RESUMO
BACKGROUND: Reducing post-sternotomy mediastinitis (PSM) requires incorporating multiple methods. However, the independent effects of these measures are not well studied. AIM: To evaluate the independent effect of preoperative disinfection using isopropyl alcohol (IPA)-chlorhexidine gluconate (CHG) and the topical application of a retrosternal gentamicin collagen sponge at wound closure on reducing PSM. METHODS: From October 2012 to August 2014, 2340 patients were included in this prospective, controlled registry. Patients were divided into four groups. In groups 1 and 2, the skin was disinfected with IPA, and in groups 3 and 4, the skin was disinfected with IPA-CHG. A retrosternal gentamicin collagen sponge was used in groups 2 and 4. Freedom from PSM up to the 30th postoperative day was the primary endpoint. The secondary endpoint was freedom from any surgical site dehiscence. A stepwise regression model was made to reveal the independent factors associated with lower incidence of PSM. FINDINGS: There were significant differences in outcome among the groups (P < 0.0001). Primary healing was highest in group 4 (91.4%), which showed the lowest rate for mediastinitis (0.9%). Multivariate analysis showed that the use of CHG and a gentamicin sponge was statistically significant (P = 0.026 and 0.013, respectively). The other significant independent factors were valve operation (P = 0.001), body mass index >30 kg/m2 (P = 0.001), preoperative stroke (P = 0.005), and blood transfusion (P = 0.022). CONCLUSION: Preoperative skin disinfection with IPA-CHG is superior to only IPA, and it should be recommended. The addition of a retrosternal gentamicin-releasing sponge further reduces the rate of mediastinitis.
Assuntos
Antibacterianos/administração & dosagem , Quimioprevenção/métodos , Clorexidina/administração & dosagem , Gentamicinas/administração & dosagem , Mediastinite/epidemiologia , Mediastinite/prevenção & controle , Esternotomia/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Animais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: To determine predictors of clinical outcome after endovascular interventions of crural arteries in patients with peripheral arterial disease. PATIENTS AND METHODS: We prospectively followed 154 limbs in 147 patients treated with below the knee endovascular interventions for critical limb ischemia (52 %) and severe claudication (48 %). Patient-immanent, hemodynamic-procedural and anatomic determinants of outcome were analyzed. Outcome was defined as event-free survival from the combined endpoint freedom from re-intervention, major amputation and death. RESULTS: Cumulative event-free survival after 12 months was 65.1 %. During follow-up 42 patients (27.3 %) required re-intervention, 8 (5.2 %) underwent major amputation and 5 (3.2 %) died. In univariate analyses, the presence of critical limb ischemia, multilevel disease, age > 72 years, impaired renal function, and long lesions (> 65 mm) were significant determinants of the study endpoint. The anatomic location of the lesion, distal patency of treated artery below the ankle, cardiovascular risk factors or concomitant cardiovascular diseases, and the type of postinterventional antithrombotic treatment did not influence outcome. CONCLUSIONS: Below-knee interventions resulted in acceptable procedural mid-term results and high rates of amputation free survival. Multilevel disease, long lesions and impaired renal function were indicative of a worse outcome.
Assuntos
Procedimentos Endovasculares , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/terapia , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica , Distribuição de Qui-Quadrado , Estado Terminal , Intervalo Livre de Doença , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Estudos de Viabilidade , Feminino , Seguimentos , Alemanha , Hemodinâmica , Humanos , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/etiologia , Claudicação Intermitente/mortalidade , Claudicação Intermitente/terapia , Isquemia/etiologia , Isquemia/terapia , Estimativa de Kaplan-Meier , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Razão de Chances , Doença Arterial Periférica/complicações , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Doença Arterial Periférica/fisiopatologia , Modelos de Riscos Proporcionais , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do TratamentoRESUMO
A 40 year old woman presented with symptoms of a systemic inflammatory disease and obstruction of the left subclavian artery. Takayasu arteriitis (TA) was clinically diagnosed and confirmed by MR angiography and FDG-PET scan showing inflammation of the aortic arch and the left subclavian artery. Immunosuppression with glucocorticoids and methotrexate resulted in immediate clinical improvement and normalization of systemic markers of inflammation. Despite that the patient developed chest pain on exertion suggesting coronary involvement, which was confirmed by dobutamine stress echocardiography. After adding the TNF-alpha blocker infliximab coronary symptoms gradually improved and a clinically stable situation could be achieved for more than 6 months. Coronary angiography and aortography showed an occluded main stem of the left coronary artery, an occluded left subclavian artery, and stenoses of the brachiocephalic trunk and the left common carotid artery. Revascularization of the coronary artery and the aortic arch and its branches was performed. The patient returned to work two months after the operation. Immunosuppressive therapy with infliximab and methotrexate is continued, glucocorticoids were stopped after one year of treatment. This case shows that vascular progress in TA patients may occur even when systemic inflammation is controlled, therefore patients have to be carefully observed for new vascular manifestations. TNF-alpha blockers may be an additional treatment option in otherwise difficult to treat TA patients allowing to perform revascularization after a stable disease state has been achieved.
Assuntos
Anticorpos Monoclonais/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Imunossupressores/uso terapêutico , Arterite de Takayasu/tratamento farmacológico , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adulto , Angiografia Coronária , Ponte de Artéria Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/imunologia , Doença da Artéria Coronariana/cirurgia , Quimioterapia Combinada , Ecocardiografia sob Estresse , Feminino , Fluordesoxiglucose F18 , Glucocorticoides/uso terapêutico , Humanos , Infliximab , Angiografia por Ressonância Magnética , Metotrexato/uso terapêutico , Tomografia por Emissão de Pósitrons , Valor Preditivo dos Testes , Compostos Radiofarmacêuticos , Indução de Remissão , Arterite de Takayasu/complicações , Arterite de Takayasu/diagnóstico , Arterite de Takayasu/imunologia , Resultado do TratamentoAssuntos
Angioplastia , Angiopatias Diabéticas/terapia , Isquemia/terapia , Perna (Membro)/irrigação sanguínea , Doença Arterial Periférica/terapia , Stents , Angiopatias Diabéticas/mortalidade , Pé Diabético/mortalidade , Pé Diabético/terapia , Stents Farmacológicos , Alemanha , Humanos , Isquemia/mortalidade , Salvamento de Membro , Doença Arterial Periférica/mortalidade , Guias de Prática Clínica como Assunto , Prognóstico , Taxa de SobrevidaAssuntos
Bactérias Anaeróbias/metabolismo , Oxalato de Cálcio/análise , Intestinos/microbiologia , Oxalatos/metabolismo , Cálculos Urinários/etiologia , Administração Oral , Ritmo Circadiano , Fezes/microbiologia , Alimentos Formulados , Humanos , Oxalatos/administração & dosagem , Oxalatos/urina , Recidiva , Fatores de Risco , Cálculos Urinários/química , Cálculos Urinários/metabolismo , Cálculos Urinários/microbiologia , Difração de Raios XRESUMO
Washed everted vesicles of the methanogenic bacterium strain Go1 were found to couple the F420H2-dependent heterodisulfide reduction with the transfer of protons across the membrane into the lumen of the everted vesicles. The transmembrane electrochemical potential of protons thereby generated was shown to be competent in driving ATP synthesis from ADP + Pi, exhibiting a stoichiometry of 2 H+ translocated or 0.4 ATP synthesized per F420H2 oxidized. This enzyme system exhibits the phenomenon of coupling and uncoupling and represents a different kind of electron transport chain with the heterodisulfide of 2-mercaptoethanesulfonate and 7-mercaptoheptanoylthreonine phosphate as terminal electron acceptor. The heterodisulfide and methane are formed in the methyl coenzyme M reductase reaction. The reducing equivalents are derived from reduced coenzyme F420, which represents an analogue of NADH + H+ in other respiratory chains. It is assumed that the proton-translocating oxidoreductase discovered in strain Go1 is of principal importance to all methanogenic bacteria not utilizing H2.