Epidemiological aspects, clinical management and short-term outcomes in elderly patients diagnosed with acute heart failure in the emergency department in Spain: results of the EDEN-34 study.

OBJECTIVE: To estimate the incidence of acute heart failure (AHF) diagnosis in elderly patients in emergency departments (ED), diagnostic confirmation in hospitalized patients, and short-term adverse events. METHODS: All patients aged ≥65 years attended in 52 Spanish EDs during 1 week were included and those diagnosed with AHF were selected. In hospitalized patients, those diagnosed with AHF at discharge were collected. As adverse events, in-hospital and 30-day mortality, and combined adverse event (death or hospitalization) at 30 days post-discharge were collected. Adjusted odds ratios (OR) for association of demographic variables, baseline status and constants at ED arrival with mortality and 30-day post-discharge adverse event were calculated. RESULTS: We included 1,155 patients with AHF (annual incidence: 26.5 per 1000 inhabitants ≥65 years, 95% CI: 25.0-28.1). In 86% the diagnosis of AHF was known at discharge. Overall 30-day mortality was 10.7% and in-hospital mortality was 7.9%, and the combined event in 15.6%. In-hospital and 30-day mortality was associated with arterial hypotension (adjusted OR: 74.0, 95% CI: 5.39-1015. and 42.6, 3.74-485, respectively and hypoxemia (2.14, 1.27-3.61; and 1.87, 1.19-2.93) on arrival at the ED and requiring assistance with ambulation (2.24, 1.04-4.83; and 2.48, 1.27-4.86) and age (per 10-year increment; 1.54, 1.04-2.29; and 1.60, 1.13-2.28). The combined post-discharge adverse event was not associated with any characteristic. CONCLUSIONS: AHF is a frequent diagnosis in elderly patients consulting in the ED. The functional impairment, age, hypotension and hypoxemia are the factors most associated with mortality.

One size does not fit all: community views on choices for TB treatment and prevention.

Treatment and prevention paradigms in TB have been dominated by a 'one-size-fits-all' approach, in which all persons are given the same treatment regimens. This stands in contrast to other health conditions, where differentiated models of care have been shown to be effective. In this Viewpoint, we make the case for considering multiple factors when deciding which regimens should be offered to people with TB infection and disease. Choice about which regimens to use should be made in conjunction with people who have TB and consider efficacy, safety, duration, pill burden, formulation, drug interactions, time spent in monitoring, drug susceptibility, compatibility with other areas of life, and availability of support services. Ideally, these choices should be considered within an equity framework with the most intensified services being offered to those considered most vulnerable.

Les paradigmes de traitement et de prévention de la TB ont été dominés par une approche « unique ¼, dans laquelle toutes les personnes reçoivent les mêmes schémas thérapeutiques. Cette approche contraste avec d'autres problèmes de santé, pour lesquels des modèles de soins différenciés se sont avérés efficaces. Dans ce point de vue, nous plaidons en faveur de la prise en compte de multiples facteurs au moment de décider des schémas thérapeutiques à proposer aux personnes atteintes de infection tuberculeuse et de TB maladie. Le choix des traitements doit être fait en collaboration avec les personnes atteintes de TB et tenir compte de l'efficacité, de l'innocuité, de la durée, du nombre de comprimés, de la formulation, des interactions médicamenteuses, du temps consacré à la surveillance, de la sensibilité aux médicaments, de la compatibilité avec d'autres domaines de la vie et de la disponibilité des services d'aide. Idéalement, ces choix devraient être envisagés dans un cadre d'équité, les services les plus intensifs étant proposés aux personnes considérées comme les plus vulnérables.

Circulation of M. tuberculosis Beijing genotype in Latin America and the Caribbean.

Lineage 2 (East Asian), which includes the Beijing genotype, is one of the most prevalent lineages of Mycobacterium tuberculosis (Mtb) throughout the world. The Beijing family is associated to hypervirulence and drug-resistant tuberculosis. The study of this genotype's circulation in Latin America is crucial for achieving total control of TB, the goal established by the World Health Organization, for the American sub-continent, before 2035. In this sense, the present work presents an overview of the status of the Beijing genotype for this region, with a bibliographical review, and data analysis of MIRU-VNTRs for available Beijing isolates. Certain countries present a prevalent trend of <5%, suggesting low transmissibility for the region, with the exception of Cuba (17.2%), Perú (16%) and Colombia (5%). Minimum Spanning Tree analysis, obtained from MIRU-VNTR data, shows distribution of specific clonal complex strains in each country. From this data, in most countries, we found that molecular epidemiology has not been a tool used for the control of TB, suggesting that the Beijing genotype may be underestimated in Latin America. It is recommended that countries with the highest incidence of the Beijing genotype use effective control strategies and increased care, as a requirement for public health systems.

Initial evaluation of fruit of accessions of Persea schiedeana Nees for nutritional value, quality and oil extraction.

Persea schiedeana Nees is an underutilized and very little known species whose fruit is consumed in Mesoamerica where it grows wild. This study was carried out to evaluate: 1) the variability of fruit characteristics of different accessions; 2) the effects of centrifugation and microwave treatment on extracting oil from the fruit and on its qualitative characteristics; 3) the nutraceutical characteristics of the fruit and seeds of different accessions. The results showed a large variability in fruit size and oil/dry matter contents among the different accessions. There was a significant relationship between the dry matter and oil contents in the pulp. The combined use of centrifugation and microwave treatments gave high oil extraction yields (67-68%). The oils had good fatty acid composition and antioxidant capacity. The results gave an initial picture about the total phenol contents and antioxidant capacities in the seeds and in the different parts of the fruit.

Prolonged concurrent hypotension and low bispectral index ('double low') are associated with mortality, serious complications, and prolonged hospitalization after cardiac surgery.

BACKGROUND: Low bispectral index (BIS) and low mean arterial pressure (MAP) are associated with worse outcomes after surgery. We tested the hypothesis that a combination of these risk factors, a 'double low', is associated with death and major complications after cardiac surgery. METHODS: We used data from 8239 cardiac surgical patients from two US hospitals. The primary outcomes were 30-day mortality and a composite of in-hospital mortality and morbidity. We examined whether patients who had a case-averaged double low, defined as time-weighted average BIS and MAP (calculated over an entire case) below the sample mean but not in the reference group, had increased risk of the primary outcomes compared with patients whose BIS and/or MAP were at or higher than the sample mean. We also examined whether a prolonged cumulative duration of a concurrent double low (simultaneous low MAP and BIS) increased the risk of the primary outcomes. RESULTS: Case-averaged double low was not associated with increased risk of 30-day mortality {odds ratio [OR] 1.73 [95% confidence interval (CI) 0.94-3.18] vs reference; P =0.01} or the composite of in-hospital mortality and morbidity [OR 1.47 (95% CI 0.98-2.20); P =0.01] after correction for multiple outcomes. A prolonged concurrent double low was associated with 30-day mortality [OR 1.06 (95% CI 1.01-1.11) per 10-min increase; P =0.001] and the composite of in-hospital mortality and morbidity [OR 1.04 (95% CI 1.01-1.07), P =0.004]. CONCLUSIONS: A prolonged concurrent double low, but not a case-averaged double low, was associated with higher morbidity and mortality after cardiac surgery.

Characterization of surgical cardiac tumors.

OBJECTIVE: The primary tumors of the heart are extremely rare. There are divided to benign, malignant and metastatic. Metastatic cardiac tumors are more common. METHODS: The incidence in contemporary echocardiographic series is reported at a higher frequency of 0.15%. 75% of cardiac tumors are benign; approximately half of these are cardiac mommas. The malignant cardiac tumors are mostly histopathologically undifferentiated, followed by leiomyosarcomas and angio-sarcomas. RESULTS: Cardiac tumors have a wide range of unique clinical presentation. Even the most benign and smallest tumor can lead to significant morbidity and mortality. The clinical presentations of the primary cardiac tumors are due to: blood flow obstruction, tumor embolization and constitutional symptoms. Clinical presentations can be varied and may resemble coronary disease, pericarditis, cardiomyopathy or valve malfunction. The recent technological advances in non-invasive imaging modalities such as echocardiography and cardiac magnetic resonance imaging is rapidly increases the early diagnosis and management approach. CONCLUSION: In this review we aim to summarize the characterization of the most common cardiac tumors. Early recognition and treatment provided the best results (Tab. 2, Fig. 6, Ref. 66).

Pre-anthesis CPPU low dosage application increases 'Hayward' kiwifruit weight without affecting the other qualitative and nutritional characteristics.

In 2008, in Central Italy, a low dosage of CPPU solution, 4 µL L(-1) (6 hL/ha), was sprayed on the canopy of vines of 'Hayward' kiwifruit, at the "break of sepals", about one week before anthesis, to study its effects on fruit weight/size and on qualitative and nutritional characteristics. At harvest, CPPU, with respect to control, significantly increased the fresh weight by about 12% (+12.6 g fruit(-1)) and consequently the yield per vine, without affecting fruit shape, firmness, dry matter (%), total soluble solids, glucose, fructose, sucrose, starch, citrate, malate, vitamin C and soluble and insoluble oxalic acid. After 3 months of storage, CPPU-treated kiwifruits and the control fruit showed no difference in dry matter content, fruit firmness and total soluble solids. The results indicate that a low dosage of CPPU applied in pre-anthesis can improve fruit weight/size without any negative effect on fruit qualitative and nutritional characteristics.

John Heysham Gibbon and the 60th anniversary of the first successful heart-lung machine: brief notes about the development of cardiac surgery in Europe and Slovakia.

The development of the heart-lung machine and its first successful clinical application in 1953 was the culmination of Dr. Gibbon's lifetime research project. Despite many technical obstacles, financial problems, and discouragement from colleagues, his goal was achieved after twenty tedious years of tireless work. Posteriorly, his academic contribution established him as a leader and pioneer in the field of cardiac surgery. Parallel to his achievement and Dr. Kirklin's surgical experience, several authors around the world attempted open-heart surgery with the heart-lung machine, particularly in Europe. In Eastern Europe and particularly in the former Czechoslovakia, the lack of access to foreign medical literature forced a group of emerging young physicians from the Second Department of Surgery at Comenius University to furtively collect data on the topic. After building the Simkovic-Bolf heart-lung machine, the first successful open-heart surgery with the new device was performed only 5 years after Dr. Gibbons' experience (Tab. 1, Fig. 4, Ref. 22).

Cardiac anesthesia and surgery in geriatric patients: epidemiology, current surgical outcomes, and future directions.

The mean life expectancy of the population of the United States is projected to increase from 78.3 years at present to over 81 years in 2025, with a concomitant increase in the percentage of the population over the age of 75 years. Elderly patients are more likely to present with valvular and coronary artery disease than younger patients, and as better perioperative management contributes to improving post-operative outcomes and lower referral thresholds, very elderly patients form an increasingly large proportion of the cardiac surgical population. This article summarizes the impact of age-related pathophysiologic changes on patients' response to cardiac surgery and anesthesia, outlines useful perioperative strategies in this age group, and reviews the literature on outcomes after valvular and coronary in elderly patients.

Management of patients undergoing multivalvular surgery for carcinoid heart disease: the role of the anaesthetist.

BACKGROUND: The management of patients with carcinoid heart disease poses two major challenges for the anaesthetist: carcinoid crisis and low cardiac output secondary to right ventricular (RV) failure. Carcinoid crises may be precipitated by the administration of catecholamines and histamine-releasing drugs. METHODS: We analysed a series of 11 patients [six males, median (range) age 60 (42-73) yr] with severe symptomatic carcinoid heart disease who underwent multivalve surgery (right-sided valves, n=8; right- and left-sided valves, n=3) between 2001 and 2007. RESULTS: All patients received octreotide intraoperatively [650 (300-1050) microg] to prevent carcinoid symptoms and vasoplegia. Those patients on a greater preoperative octreotide regime required additional intraoperative octreotide [median (range) dose 320 (300-850) vs 750 (650-1050) mug]. Similarly, the use of greater doses of aprotinin (> 5 KIU) was associated with greater requirements for octreotide [475 (300-700) vs 750 (320-1050) microg] and higher glucose levels (> or =8.5 mmol litre(-1)). Catecholamines were generally required in those patients who presented with a worse New York Heart Association functional class. Overall mortality was 18% (n=2) and only one episode of mild intraoperative carcinoid crisis was observed. CONCLUSIONS: Carcinoid crisis and RV failure still remain the primary challenges for the anaesthesiologist while managing patients with carcinoid heart disease. Our study supports the administration of catecholamines to wean patients off cardiopulmonary bypass, particularly in the presence of myocardial dysfunction. Those patients on higher octreotide dosages may require close intraoperative glucose monitoring. Despite high operative mortality, surgical outcome has been improved potentially due to earlier patient referral and better perioperative management.

[Anxiety and depression among renal transplantation candidates: impact of donor availability]. / Ansiedad y depresión en candidatos a trasplante renal: impacto de la disponibilidad de donador.

BACKGROUND: Among the kidney transplantation candidates, regardless if they already have a living related donor (LRD) or if they are waiting for a cadaveric donor (CD), the transplantation process is highly stressful, and the stress intensity is proportioned to the waiting time for surgery. The patients waiting for a CD have no certainty about receiving a kidney in time for surviving, or, when the patient's relatives refused the donation, they may feel rejected by their family. In chronic diseases, psychiatric comorbidity affects the disease evolution, dampering the treatment efficacy, leading to long-term hospitalizations and a more severe emotional stress. OBJECTIVE: To calculate the difference of anxiety and depression levels between LRD and CD patients. METHODS: The Hospital Anxiety and Depression scale (HAD) was applied to the kidney transplantation candidates who attended their first psychiatric evaluation along a year, they were grouped according to their kind of donor (LRD= 31, CD= 12). Statistical analysis was performed by means of Fisher and Mann-Whitney tests. RESULTS: 33.33% of the LRD patients were anxious (6.60+/- 2.65 points) and 40% were depressed (5.9+/- 3.29); 75% of the CD patients were anxious (p= 0.005) (10.17+/- 2.48, p< 0.001) and 90% were depressed (p= 0.088) (12.0+/- 9.33, p= 0.005). CONCLUSIONS: The CD patients have a greater risk for anxiety and more severe depressive disorders than the LRD patients. Comparing this sample against 100 patients with chronic diseases, we found no differences with CD patients, but they have a higher risk for anxiety and depression than LRD patients, this may suggest that the last mentioned patients may overestimate the prognosis of their disease.

Ansiedad y depresión en candidatos a trasplante renal: impacto de la disponibilidad de donador / Anxiety and depression among renal transplantation candidates: impact of donor availability

Introducción: Entre los candidatos a trasplante renal, independientemente de que dispongan un donador vivo relacionado (DVR) o esperen un donador cadavérico (DC), el proceso del trasplante produce un estrés intenso, el cual es proporcional al tiempo de espera para la cirugía. Quienes esperan DC no tienen la certeza de obtener un órgano a tiempo para sobrevivir, o bien, cuando sus parientes se niegan a donar, los enfermos sienten ser rechazados por su familia. En enfermedades crónicas, la comorbilidad psiquiátrica afecta la evolución del padecimiento y reduce la eficacia del tratamiento, llevando a internamientos largos y a un mayor desgaste emocional. Objetivo: Determinar la diferencia de niveles de ansiedad y depresión en pacientes de DC en comparación a los pacientes con DVR. Metodología: Se aplicó la escala hospitalaria de ansiedad y depresión (HAD) a los candidatos a trasplante renal que acudieron a su primer consulta psiquiátrica a lo largo de un año, agrupándose de acuerdo al donador que disponen (DVR= 31, DC= 12). El análisis estadístico se realizó mediante las pruebas de Fisher y de Mann-Whitney. Resultados: El 33,33 por ciento de los pacientes con DVR presentaron ansiedad (6,60ñ 2,65 puntos) y 40 por ciento depresión (5,9ñ 3,29); el 75 por ciento de los pacientes de DC mostraron ansiedad (p= 0,005) (10,17ñ 2,48, p< 0,001) y 90 por ciento depresión (p= 0,088) (12,0ñ 9,33, p= 0,005). Conclusiones: Los pacientes de DC tienen mayor riesgo de padecer ansiedad que los enfermos con DVR y sufren cuadros depresivos más severos. Comparando esta muestra contra 100 enfermos crónicos, no encontramos diferencias con los pacientes de DC, pero sí tienen mayor riesgo de ansiedad y depresión que los pacientes con DVR, lo cual indicaría que estos últimos enfermos pudieran tener ideas sobrevaloradas sobre la evolución de su enfermedad (AU)

Mechanism of ketotifen action in hypersensitivity reactions. Its effect on cellular enzymatic activities.

In this study we observed that asthmatics had less methyltransferase activity and greater phosphodiesterase activity than healthy individuals. These enzymatic activities were nearer to values obtained in healthy individuals when we preincubated cells with ketotifen. The modulator effect of this drug on these two enzymes permits, on the one hand, to re-establish the beta-receptor numbers expressed on the membrane, and on the other hand, to inhibit mediator secretion provoked by antigenic stimulus. With its action on adenylate cyclase and phosphodiesterase activities, it allows cAMP intracellular accumulation and hinders the secretory process. Through its action on methyltransferase activity, it is responsible for the normalization of beta-receptor expression observed in asthmatic patients treated with ketotifen.

Number of beta-receptors in rhinitic pollinic patients.

The study was carried out on venous blood from 67 patients with seasonal rhinoconjunctivitis caused by sensitization to grass pollen and 30 control individuals. Total IgE determination, antigen-specific histamine release test against two concentrations of Phleum pratense, and quantification of beta 2-adrenergic receptor numbers in lymphocyte membrane of peripheral blood were done on all patients. Those pollinic patients who were asymptomatic at the time of the study had 500.07 +/- 237.27 receptors/cell; no significant differences were established with the control group, with 541.53 +/- 123.63 receptors/cell. However, both the control group and asymptomatic patients had receptor numbers which were significantly higher than those of symptomatic pollinic patients, with 376.81 +/- 158.65 receptors/cell (p < 0.01 and p < 0.05, respectively). The average decrease in number of receptors in symptomatic pollinic patients was 30.42% in relation to controls and 24.65% in relation to asymptomatic patients. Within the subgroup of pollinic patients, studied both in and out of season, the number of beta 2-adrenergic receptors had an average decrease of 13.22% during pollination, with 363.7 receptors/cell. Once the pollination season was over, this figure increased to 419.1 receptors/cell, establishing significant differences with p < 0.025. The number of beta 2-adrenergic receptors did not correlate with total seric IgE figures or with antigen-specific histamine release. These data indicate that the decrease of these receptors does not constitute the causal factor of atopic diseases; it seems more likely to be a consequence of the same.

Number of beta-receptors in patients allergic to Dermatophagoides pteronyssinus.

This study was carried out on 96 atopic patients with monosensitization against Dermatophagoides pteronyssinus and 30 control individuals. The patients were divided into 3 subgroups: 27 asymptomatic patients, 27 patients who only presented nasal symptomatology, and 27 patients with marked bronchial symptomatology. Total serum IgE, antigen-specific histamine release, and the number of beta 2-adrenergic receptors in peripheral blood lymphocytes in all patients were determined. The control group presented the highest number of beta-receptors in comparison with the bronchial symptomatic and nasal symptomatic patients. However, asymptomatic patients presented numbers of beta-receptors similar to controls, with no significant differences between both groups. No significant correlation was found between beta-adrenergic receptors and levels of total serum IgE. On the other hand, correlation between beta-receptors and specific histamine release was detected only in symptomatic nasal patients. It can be postulated that the decrease in beta-receptors is a consequence, and not the cause, of atopy.

Effect of ketotifen on the methyltransferase activity of asthmatic patients.

The results of this study have revealed that asthmatic individuals have less methyltransferase activity, compared to healthy individuals. This is reflected in a less fluidity of the plasmatic membrane and thus, presents with less beta-receptors compared to healthy subjects. Ketotifen is capable of partially reversing this situation where it stimulates methyltransferase activity of asthmatic individuals approaching the enzyme activity to healthy individuals.

Does ketotifen act by directly stimulating beta-adrenergic system?

Through this study we proved that the inhibitory effect ketotifen has on antigen-specific histamine release (ASHR) does not have any relation with beta-adrenergic system stimulation. However, it increases the inhibitory effect of histamine release caused by isoproterenol. Therefore, although ketotifen does not directly stimulate beta-adrenergic receptors to inhibit mediator secretion, its action correlates with the response produced through the stimulation of these receptors.

Effect of ketotifen on phosphodiesterase activity from asthmatic individuals.

It was demonstrated, in this study, that phosphodiesterase activity was elevated in asthmatic patients compared to healthy individuals. This may be reason why various authors found higher intracellular cAMP levels in healthy individuals than in asthmatic patients. We also demonstrated that the efficacy of ketotifen in inhibiting antigen-specific histamine release is due to the potent inhibitor effect of ketotifen on cellular phosphodiesterase activity which then allowed intracellular cAMP accumulation, and as a consequence prevented mediators release.

Membrane IgE and adenyl cyclase activity in the dynamics of bronchospasm. Ketotifen as a blocker of antigen action.

A continuous exposition to antigen provokes an increase of IgE synthesis in individuals sensitized to that antigen. This increase in the synthesis is hardly seen to be reflected in seric levels; however, it is clearly seen in the quantity of IgE associated with membranes as this value increases considerably. This fact is due to the characteristic of IgE which tends to fix itself to basophil membrane. On the other hand, although no difference exists in basal adenyl cyclase activity of asthmatic and healthy individuals, the sensitivity of this enzyme to isoproterenol (beta-agonist) is greater in healthy than in asthmatic individuals. The antigenic stimulus makes adenyl cyclase activity descend in these individuals; this does not happen when the cells are treated with ketotifen before stimulating them with the antigen.