Tombstone cost and longevity: The San Pedro Cemetery Museum in Medellín in Colombia.

BACKGROUND: Studies in the West suggest that tombstone cost is associated with longevity. The objective of this observational study was to investigate the association between tombstone cost and longevity in a large cemetery in Latin America. METHODS: Age at death was obtained from 2,273 consecutive death certificates held at the San Pedro Cemetery Museum in Medellín in Colombia. Subjects died in 2022, 2021, or 2020. Tombs are arranged in galleries in the cemetery and tombstone cost was based on the material from which the tombstone was made, its position in the gallery, and its ornamentation. Analysis of variance was used and the assumption of equal variance was not violated. RESULTS: Approximately 77% of tombstones were of low cost, 21% of medium cost, and 2% of high cost. Data from 1,751 subjects were used to investigate differences in longevity according to tombstone cost while adjusting for sex, civil status, violent death, and year of death. Longevity was similar in the low-cost group and medium-cost group: 64.3 years (63.2, 65.3) versus 63.3 years (61.3, 65.3) [estimated mean (95% confidence interval)]. Longevity was lower in the high-cost group: 47.0 years (40.1, 53.9). CONCLUSIONS: The inverse association between tombstone cost and longevity would suggest that people in Medellín are inclined to spend more on tombstones when commemorating the tragic death of a young person.

Optimized microwave-assisted azadirachtin extraction using response surface methodology.

The neem tree (Azadirachta indica A. Juss) is grown mainly for shade, fuel, and numerous non-timber forest products using its leaves, fruit, and bark. It produces an essential oil that is used as a source for obtaining bioinsecticides, with a broad spectrum of action in agricultural production. Its bioinsecticidal activity is due to the presence of triterpenes, such as azadirachtin, a product in continued growth of the global biopesticide market. Optimal conditions for neem oil extraction using response surface methodology (RSM) and microwave-assisted extraction (MAE) methods have been defined. However, the extraction conditions for these methods tend to consume high volumes of organic solvent and long extraction times. The aim of the present study is to determine the optimal conditions for the extraction of azadirachtin from neem seeds in a hydroalcoholic medium using MAE and RSM with a Box-Behnken design (BBD). A BBD was applied to evaluate the effects of the factors, magnetron voltage (X1), extraction time (X2), and pH of the extraction medium (X3), on the yield of the azadirachtin extraction process. The effect of each variable on the extraction yield was studied independently, considering the pure coefficients (linear and quadratic) on the three levels that were studied in the experiments. Moreover, the study experiments were conducted in triplicate, data were presented as mean and standard deviation, homogeneity of variances was estimated using Levene's test, and a two-way ANOVA with Tukey's post hoc analysis was performed to identify the experimental conditions that allowed us to find the highest extraction yield and to analyze whether the response surface model adequately described our data. The most significant effects of the model correspond to quadratic and interaction effects (p < 0.0001); the quadratic terms voltage (X1), extraction time (X2), and pH (X3); and the interaction effects between voltage-pH (X1*X3) and time-pH (X2*X3), which had a significant influence on the model. Moreover, a canonical analysis was performed. The optimal conditions were as follows: 69.22 V, 6.89 min, and a pH value of 4.35, coinciding with the zones shown in the contour plots. Furthermore, the response obtained at the optimal conditions was 37.5 µg of azadirachtin per gram of pretreated seed.

Combined surgical treatment in aortic type A dissection.

Acute Stanford type A aortic dissection is a fatal event that, for its high mortality when left untreated, requires urgent surgical intervention. The established treatment includes repair of the ascending aorta and various portions of the aortic arch, leaving the descending aorta untreated. We report the case of a 62-year-old man in whom a combined approach of the ascending aorta with surgical correction and transluminal placement of a stent in the aortic arch was performed.

[Effects of simvastatin on acute-phase protein levels after cardiac surgery]. / Efecto de la simvastatina en la concentración de las proteínas de fase aguda después de la cirugía cardíaca.

BACKGROUND AND OBJECTIVE: There is contradictory evidence as to whether the pleiotropic effects of statins improve morbidity/mortality rates in coronary artery bypass grafting with extracorporeal circulation, as they reduce the protein plasma levels in the acute phase. PATIENTS AND METHOD: This randomized prospective study included 44 patients undergoing elective coronary artery bypass grafting with extracorporeal circulation who were allocated to one of 2 groups: group A (n = 22), patients taking simvastatin, and group B, control (n = 22). The plasma levels of interleukin-6, complement 4 and C-reactive protein were determined. RESULTS: No significant differences were noted between the 2 groups with respect to the acute-phase protein levels, or the postoperative complications. In both groups, compared with the initial levels, interleukin-6 levels peaked at 6 h after surgery and C-reactive protein at 48 h. Complement 4 levels decreased from the start of the cardiopulmonary bypass and returned progressively toward the baseline value at 48 h after surgery. CONCLUSIONS: Simvastatin in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass produces no significant differences in the levels of acute-phase protein.

[Myocardial revascularization in the female population]. / Revascularización miocárdica en la población femenina.

OBJECTIVES: To analyze the factors that influence outcomes of surgical myocardial revascularization in the female population. PATIENTS AND METHOD: This is a retrospective study in which 128 woman, subjected to GABC[IBM1] from January to September 2004, were enrolled in an univariate and multivariate analysis of risk factors associated with morbidity and mortality. RESULTS: The mean age was 69.19 +/- 9.05 [IBM2] years, the most frequent pathologies, comorbilities, were dyslipemia, hypertension, and myocardial infarction. Unestable angina was found in 63.28% patients and stenosis in the left main coronary artery 42.96%; NYHA III-IV in 23.43%. The EuroSCORE mean preoperative risk was [IBM3] 5.57. Twelve surgeries were emergencies. Mean of grafts was 2.57. Mortality corresponded to 5.4% in programmed surgeries, 7% global. Univariate analysis identified this risk factors releated to mortality (p < 0.05): age older than 67 years, NYHA III-IV and emergency surgery, complicated in 25.2%. Follow-up was kept in 90.8% of patients, mean follow-up time was 17.11 (+/- 14.94) months; 115 patients did not present angina. The risk factor for angina during follow-up, in the univariate analysis (p < 0.05) was not having used the left internal thoracic artery as graft for the anastomosis of the anterior descending artery. CONCLUSIONS: Emergency surgery, age older than 67 years, and NYHA III-IV, were independent risk factors associated with mortality in this group. The use of artery grafts associated to reduced angina during follow-up.

[Cardiac surgery in octogenarians: current situation and future perspectives]. / Cirugía cardíaca en octogenarios: situación actual y perspectivas de futuro.

BACKGROUND AND OBJECTIVE: Increasing life expectancy makes cardiac surgery in octogenarians not very uncommon. We evaluated the characteristics and outcomes of patients aged over 80 undergoing cardiac surgery in our centre. PATIENTS AND METHOD: We retrospectively analyzed preoperative risk factors, in-hospital morbimortality, and long term survival in 120 patients aged 80 years--mean age (standard deviation): 81.53 (1.83)--who underwent cardiac surgery between 2000 and 2005, in comparison with 2425 younger patients referred to our center during the same period. RESULTS: Preoperatively, octogenarians presented arterial hypertension, renal failure, unstable angina, left main coronary stenosis and New York Heart Association (NYHA) functional class III or IV more frequently than younger patients. Combined cardiac surgery procedures (valvular plus coronary) were also significatively higher (20% vs. 9.85%). Hospital mortality (15.8%) was twice as higher as in the non octogenarian population and postoperative intensive care units and hospital stay was longer. 45% suffered some postoperative complication. In the multivariate analysis, urgent procedure, mitral valve surgery and presentation of any postoperative complication were identified as predictors of mortality, and female sex was identified as a risk factor for postoperative morbidity. Survival at one, 3 and 5 years was 91.20%, 80.73% and 69.20%, respectively. 98.7% of the patients were in I-II NYHA functional class and 92.5% satisfied with overall surgery outcome when they were interviewed. CONCLUSIONS: Despite more preoperative co-morbidity and worse functional class, cardiac surgery in octogenarians can be performed with an acceptable mortality. Our patients have a satisfactory quality of life and would undergo a cardiac surgery procedure again. Specific measurements in preoperative and immediate postoperative periods, in order to reduce higher morbidity rates, are advisable.

[Valve replacement with the Omnicarbon valve prosthesis. A 10-year follow-up]. / Troca de valva com a prótese valvar modelo Omnicarbon. Seguimento clínico de 10 anos.

OBJECTIVE: We retrospectively examined the outcomes of 264 patients who underwent consecutive Omnicarbon valve implantation surgery between April 1985 and May 1995. METHODS: At the time of surgery, patients who received this mechanical prosthesis averaged 57+/-11 years of age. Omnicarbon valves were placed in the aortic position in 36% of the cases, in the mitral position in 44%, and in both positions in 20%. Follow-up was carefully performed, with most patients undergoing physical examination at our clinic. While taking the case history, cardiac physicians specifically questioned the patient about valve-related complications. RESULTS: Accumulated total patient-years is 1291, with a mean follow-up time of 5.4 years. Survival at 10 years is 79.4+/-3.9%, including all causes of death and early mortality. Complications recorded during the 11-year study include: thromboembolism (0.1%), hemorrhage (0.4%), endocarditis (0.2%), and nonstructural failure (1.2%). No hemolytic anemia, valve thrombosis, or structural failure was detected during this long-term experience. Functional capability of these patients was subjectively assessed by the NYHA classification system. With follow-up time averaging over 5 years, 97% of our Omnicarbon valve patients are in NYHA I or II. CONCLUSION: The Omnicarbon mechanical prosthesis provides a good clinical performance for up to 10 years in both the aortic and mitral positions. Results indicated a low incidence of thromboembolism and of hemorrhagic complications.

Spontaneous coronary dissection during postpartum: etiology and controversies in management.

A 31-year-old female with a history of toxic oil syndrome in childhood, presented with spontaneous left main coronary dissection 4 weeks after an uncomplicated delivery. She had an extensive myocardial infarction, severe left ventricular dysfunction and cardiogenic shock which did not resolve following urgent surgical revascularization. Temporary left ventricular support and heart transplantation were necessary. We analyze the etiology and treatment sequence in what to our knowledge is the first case with these characteristics to be reported.

[Results of isolated and combined surgical coronary revascularization in patients over 75]. / Resultados de la cirugía de revascularización coronaria aislada y combinada en pacientes mayores de 75 años.

BACKGROUND: Increase in life expectancy is causing an increase of surgical myocardial revascularization procedures in the elderly. We evaluate the evolution of this type of interventions in people older than 75 years, taking into account the risk factors, results and survival. PATIENTS AND METHOD: Between July 1988 and May 2001, 237 isolated or combined myocardial revascularization procedures were carried out in patients older than 75 years (Group I), while 1177 were performed in younger patients (Group II). We retrospectively analyzed the mortality risk factors, surgical procedures, postoperative complications and survival in Group I patients. RESULTS: Preoperatively, Group I patients showed a more frequent left ventricular dysfunction, left main coronary stenosis, emergency surgery and combined procedures, while Group II patients displayed more common preoperative myocardial infarction and dyslipemia. Mortality in Group I was 20.7% vs 9.09% in Group II. Mortality was higher for mixed procedures (27.1%) than for isolated myocardial revascularization (13.8%). Postoperative complications were present in 48.5% patients. Significant preoperative risk factors of mortality in Group I were: female sex, high-risk ergometry, III-IV NYHA functional class, and atrial arrhythmia. The preoperative NYHA functional class was also a morbidity risk factor. Survival at 1, 3 and 5 years was present in 98.4%, 92.1% and 81% patients, respectively, NYHA functional class I-II being present in 94.18% patients. CONCLUSIONS: Myocardial revascularization surgery in people older than 75 years leads to an increase of morbimortality. Anyway, long-term survivors' quality of life makes us think of surgery as a valid treatment alternative.

[Toll-like receptor 2 R753Q polymorphisms are associated with an increased risk of infective endocarditis]. / El polimorfismo R753Q del toll-like receptor 2 se asocia a un aumento en el riesgo de sufrir endocarditis infecciosa.

The ability to respond to the ligands of toll-like receptors (TLR) could be affected by single nucleotide polymorphisms in TLR codifying genes. The influence of the polymorphisms TLR2 (R753Q, R677W), TLR4 (D299G, T399I) and CD14 (C-159T) was consecutively studied in 65 patients with infective endocarditis. The control group (n=66) consisted of healthy volunteers. All the polymorphisms were genotyped by means of restriction analysis after their amplification. An association between endocarditis and variants of TLR2 R753Q (P <.001) was observed, but no association with other polymorphisms was found. The TLR2 R753Q co-dominant (odds ratio=13.33), recessive (odds ratio=9.12) and dominant (odds ratio=3.65) genotypes showed a positive association with the infective endocarditis phenotype. The polymorphism TLR2 R753Q was associated with a greater susceptibility towards the development of infective endocarditis. Further studies are required to validate these results and identify other genetic risk factors.

Intraoperative PaO2 is not related to the development of surgical site infections after major cardiac surgery.

BACKGROUND: The perioperative use of high inspired oxygen fraction (FIO2) for preventing surgical site infections (SSIs) has demonstrated a reduction in their incidence in some types of surgery however there exist some discrepancies in this respect. The aim of this study was to analyze the relationship between PaO2 values and SSIs in cardiac patients. METHODS: We designed a prospective study in which 1,024 patients undergoing cardiac surgery were analyzed. RESULTS: SSIs were observed in 5.3% of patients. There was not significant difference in mortality at 30 days between patients with and without SSIs. In the uni and multivariate analysis no differences in function of the inspired oxygen fraction administrated were observed. CONCLUSIONS: We observed that the PaO2 in adult cardiac surgery patients was not related to SSI rate.

Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus.

We describe the rationale, methodology, and our preliminary experience with a new surgical technique for mitral valve replacement in patients with severe calcification of the mitral annulus in which the conventional techniques can not be applied. In contrast with other procedures published in the literature for these patients, in which the placement of the prosthesis is supra-annular, we plicate both mitral leaflets and the atrial wall creating a new annulus that allows the intra-annular placement of the prosthesis.

Risk factors for mediastinitis and endocarditis after cardiac surgery.

A prospective open-cohort study was performed in 838 adults undergoing coronary revascularization or valve surgery to define the risk factors for development of surgical site infections. Patients diagnosed with mediastinitis or endocarditis during follow-up were compared with patients with no such infection. After 1 year of follow-up, 22 (2.6%) patients had developed mediastinitis or endocarditis. No preoperative or intraoperative variables were identified as risk factors. By multivariate analysis of postoperative variables, respiratory insufficiency, microorganisms in blood cultures, and intensive care unit stay were independent risk factors for the development of these complications. The type of antibiotic prophylaxis had no influence on the incidence of organ or space infections after cardiac surgery.

Comparative study of single-dose and 24-hour multiple-dose antibiotic prophylaxis for cardiac surgery.

OBJECTIVE: Use of single-dose antibiotic prophylaxis is associated with reduced antibiotic resistance, lower costs, and fewer problems with drug toxicity and superinfections. We tested the hypothesis that single doses of cefazolin are as effective as a 24-hour regimen of cefazolin in preventing surgical site infections in adults undergoing cardiac procedures. METHODS: This random, prospective, clinical study included 838 adult patients undergoing elective coronary artery bypass grafting, valve operations, or both. These patients were randomly given a single dose of cefazolin (2 g) or a 24-hour treatment (2-g initial dose, followed by 1 g every 8 hours). Investigators blinded to the drug regimen diagnosed wound infections according to Centers for Disease Control and Prevention criteria. Patient clinical and demographic characteristics were noted, with follow-up for 12 postoperative months. The primary objective was to compare the incidence of surgical infections between groups up to 12 months postoperatively. RESULTS: A total of 419 patients received single-dose cefazolin, and another 419 received the 24-hour treatment. Surgical site infection occurred in 35 (8.3%) patients receiving single doses and 15 (3.6%) patients administered the 24-hour treatment (P = .004). We identified no differences between groups for mortality or duration of hospitalization (preoperative hospitalization, intensive care unit stay, and hospitalization after surgical intervention). The microorganisms isolated showed a similar distribution in both groups. The germs isolated were gram-positive cocci in 86% of the surgical site infections. CONCLUSIONS: Single-dose cefazolin used as antibiotic prophylaxis in cardiac surgery is associated with a higher surgical site infection rate than the 24-hour, multiple-dose cefazolin regimen.

[Cardiac surgery with extracorporeal circulation in cancer patients: influence on surgical morbidity and mortality and on survival]. / Cirugía cardiaca con circulación extracorpórea en pacientes oncológicos: influencia en la morbimortalidad quirúrgica y la supervivencia.

INTRODUCTION AND OBJECTIVES: Morbimortality related to cardiac surgery may be superior in patients with malignant neoplastic disease. Inflammatory phenomena and immunologic changes secondary to extracorporeal circulation use can also increase tumor recurrence. We evaluate characteristics and results of cardiac surgery in our neoplastic patients. METHODS: Out of 2146 consecutive patients who underwent cardiac surgery with extracorporeal circulation, 89 (4.2%) had been previously affected by cancer. Cancer was active (recent diagnosis or under treatment) in 33 patients (group A) and 56 (group B) were in remission. Both groups were matched with 165 patients with no tumor, according to age, gender, type of surgery, and comorbidity (group C). We retrospectively evaluated incremental risk factors for surgical morbimortality, survival and tumor recurrence. RESULTS: Median interval between cancer diagnosis and surgery was 60 months and mortality and morbidity were 4.5% and 36%, respectively, vs 5,4% and 32,7% in group C. During follow-up, 12 patients died (8 due to cancer), 16 suffered cancer recurrence and 2 new tumors were diagnosed. Statistical analysis did not permit us to identify any incremental risk factor for mortality. Postoperative morbidity was increased in case of preoperative renal failure. During follow-up, survival was significantly decreased in group A, in case of preoperative left ventricular dysfunction or pulmonary obstructive disease, and when interval between cancer diagnosis and cardiac surgery was under 2 years. CONCLUSIONS: We have not observed an increase in cardiac surgery morbimortality in cancer patients. Anyway, survival is decreased in case of active or recently diagnosed cancer.

Analysis of inflammatory response and utility of N-terminal pro brain-type natriuretic peptide in cardiac surgery with extracorporeal circulation.

OBJECTIVES: Cardiac surgery with cardiopulmonary bypass (CPB) elicits an inflammatory response. During and after cardiac surgery, we examined the pattern of cytokine release of interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF)-alpha, to investigate inflammatory response. We analyzed N-terminal pro brain-type natriuretic peptide (NT-proBNP) as a marker of ventricular function. METHODS: Consecutive patients (n = 58) undergoing elective cardiac surgery with extra-corporeal circulation were recruited into the study. Blood samples for analysis of the biochemical markers were taken at seven time points for cytokines and TNF, and three for Nt-proBNP. RESULTS: All markers increased significantly after CPB. IL-6 and IL-8 levels were higher in men. IL-8 was related to a need for inotropic support. IL-6 was related to the time of CPB (P = 0.004), aortic clamping (P = 0.013), length of stay in intensive care unit (ICU) (P = 0.004) and mechanical ventilation for more than 12 h (P = 0.006). The levels of NT-proBNP were higher in cases of ventricular dysfunction (P = 0.003) and functional class III/IV (P = 0.001). The postoperative values were related to age (P < 0.05), creatinine values (P < 0.001), mechanical ventilation time (P < 0.001) and stay in the ICU (P = 0.001). CONCLUSION: Our data indicate a relationship between cytokine levels and sex, time of CPB and aortic clamping, The increase of cytokines correlates with a need for inotropic support, mechanical ventilation and length of stay in ICU. We confirmed the predictive role, and its utility in the risk stratification of the NT-proBNP, and its importance in early diagnosis of postoperative ventricular dysfunction.

Isolated right-sided valvular endocarditis in non-intravenous drug users.

INTRODUCTION AND OBJECTIVES: Characteristics of isolated right-sided endocarditis in patients without a pacemaker and who are not intravenous drug users (IVDU) are poorly understood. The aim of this study was to investigate the current frequency of this entity and describe its clinical, microbiological, echocardiographic and prognostic profile. METHODS: We have prospectively analyzed 17 consecutive cases of isolated right-sided endocarditis in non-IVDU who did not have a pacemaker, out of a total of 583 consecutive episodes of endocarditis (2.9%). RESULTS: Mean age was 38+/-15 years; 11 of the 17 patients were men. Almost half of the patients had at least one predisposing disease. An intravascular catheter was the most frequent port of entry (35%). The most common signs and symptoms on admission were fever, dyspnea, septic pulmonary embolisms, pleural effusion and right-sided heart failure. The most frequent microorganism was Staphylococcus aureus (41%). In most cases (82%) the infection was located in the tricuspid valve. Recurrent pulmonary embolisms were the most frequent complication and the main cause for surgery, which was needed in 5 patients (29%). Two patients died during hospitalization (12%), both from septic shock. During follow-up one patient died of unknown causes 1 month after discharge, and other relapsed 3 months after discharge. CONCLUSIONS: Isolated right-sided endocarditis should be included in the differential diagnosis of patients with febrile syndrome, respiratory symptoms and predisposing disease, even when they do not have a pacemaker and are not IVDU. The presence of intravascular catheters and Staphylococcus bacteriemia should heighten suspicion of endocarditis.