RESUMO
BACKGROUND: Few studies have addressed the challenges associated with international students as they adapt to studying medicine in a new host country. Higher level institutions have increasing numbers of international students commencing programmes. This paper explores the experiences of a cohort of students in the early years of medical school in Ireland, where a considerable cohort are from an international background. METHODS: A mixed exploratory sequential study design was carried out with medical students in the preclinical component of a five year undergraduate programme. Data for the qualitative phase was collected through 29 semi-structured interviews using the peer interview method. Thematic analysis from this phase was incorporated to develop an online questionnaire combined with components of the Student Adaptation to College Questionnaire and Student Integration Questionnaire. First year students were anonymously surveyed online. The Mokken Scaling procedure was used to investigate the students' experiences, both positive and negative. RESULTS: Three main themes are identified; social adjustment, social alienation and cultural alienation. The response rate for the survey was 49% (467 Respondents). The Mokken Scaling method identified the following scales (i) Positive experience of student life; (ii) Social alienation, which comprised of negative items about feeling lonely, not fitting in, being homesick and (iii) Cultural alienation, which included the items of being uncomfortable around cultural norms of dress and contact between the sexes. With the threshold set to H = 0.4. Subscales of the positive experiences of student life scale are explored further. CONCLUSIONS: Overall student adjustment to a western third level college was good. Students from regions where cultural distance is greatest reported more difficulties in adjusting. Students from these regions also demonstrate very good adaptation. Some students from the host country and more similar cultural backgrounds were also struggling. Acculturation is more complex than being associated with cultural distance and worthy of further exploration.
Assuntos
Ajustamento Social , Estudantes de Medicina/psicologia , Aculturação , Cultura , Feminino , Humanos , Entrevistas como Assunto , Irlanda , Masculino , Faculdades de Medicina , Isolamento Social , Inquéritos e QuestionáriosRESUMO
Sex trafficking within Ireland is a hidden phenomenon. In 2010, 78 alleged victims were reported to An Garda Siochina and the recorded levels of human trafficking into Ireland have remained at this level for the last four years. Despite this, no Irish guidelines or referral pathways exist to assist health care professionals. This paper highlights that health care professionals are not aware of this occurrence nor have they been trained to identify victims. Due to a lack of awareness many potential opportunities to detect these victims may be missed. While there is no single set of symptoms or signs that differentiates sex-trafficked victims from other sex workers, an awareness of common physical and psychological health problems associated with sex trafficking by health care professionals may increase victim detection rates. This paper summarises indicators, approach mechanisms, screening questions and a referral guideline relevant to the Irish health care system. This step-by-step guide can be used by health care professionals who encounter such a situation.
Assuntos
Vítimas de Crime , Pessoal de Saúde , Tráfico de Pessoas , Administração dos Cuidados ao Paciente , Atitude do Pessoal de Saúde , Vítimas de Crime/psicologia , Vítimas de Crime/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/psicologia , Pessoal de Saúde/normas , Necessidades e Demandas de Serviços de Saúde , Indicadores Básicos de Saúde , Tráfico de Pessoas/prevenção & controle , Tráfico de Pessoas/estatística & dados numéricos , Humanos , Irlanda , Programas de Rastreamento/métodos , Programas de Rastreamento/organização & administração , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/organização & administração , Guias de Prática Clínica como AssuntoRESUMO
OBJECTIVE: The aim of this study was to determine if the individual physical characteristics of the extirpated transformation zone after large loop excision of the transformation zone (LLETZ) might predict the relative risk of adverse obstetric outcome, specifically preterm labour (PTL). DESIGN: A retrospective observational study. SETTING: University teaching hospital in Dublin (Coombe Women & Infants University Hospital, CWIUH). POPULATION: Women who had LLETZ treatment for cervical intraepithelial neoplasia (CIN) in the colposcopy service between 1999 and 2002, and who subsequently had a pregnancy at the CWIUH. METHODS: Case records and histology reports for eligible women were examined. Age, parity, smoking history, pregnancy complications and CIN grade were recorded. Exclusion criteria were age >42 years, previous treatment for CIN, previous premature labour or twin pregnancies. The Student's t-test, Mann-Whitney U-test, analysis of variants (ANOVA) and logistic regression were employed to analyse the data. MAIN OUTCOME MEASURES: Gestational age at birth, PTL (i.e. <37 weeks of gestation) and miscarriage rate (<24 weeks of gestation). RESULTS: Out of 1808 women who underwent LLETZ treatment, a total of 353 women were identified who subsequently had a pregnancy at the CWIUH, with 321 being eligible for inclusion in the study. Of these, 76.3% delivered at term, 9.1% delivered at <37 weeks of gestation and 14.6% miscarried at <24 weeks of gestation. There was a three-fold increase in the risk of PTL if the excision volume exceeded 6 cm(3) (RR = 3.00; 95% CI 1.45-5.92), or when the thickness of the excised tissue was greater than 12 mm (RR = 2.98; 95% CI 1.27-7.01). The time interval between LLETZ and pregnancy did not appear to have an effect on PTL rates. We found no association between the grade of CIN and the risk of PTL. CONCLUSIONS: This study reveals that the thickness and the total volume of the excised transformation zone are associated with an increased risk of PTL. Excisions thicker than 1.2 cm and larger than 6 cm(3) carry a three times greater risk for PTL.
Assuntos
Aborto Espontâneo/epidemiologia , Colo do Útero/patologia , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Trabalho de Parto Prematuro/epidemiologia , Displasia do Colo do Útero/patologia , Neoplasias do Colo do Útero/patologia , Colo do Útero/diagnóstico por imagem , Colo do Útero/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Irlanda/epidemiologia , Morbidade , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Fatores de Risco , Ultrassonografia , Neoplasias do Colo do Útero/cirurgia , Displasia do Colo do Útero/cirurgiaRESUMO
AIMS: Immune checkpoint inhibitors (ICIs) are used in incurable urothelial cancers, both in chemo-naïve and platinum-refractory patients. Efficacy and toxicity data published outside controlled clinical trials are limited. We report overall survival, progression-free survival and toxicities of ICIs in locally advanced (LABC) or metastatic bladder cancer (MBC). We aimed to develop and validate a prognostic model for these patients. MATERIALS AND METHODS: A multicentre real-world individual patient-level data study (n = 272) evaluating ICIs in the first-line platinum-ineligible or platinum-refractory setting for LABC/MBC between March 2017 and February 2020 was undertaken. Cox regression analyses evaluated the association of prognostic factors with overall survival. Data were split to create a training (n = 208) and validation (n = 64) cohort. The backward elimination method with a P-value cut-off of 0.05 was used to develop a reduced prognostic model using the training data set. The concordance index and assessment of observed versus predicted survival probabilities were used to evaluate the final model. RESULTS: The median follow-up was 18.9 (15.8-21.5) months. The median overall survival and progression-free survival in the training cohort were 9.2 (95% confidence interval 7.4-10.5) and 4.5 months (3.5-5.7), respectively. The most common grade 1/2 adverse events recorded were fatigue (47.8%) and infection (19.9%). Five key prognostic factors found in the training set were low haemoglobin, high neutrophil count, choice of immunotherapy favouring pembrolizumab, presence of liver metastasis and steroid use within 30 days of treatment. The concordance index for the training and validation cohorts was 0.66 (standard error = 0.05) and 0.64 (standard error = 0.04), respectively, for the final model. A nomogram was developed to calculate the expected survival probabilities based on risk factors. CONCLUSIONS: Real-world data were used to produce a validated prognostic model for overall survival in LABC/MBC treated with ICIs. This model could assist in patient stratification, interpreting and framing future trials incorporating PD-1/PD-L1 inhibitors in LABC/MBC.
Assuntos
Imunoterapia , Neoplasias da Bexiga Urinária , Hemoglobinas , Humanos , Inibidores de Checkpoint Imunológico/uso terapêutico , Imunoterapia/métodos , Nomogramas , Platina/uso terapêutico , Receptor de Morte Celular Programada 1 , Esteroides/uso terapêutico , Neoplasias da Bexiga Urinária/tratamento farmacológico , Neoplasias da Bexiga Urinária/patologiaRESUMO
Cervical cancer represents the second common cancer in women and is a major public health issue in Ireland and worldwide. Despite appropriate treatment of precancerous lesions, women with dysplasia are at relatively increased risk, and require follow up. We aimed to evaluate the compliance rate with follow up cytology advice given to patients discharged from the colposcopy clinic and to identify predictive factors for poor compliance. This is a retrospective cohort study of patients initially managed in our institution in 2001. Patients were evaluated for adherence with the recommendations received at the time of discharge from the clinic. Of the 116 women that were initially contacted, 100 agreed to participate in the study (86% response rate). Sixty women (60%) were entirely compliant. While older patients (> 40 years) were significantly less likely to show complete compliance (OR: 0.12; 950/ Cl: 0.02-0.58; p = 0.009).
Assuntos
Colposcopia , Continuidade da Assistência ao Paciente , Citodiagnóstico , Cooperação do Paciente , Neoplasias do Colo do Útero/patologia , Adolescente , Adulto , Análise de Variância , Biópsia , Distribuição de Qui-Quadrado , Feminino , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Estudos Retrospectivos , Inquéritos e Questionários , Esfregaço VaginalRESUMO
Fragile X syndrome and other trinucleotide diseases are characterized by an elongation of a repeating DNA triplet. The ensemble-averaged lambda exonuclease digestion rate of different substrates, including one with an elongated FMR1 gene containing 120 CGG repeats, was measured using absorption and fluorescence spectroscopy. By use of magnetic tweezers sequence-dependent digestion rates and pausing was measured for individual lambda exonucleases. Within the triplet repeats a lower average and narrower distribution of rates and a higher frequency of pausing was observed.
Assuntos
Exonucleases/química , Proteína do X Frágil da Deficiência Intelectual/química , Proteína do X Frágil da Deficiência Intelectual/genética , Repetições de Trinucleotídeos , Absorção , Bacteriófago phi X 174 , Fluorescência , Espectrometria de Fluorescência , Temperatura , Fatores de TempoRESUMO
OBJECTIVE: It is well-established that maternal smoking has adverse birth outcomes (low birthweight, LBW, and preterm births). The comprehensive Irish workplace smoking ban was successfully introduced in March 2004. We examined LBW and preterm birth rates 1 year before and after the workplace smoking ban in Dublin. DESIGN: A cross-sectional observational study analysing routinely collected data using the Euroking K2 maternity system. SETTING: Coombe University Maternal Hospital. POPULATION: Only singleton live births were included for analyses (7593 and 7648, in 2003 and 2005, respectively). METHODS: Detailed gestational and clinical characteristics were collected and analysed using multivariable logistic regression analyses and subgroup analyses. MAIN OUTCOME MEASURES: Maternal smoking rates, mean birthweights, and adjusted odds ratios (ORs) of LBW and preterm births in 2005 versus 2003. RESULTS: There was a 25% decreased risk of preterm births (OR, 0.75; 95% CI, 0.59-0.96), a 43% increased risk of LBW (OR, 1.43; 95% CI, 1.10-1.85), and a 12% fall in maternal smoking rates (from 23.4 to 20.6%) in 2005 relative to 2003. Such patterns were significantly maintained when specific subgroups were also analysed. Mean birthweights decreased in 2005, but were not significant (P=0.99). There was a marginal increase in smoking cessation before pregnancy in 2005 (P=0.047). CONCLUSIONS: Significant declines in preterm births and in maternal smoking rates after the smoking ban are welcome signs. However, the increased LBW birth risks might reflect a secular trend, as observed in many industrialised nations, and merits further investigations.
Assuntos
Recém-Nascido de Baixo Peso , Nascimento Prematuro/epidemiologia , Fumar/epidemiologia , Adolescente , Adulto , Peso ao Nascer , Estudos Transversais , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Irlanda/epidemiologia , Idade Materna , Gravidez , Nascimento Prematuro/etiologia , Efeitos Tardios da Exposição Pré-Natal , Fumar/efeitos adversos , Fumar/legislação & jurisprudência , Abandono do Hábito de Fumar/estatística & dados numéricos , Local de Trabalho/legislação & jurisprudência , Adulto JovemRESUMO
BACKGROUND: Point prevalence surveys (PPSs) collect data on hospital-acquired infections (HAIs) at one point in time but do not provide information on incidence over the entire admission or impact on patients or healthcare resources. Retrospective record review examines the entire admission to determine adverse event prevalence, incidence, preventability, physical impairment and additional length of stay. AIM: To establish whether European HAI surveillance definitions can be applied to the Irish National Adverse Events Study (INAES) retrospective record review data to determine HAI burden. METHODS: In the INAES, 1574 admissions were reviewed using a two-stage methodology and 247 adverse events were found. These were examined against European HAI case definitions to determine whether the event was an HAI. Results were compared with the 2011/12 European PPS data for Ireland. FINDINGS: The prevalence of HAI adverse events in INAES was 4.4% (95% confidence interval (CI) 3.1-6.1%) with an incidence of 3.8 (95% CI 2.5-5.2) HAI adverse events per 100 admissions. The PPS HAI prevalence for Ireland was 5.2%. HAI types and micro-organisms were similar in INAES and the PPS. Approximately three-quarters of INAES HAI adverse events were preventable, 7% caused permanent impairment and 7% contributed to death. A mean of 10 additional bed days were attributed to HAI adverse events, equivalent to 9400 per event. CONCLUSION: Retrospective record review is an accurate source of information on HAI incidence, preventability and impact that complements PPS prevalence rates. HAI adverse events result in higher costs to the healthcare system than other adverse events.
Assuntos
Infecção Hospitalar/epidemiologia , Métodos Epidemiológicos , Prontuários Médicos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Europa (Continente)/epidemiologia , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Inquéritos e Questionários , Adulto JovemRESUMO
The intravenous administration of heparin to patients before open heart surgery reduced ristocetin cofactor activity by 58% (P less than 0.01, t test), and this impairment of von Willebrand factor-dependent platelet function was closely related to plasma heparin levels (r2 = 0.9), but not to plasma von Willebrand factor (vWF) levels. We hypothesized that heparin may inhibit vWF-dependent platelet hemostatic functions by directly binding vWF in solution and interfering with vWF-GpIb binding. Using the in vitro techniques of ristocetin-induced platelet agglutination, fluorescent flow cytometric measurement of vWF-platelet binding, and conventional radioligand binding assays we observed that heparin inhibited both vWF-dependent platelet function and vWF-platelet binding in a parallel and dose-dependent manner. Heparin also inhibited platelet agglutination induced by bovine vWF and inhibited the binding of human asialo-vWF to platelets in ristocetin-free systems. The inhibitory potency of heparin was not dependent upon its affinity for antithrombin III, but was molecular weight dependent: homogeneous preparations of lower molecular weight were less inhibitory. Heparin impairment of vWF function may explain why some hemorrhagic complications of heparin therapy are not predictable based on techniques for monitoring the conventional anticoagulant effects of heparin.
Assuntos
Plaquetas/efeitos dos fármacos , Heparina/farmacologia , Fator de von Willebrand/fisiologia , Aglutinação , Plaquetas/metabolismo , Heparina/metabolismo , Humanos , Técnicas In Vitro , Ristocetina/farmacologia , Relação Estrutura-Atividade , Fator de von Willebrand/análiseRESUMO
E2F is a mammalian transcription factor that appears to play an important role in cell cycle regulation. While at least two proteins (E2F-1 and DP-1) with E2F-like activity have been cloned, studies from several laboratories suggest that additional homologs may exist. A novel protein with E2F-like properties, designated E2F-2, was cloned by screening a HeLa cDNA library with a DNA probe derived from the DNA binding domain of E2F-1 (K. Helin, J. A. Lees, M. Vidal, N. Dyson, E. Harlow, and A. Fattaey, Cell 70:337-350, 1992). E2F-2 exhibits overall 46% amino acid identity to E2F-1. Both the sequence and the function of the DNA and retinoblastoma gene product binding domains of E2F-1 are conserved in E2F-2. The DNA binding activity of E2F-2 is dramatically enhanced by complementation with particular sodium dodecyl sulfate-polyacrylamide gel electrophoresis-purified components of HeLa cell E2F, and anti-E2F-2 antibodies cross-react with components of purified HeLa cell E2F. These observations are consistent with a model in which E2F binds DNA as a heterodimer of two distinct proteins, and E2F-2 is functionally and immunologically related to one of these proteins.
Assuntos
Proteínas de Transporte , Proteínas de Ciclo Celular , Fatores de Transcrição/genética , Sequência de Aminoácidos , Sequência de Bases , Sítios de Ligação/genética , Clonagem Molecular , Sequência Conservada , Primers do DNA/genética , DNA Complementar/genética , Proteínas de Ligação a DNA/química , Proteínas de Ligação a DNA/genética , Proteínas de Ligação a DNA/metabolismo , Fatores de Transcrição E2F , Fator de Transcrição E2F1 , Fator de Transcrição E2F2 , Glutationa Transferase/genética , Células HeLa , Humanos , Dados de Sequência Molecular , Conformação Proteica , RNA Mensageiro/genética , Proteínas Recombinantes de Fusão/genética , Proteína 1 de Ligação ao Retinoblastoma , Fator de Transcrição DP1 , Fatores de Transcrição/química , Fatores de Transcrição/metabolismoRESUMO
The objective of the study is to translate the Rose Questionnaire (RQ) into a Bahasa Melayu version and adapt it cross-culturally, and to measure its inter-rater and intrarater reliability. This cross sectional study was conducted in the respondents' homes or workplaces in Kelantan, Malaysia. One hundred respondents aged 30 and above with different socio-demographic status were interviewed for face validity. For each inter-rater and intra-rater reliability, a sample of 150 respondents was interviewed. Inter-rater and intra-rater reliabilities were assessed by Cohen's kappa. The overall inter-rater agreements by the five pair of interviewers at point one and two were 0.86, and intrarater reliability by the five interviewers on the seven-item questionnaire at poinone and two was 0.88, as measured by kappa coefficient. The translated Malay version of RQ demonstrated an almost perfect inter-rater and intra-rater reliability and further validation such as sensitivity and specificity analysis of this translated questionnaire is highly recommended.
Assuntos
Angina Instável/epidemiologia , Inquéritos e Questionários/normas , Adulto , Idoso , Estudos Transversais , Feminino , Humanos , Entrevistas como Assunto , Idioma , Malásia/epidemiologia , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , TraduçãoRESUMO
AIMS: Radiotherapy is an important radical treatment for prostate cancer patients with services continually evolving. This survey aims to gain an insight in to the variation of radiotherapy practices in the UK, focussing on pre-treatment preparations, on-treatment review and management of radical prostate cancer patients undergoing radiotherapy. To our knowledge this is the first survey reported focussing on prostate radiotherapy practices with responses from a mix of health professionals. MATERIALS AND METHODS: A national survey was designed based on current known practices in supportive care and management of prostate cancer patients. The survey was distributed to lead radiotherapy personnel in radiotherapy services across the UK with a 77% response rate (n = 54). RESULTS: Pre-treatment protocols were mandated in the majority of departments. Use of bladder filling (98%) and bowel emptying (66%) were frequently deployed. Bowel preparation varied between use of laxatives (13%) or enemas (41%) to achieve consistency. On-treatment reviews were carried out by a mix of health professionals; most commonly shared between oncologists and radiographers (20%). Radiographers reviewing patients were independent prescribers in 22% of departments. Toxicity grading tools were not used by almost half of departments (47%) either at baseline and/or on-treatment reviews. Written information about follow-up was given to patients towards the end of their radiotherapy; however, fewer departments included the length of hormone duration (13%). CONCLUSION: This survey has demonstrated variations in practice exist across the UK. These variations suggest that important questions about the best methods for treatment accuracy and patient management need to be established through further research.
Assuntos
Padrões de Prática Médica/estatística & dados numéricos , Neoplasias da Próstata/radioterapia , Humanos , Masculino , Inquéritos e Questionários , Reino UnidoRESUMO
The already inadequate health systems of sub-Saharan Africa have been badly damaged by the emigration of their health professionals, a process in which the UK has played a prominent part. In 2005, there are special opportunities for the UK to take the lead in addressing that damage, and in focusing the attention of the G8 on the wider problems of health-professional migration from poor to rich countries. We suggest some practical measures to these ends. These include action the UK could take on its own, with the African countries most affected, and with other developed countries and WHO.
Assuntos
Países em Desenvolvimento , Emigração e Imigração/estatística & dados numéricos , Médicos Graduados Estrangeiros/estatística & dados numéricos , Mão de Obra em Saúde/estatística & dados numéricos , África Subsaariana , Educação de Pós-Graduação em Medicina , Pessoal de Saúde/educação , Mão de Obra em Saúde/economia , Cooperação Internacional , Seleção de Pessoal , Reino UnidoRESUMO
This cross-sectional study was aimed to identify the predictors of medication noncompliance in hypertensive patients. The study was conducted at the Family Medicine Clinic, Hospital Universiti Sains Malaysia, Kelantan, Malaysia, which is a university-based teaching hospital. All hypertensive patients aged 40 or over-registered from January to June 2004, who had been on treatment for at least 3 months, were screened. Previously validated self-administered questionnaires were used to assess the compliance and psychosocial factors. A total of 240 hypertensive patients were recruited in the study. Of these, 55.8% were noncompliant to medication. Logistic regression showed that age (adjusted odds ratio (OR): 0.96; 95% confidence interval (CI): 0.92-0.997; P: 0.035), patient satisfaction (adjusted OR: 0.97; 95% CI: 0.93-0.998; P: 0.036) and medication barrier (adjusted OR: 0.95; 95% CI: 0.91-0.987; P: 0.009) were significant predictors of medication noncompliance. Therefore, younger age, poor patient satisfaction and medication barrier were identified as independent psychosocial predictors of medication noncompliant in hypertensive patients.
Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/psicologia , Recusa do Paciente ao Tratamento/psicologia , Adulto , Feminino , Humanos , Hipertensão/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Razão de Chances , Satisfação do Paciente , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) is an important tool in the management of advanced germ cell testis cancer, particularly non-seminoma. AIM: We present the 16-year experience with PC-RPLND in a single Irish tertiary referral centre, and compare our results to the major speciality centres worldwide. METHODOLOGY: All 78 patients undergoing PC-RPLND for the treatment of metastatic testis cancer between January 1996 and December 2011 were included. Medical records were reviewed and up to date follow-up obtained from primary referral centres, patient's GPs and individual patient interview. RESULTS: The mean age at diagnosis was 28.5 ± 7 years. Initial pathology included non-seminoma 62.8 %, seminoma 6.4 % and combined 19.2 %. All patients underwent pre-operative chemotherapy. The resection template utilised was bilateral infra-hilar in 29.5 %, unilateral infra-hilar in 46.2 % and supra-hilar in 20.5 %. Complete abdominal remission was achieved in all but one patient. Additional procedures were required in 38.5 % of patients (n = 30). Clavien Dindo grade three or four complications were seen in 8.9 %, including five patients who required early reoperation. Histology of RPLND specimen showed mature teratoma (41 %) and active cancer (11.5 %). Follow-up data were available for 66 patients (85 %). Median follow-up was 101 (11-207) months. Nine patients relapsed with median time to relapse 15 (8-60) months. Overall 5-year survival rate was 95.2 % (four deaths). CONCLUSION: In this relatively small series due to small population and low disease incidence, we have shown acceptable peri-operative course, morbidity and oncological outcomes with PC-RPLND compared to major international centres.
Assuntos
Excisão de Linfonodo/métodos , Neoplasias Embrionárias de Células Germinativas/cirurgia , Neoplasias Retroperitoneais/cirurgia , Neoplasias Testiculares/cirurgia , Adulto , Gerenciamento Clínico , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Excisão de Linfonodo/mortalidade , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/cirurgia , Neoplasias Embrionárias de Células Germinativas/tratamento farmacológico , Neoplasias Embrionárias de Células Germinativas/mortalidade , Orquiectomia/métodos , Orquiectomia/mortalidade , Estudos Prospectivos , Reoperação/mortalidade , Neoplasias Retroperitoneais/tratamento farmacológico , Neoplasias Retroperitoneais/mortalidade , Espaço Retroperitoneal , Estudos Retrospectivos , Taxa de Sobrevida , Neoplasias Testiculares/tratamento farmacológico , Neoplasias Testiculares/mortalidade , Resultado do TratamentoRESUMO
BACKGROUND: Although a raised plasma homocysteine is a risk factor for vascular disease, it is not known whether it is associated with an adverse cardiac outcome in patients admitted with acute coronary syndromes. We evaluated the relationship between plasma homocysteine and short-term (28 days) and long-term (median 2.5 years) prognosis in acute coronary syndromes. METHODS AND RESULTS: We evaluated the relationship of quintiles of homocysteine to fatal and nonfatal coronary disease early (28 days) and late (29 days to a median of 2. 5 years) after admission to a single unit of patients with unstable angina (n=204) and myocardial infarction (n=236). The end points studied were cardiac death (n=67) and/or myocardial (re)infarction (n=30). Cox regression and logistic regression were used to estimate the relationship of homocysteine to coronary events. The event rate within the first 28 days (22 cardiac deaths and 5 nonfatal infarctions) was not related to the admission homocysteine level. In the 203 unstable angina and 214 myocardial infarction survivors, an apparent threshold effect was seen on long-term follow-up, with a significant step-up in the frequency of events between the lowest 3 quintiles (14 cardiac deaths and 11 nonfatal infarctions) and the upper 2 quintiles (31 fatal and 12 nonfatal events). Patients in the upper 2 quintiles (>12.2 micromol/L) had a 2.6-fold increase in the risk of a cardiac event (95% CI, 1.5 to 4.3, P<0.001). CONCLUSIONS: Elevated total homocysteine levels on admission strongly predict late cardiac events in acute coronary syndromes.
Assuntos
Angina Instável/sangue , Angina Instável/fisiopatologia , Homocisteína/sangue , Infarto do Miocárdio/sangue , Infarto do Miocárdio/fisiopatologia , Doença Aguda , Adulto , Idoso , Angina Instável/complicações , Angina Instável/epidemiologia , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/epidemiologia , Concentração Osmolar , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores de TempoRESUMO
This study examines the risk factor profile, in-hospital course and outcome of 337 women and 643 men admitted with a first episode of acute coronary insufficiency or myocardial infarction. The women were older than the men and had a risk factor profile dominated by hypertension and hypercholesterolemia rather than smoking. Women had a higher rate of unstable angina than did men after adjustment for age distribution. Women with acute infarction showed a higher rate of complications, which was associated with their greater age. They had a higher in-hospital mortality rate (12.6%) than did men (6.6%, p = 0.002). A logistic regression was used to adjust mortality and complication rates for differences in age between the sexes. When this was done, women and men had similar in-hospital prognoses. It is concluded that differences in risk factor profile may result in differences between the sexes in the expression of acute coronary heart disease, but that gender as such does not exert an independent influence on short-term prognosis in this disease.
Assuntos
Angina Pectoris/fisiopatologia , Angina Instável/fisiopatologia , Infarto do Miocárdio/fisiopatologia , Fatores Sexuais , Adulto , Fatores Etários , Idoso , Angina Instável/sangue , Angina Instável/complicações , Angina Instável/mortalidade , Colesterol/sangue , Feminino , Hospitalização , Humanos , Hipertensão/etiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Prognóstico , Análise de Regressão , Fatores de Risco , FumarRESUMO
OBJECTIVES: This study was conducted to determine whether the amount of myocardial damage during acute coronary syndromes (ACS) is related to the admission plasma homocysteine concentration. BACKGROUND: Elevated homocysteine levels are associated with increased thrombosis in patients presenting with ACS. It is not known whether this association is reflected in the degree of myocardial injury in those patients. METHODS: We studied consecutive patients presenting with acute myocardial infarction (MI) (n = 205) and unstable angina pectoris (UAP) (n = 185). Plasma samples were collected on admission and prior to clinical intervention and were assayed for homocysteine by high performance liquid chromatography (HPLC). Myocardial necrosis was assessed by measurements of cardiac troponin T (cTnT) on admission and 12 h after admission (peak cTnT). The patients were studied by quintiles of homocysteine concentration. RESULTS: There was a significant increase in peak cTnT in the 5th homocysteine quintile in MI (analysis of variance [ANOVA], p = 0.005), the levels being 4.10, 3.86, 4.13, 6.20 and 7.85 microg/liter for quintiles 1 to 5, respectively (p < 0.0001, for top vs. bottom quintile). Similarly, there was a step-up in peak cTnT levels in the top homocysteine quintile in UAP (ANOVA, p < 0.0001), the levels being 0.03, 0.03, 0.02, 0.04 and 0.15 microg/liter, (p < 0.0001 for top vs. bottom quintile). In a multivariate regression model, the association between peak cTnT and the top homocysteine quintile remained strong after adjustment of other confounders including age, gender, final diagnosis and thrombolysis treatment (odds ratio [OR]: 2.92 (1.75-4.87) p < 0.0001). The patients with UAP were further examined according to peak cTnT levels below (cTnT negative) or above (cTnT positive) 0.1 microg/liter. Homocysteine levels were significantly higher in cTnT positive than cTnT negative patients; 13.8 (11.7-15.3) vs. 10.3 (9.4-11.3) micromol/liter, respectively, p = 0.002. CONCLUSIONS: Elevated homocysteine levels are associated with a higher risk of ischemic myocardial injury in patients presenting with ACS.
Assuntos
Angina Instável/sangue , Homocisteína/sangue , Infarto do Miocárdio/sangue , Miocárdio/metabolismo , Angina Instável/diagnóstico por imagem , Aspartato Aminotransferases/sangue , Biomarcadores/sangue , Cromatografia Líquida de Alta Pressão , Angiografia Coronária , Creatina Quinase/sangue , Eletrocardiografia , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Hidroxibutirato Desidrogenase/sangue , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Troponina T/sangueRESUMO
OBJECTIVE: To investigate the incidence and prognostic significance of fasting hyperglycemia in a large group of patients with a first myocardial infarction. RESEARCH DESIGN AND METHODS: Blood glucose was measured after an 8-h overnight fast in 752 patients with a first myocardial infarction. Three groups of patients were identified: patients with normal fasting blood glucose (92.5%), patients with fasting hyperglycemia but no prior history of glucose intolerance (3%), and patients previously known to have diabetes mellitus (4.5%). RESULTS: The fasting hyperglycemic patients were significantly older and had significantly more in-hospital complications than the normal blood glucose group. Previously known diabetic subjects tended to be older and had more mechanical complications postinfarction than the group with normal blood glucose but the difference did not reach statistical significance. There was no significant difference between the diabetic subjects and patients with fasting hyperglycemia in mean age and in-hospital prognosis. CONCLUSIONS: Fasting hyperglycemia detected after a first myocardial infarction is associated with a poor in-hospital prognosis that was not due to larger infarct size, as reflected in peak levels of cardiac enzymes. The measurement of a fasting blood glucose level provides additional information in identifying high-risk groups of patients postinfarction.