities. It is shown that the atrioventricular septal defect, the straddling mitral valve and the isolated mitral cleft all have their own specific developmental backgrounds.
Assuntos
Valva Mitral/anormalidades , Comunicação Atrioventricular/etiologia , Septos Cardíacos/embriologia , Humanos , Valva Mitral/embriologiaRESUMO
The anomalies of the aortic arch are consequences of malformations in the first twelve weeks of the intrauterine life. Embryologically it is possible to explain and classify all of them. Most remain asymptomatic and do not need treatment. About one third of all anomalies are causing tracheo-esophageal compression with consequent complaints. In most cases the symptomatology starts in the first days of life. Some of them can be temporarily treated conservatively. The prognosis of patients, who need surgery is good, even in small infants. Surgery consists mainly in section of the atretic or hypoplastic part of the double aortic arch, section of the aberrant subclavian artery, section of the Botal ligament or duct and liberation of the trachea and esophagus. A normal configuration of trachea and esophagus is reached after several months or even more than a year. There are no reports on reoperations for secondary strictures. In the University Hospital of Nijmegen and Leiden we operated on 17 patients. There were 8 patients of group I A --- Edwards classification -- double aortic arch with both aortic arches open and left Botal duct or ligament; 4 patients of group I B, double aortic arch with one atretic aortic arch with a left Botal ligament; 3 patients of group II B, with a left aortic arch and aberrant right subclavian artery and a left Botal ligament; 2 patients of group III B with a right aortic arch and an aberrant left subclavian artery and a left Botal duct or ligament. Of our 17 patients one died during the operation because of a haemorrhage and overtransfusion; an other one died three weeks postoperatively from an endotracheal bleeding. All the other patients are without complaints and remained so.
Assuntos
Aorta/anormalidades , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Recém-NascidoRESUMO
BACKGROUND: Increased blood levels of alanine amino transferase (ALT, also known as SGPT; serum glutamic pyruvic transaminase) serve as a marker of liver injury by various mechanisms. Less is known about the clinical implications associated with low-normal ALT levels. Previous studies showed low ALT levels to be associated with poor long-term outcomes among elderlies, serving as a biomarker for increased incidence of frailty and subsequent risk of mortality. However, it has not been determined yet whether low-normal ALT values might be predictive of frailty and mortality in younger, middle-aged adults. METHODS: We conducted a historical prospective cohort analysis. RESULTS: A total of 23,506 adults with ALT levels within the normal range, at the mean age of 48 ± 11 years, participating in an annual screening program for preventive medicine, were followed-up for a median period of 8.5 years during which 638 died. Low-normal ALT values (serum ALT activity <17IU/L) were found to be predictive for increased risk of all-cause mortality (HR=1.6; 95% CI 1.34-1.92; p<0.001). Statistically significant correlation was demonstrated even after applying a multifactorial model correction for age, gender, eGFR, low albumin, arterial hypertension, diabetes mellitus and ischemic heart disease. CONCLUSIONS: We suggest that low-normal ALT values may serve as an independent predictive marker for increased long-term mortality in middle-aged adults.