Asthma-chronic obstructive pulmonary disease overlap and cost-related medication non-adherence among older adults in the United States.

BACKGROUND: Cost-related medication non-adherence (CRN) can negatively impact health outcomes in older adults with asthma and chronic obstructive pulmonary disease (COPD) overlap (ACO) by reducing access and adherence to essential medications. The objective of this study is to examine the association of ACO to any CRN and specific forms of CRN among a nationally representative sample of older (age ≥ 65 years) adults. METHODS: We adopted a cross-sectional study design using data from pooled cross-sectional Medicare Current Beneficiary Surveys (MCBS) (2006-2013) and linked fee-for-service Medicare claims. Unadjusted and adjusted logistic regressions that accounted for the complex survey design examined the association of ACO to any CRN and specific forms of CRN. RESULTS: Among older adults with ACO, 16% reported any CRN. The most common form of CRN was "failing to get prescription". As compared to older adults with no asthma and no COPD, those with ACO were more likely to report any CRN (adjusted odds ratios [AOR] = 1.50, 95%CI = [1.14, 1.96]) and all forms of CRN. However, when the number of unique medications was added to the model, there were no statistically significant differences in CRN between the two groups. CONCLUSIONS: Older adults with ACO represent a vulnerable population with increased risk for CRN. Multiple factors can contribute to CRN including: a higher number of prescribed medications, multiple co-morbidities, and cost of therapies. Medication comprehensive review interventions have the potential of reducing the risk of CRN among the older Medicare beneficiaries with ACO.

Occupational musculoskeletal disorders management using Fuzzy TOPSIS Assessment of Repetitive Tasks (ART).

BACKGROUND: In order to evaluate occupational disorders and ergonomic problems in a workplace, Multiple Criteria Decision Making (MCDM) problem solving methods such as Fuzzy Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) can be utilized. OBJECTIVE: In this paper, Musculoskeletal Disorder (MSD) risk factors were evaluated in a manufacturing company in Iran by a method called Assessment of Repetitive Tasks (ART) of the upper limbs integrated with Fuzzy TOPSIS in order to prioritize the corrective actions. METHODS: This study was done with a descriptive-analytical approach. The company under study had 240 employees who were working in seven different shops. Out of all tasks, 13 tasks were included in the study. Required information was gathered by a demographic questionnaire and ART method. Also, Fuzzy TOPSIS was utilized for the prioritization of the company shops based on the ergonomic control needs. RESULTS: Data analysis from ART indicated that 74.6% of the reviewed tasks were high risk. Based on the F- TOPSIS-ART results, Production shop prioritized as the highest need for MSD control. CONCLUSIONS: Because there is time and financial resources limit in ergonomic control activities, a fuzzy prioritization approach such as Fuzzy TOPSIS ART can be used to take advantage of the available resources and control risks to as low as reasonably practicable (ALARP) level.

Analyses of coronary graft patency after aprotinin use: results from the International Multicenter Aprotinin Graft Patency Experience (IMAGE) trial.

OBJECTIVE: We examined the effects of aprotinin on graft patency, prevalence of myocardial infarction, and blood loss in patients undergoing primary coronary surgery with cardiopulmonary bypass. METHODS: Patients from 13 international sites were randomized to receive intraoperative aprotinin (n = 436) or placebo (n = 434). Graft angiography was obtained a mean of 10.8 days after the operation. Electrocardiograms, cardiac enzymes, and blood loss and replacement were evaluated. RESULTS: In 796 assessable patients, aprotinin reduced thoracic drainage volume by 43% (P < .0001) and requirement for red blood cell administration by 49% (P < .0001). Among 703 patients with assessable saphenous vein grafts, occlusions occurred in 15.4% of aprotinin-treated patients and 10.9% of patients receiving placebo (P = .03). After we had adjusted for risk factors associated with vein graft occlusion, the aprotinin versus placebo risk ratio decreased from 1.7 to 1.05 (90% confidence interval, 0.6 to 1.8). These factors included female gender, lack of prior aspirin therapy, small and poor distal vessel quality, and possibly use of aprotinin-treated blood as excised vein perfusate. At United States sites, patients had characteristics more favorable for graft patency, and occlusions occurred in 9.4% of the aprotinin group and 9.5% of the placebo group (P = .72). At Danish and Israeli sites, where patients had more adverse characteristics, occlusions occurred in 23.0% of aprotinin- and 12.4% of placebo-treated patients (P = .01). Aprotinin did not affect the occurrence of myocardial infarction (aprotinin: 2.9%; placebo: 3.8%) or mortality (aprotinin: 1.4%; placebo: 1.6%). CONCLUSIONS: In this study, the probability of early vein graft occlusion was increased by aprotinin, but this outcome was promoted by multiple risk factors for graft occlusion.

Surgical removal of a mobile, pedunculated left ventricular thrombus: report of 4 cases.

During an 11-month period, 4 patients underwent surgical removal of a mobile, pedunculated left ventricular thrombus. All 4 patients had a history of myocardial infarction. Two of the 4 patients had systemic emboli, and in the 2 others, the ventricular thrombi were removed to prevent emboli. The thrombus was removed during the acute phase of myocardial infarction in 2 patients and one and two years, respectively, following the infarct in the remaining 2 patients. Concomitant coronary artery bypass grafting was performed in 3 patients. There were no early or late deaths, and none of the patients had clinical or echocardiographic evidence of recurrent thrombi or emboli at follow-up 3 to 15 months later. These results indicate that left ventricular thrombectomy might be an effective treatment for patients with mobile, pedunculated, left ventricular thrombi. However, additional experience is required to compare surgical and medical treatment.

Massive hemoptysis complicating Behçet's syndrome: the importance of early pulmonary angiography and operation.

A 16-year-old patient with Behçet's syndrome had massive hemoptysis due to a ruptured aneurysm of a segmental artery of the left lung. Emergency left lower lobectomy was performed. The patient is well 12 months after operation. There have been no further episodes of hemoptysis.

Mid-term clinical and echocardiographic follow up of patients with CarboMedics valves in the tricuspid position.

BACKGROUND AND AIM OF THE STUDY: Debate continues regarding tricuspid valve replacement (TVR) with a mechanical prosthesis. Experience with bileaflet prostheses is limited; hence the study aim was to explore early and mid-term outcome and hemodynamic data in patients with bileaflet CarboMedics prosthetic valves in the tricuspid position. METHODS: The study population included 25 patients (21 females, four males; mean age 50.5 +/- 13.4 years) who underwent TVR with a CarboMedics valve over a six-year period. Routine clinical examinations and details of transthoracic echocardiography (TTE) were reviewed. Additional TTE, transesophageal echocardiography (TEE) and fluoroscopy were performed as indicated. The number of previous cardiac operations was zero, one and two in 36%, 32% and 32% of patients, respectively. Previous tricuspid surgery was performed in eight cases (32%); concurrent mitral valve replacement was performed in 17 (68%). The hospital mortality rate was 24% and late mortality rate 12%. Seventeen early survivors (13 females, four males) were followed up for 46 +/- 28 months (range: 4-96 months). RESULTS: Among early survivors, the mean and peak transvalvular gradients were 4.0 +/- 1.7 and 7.9 +/- 3.3 mmHg, respectively. Commonly observed INR levels were >2.5 in seven patients (41%), and >3.0 in only three (18%). Five patients (29% of mid-term survivors) experienced a total of 13 episodes of obstructive valve thrombosis, mostly with inappropriate anticoagulation. One patient required emergency re-do surgery; the others responded initially to thrombolysis or intensified antithrombotic treatment, but experienced at least two additional relapses. Aside from thrombotic episodes, all patients but two were in NYHA functional class II-III, and all but four required diuretics. CONCLUSION: TVR with bileaflet mechanical valves carries a high perioperative mortality and mid-term morbidity. Among patients with poor or fair anticoagulation, these valves were associated with a high incidence of obstructive valve thrombosis. If poor patient compliance is anticipated, insertion of a bioprosthesis should be encouraged.

Preparation of the internal thoracic artery by vasodilator drugs: is it really necessary? A randomized double-blind placebo-controlled clinical study.

OBJECTIVE: The internal thoracic artery has become the conduit of choice for coronary artery bypass grafting. To avoid spasm of the artery, and increases in its diameter and flow, various vasodilators have been used either intraluminally or by topical application by different surgeons. In order to define the best vasodilating agent for preparation of the internal thoracic artery, a randomized double-blind placebo-controlled clinical study was performed in a group of patients submitted for elective coronary artery bypass grafting. METHODS AND RESULTS: Eighty (80) consecutive patients submitted for elective first time coronary artery bypass grafting were randomly subdivided into five treatment groups. Free flow of the left internal thoracic artery was measured using an electromagnetic flow meter. The first measurement was performed shortly after the internal thoracic artery was dissected from the chest wall and the second just prior to performing distal anastomosis to the left anterior descending coronary artery. During the time interval between the two measurements the internal thoracic artery was immersed in a special applicator tube containing 20 ml solution of one of the following drugs: papaverin 2 mg/ml, nitroglycerin 1 mg/ml, verapamil 0.5 mg/ml, nitroprusside 0.5 mg/ml, normal saline 0.9%. RESULTS: No statistically significant differences were found between the groups in respect to age, body surface area, bypass time, cross clamping time, and time interval between the two flow measurements. Mean arterial pressure at the time of the first and second internal thoracic artery flow measurements did not show statistically significant differences either within or between the groups. In all five groups, the free flow of the internal thoracic artery increased significantly with time. However, no statistically significant differences were shown between the five groups with respect to second flow (P = 0.2). CONCLUSIONS: Within the limits of our study design, we suggest that preparation of the LITA by topical vasodilator drugs using a special applicator tube does not result in a significantly superior free flow than placebo.

Instability of leukocyte aggregation: lack of evidence for leukoembolization during various states of inflammation.

This study centers on the question of whether the phenomenon of leukocyte aggregation, which is typical to inflammatory conditions, is pathogenic per se. We examined patients and laboratory animals in whom the presence of aggregated leukocytes in the peripheral blood was documented by direct visualization and where, despite the presence of aggregated leukocytes, neither the patients nor the laboratory animals showed clinical or pathological evidence for leukoembolization. Our in vitro findings about the reversibility of the phenomenon of leukocyte aggregation help to explain the above-mentioned observations as well as the well-known daily clinical experience that, despite complement activation and other aggregatory stimuli, there is no clinical or pathological evidence for leukoembolization.

Late partial tamponade of the right atrium. A case report.

An unusual case of late partial tamponade of the right atrium is reported in a patient 35 days after aortic valve replacement. Chest x-rays, echocardiograms and ECG were not helpful. The diagnosis was made by emergency bedside right heart catheterization which showed a 7 cm H2O gradient between the junction of the superior vena cava and right atrium and also a 12 cm H2O pressure difference between the femoral vein and the right atrium with a normal capillary wedge pressure. Re-thoracotomy with evacuation of blood clots and control of bleeding points improved the hemodynamics dramatically. However the patient succumbed 3 weeks later due to irreversible brain damage. This is thought to be the first report of a late partial right atrial tamponade in the English medical literature.

Massive spontaneous hemothorax as a presenting sign of aneurysmal rupture of the internal thoracic artery. A case report.

Massive spontaneous hemothorax is a very uncommon, life-threatening situation. Acute dissection and ruptured aorta can be one of the differential diagnoses, but usually the clinical feature is completely different, and very few patients have survived this event and received medical attention. Among other causes of spontaneous bleeding, some are extremely rare, demanding precise diagnosis and judicial and immediate intervention. We describe a patient who presented with a massive hemothorax. There was no immediately apparent cause. Emergent angiography revealed active bleeding from an extremely unusual source: aneurysmal dilatation of the internal thoracic artery.

Tricuspid stenosis due to intravenous leiomyomatosis--a call for caution: case report and review of the literature.

Extension of a benign intravenous leiomyomatous tumor from the pelvis into the right atrium resulted in severe tricuspid stenosis in a 28-year-old woman. Absence of the Budd-Chiari syndrome and other abdominal manifestations led to a misdiagnosis of a primary right atrial tumor, with a fatal outcome during operation. In our search of the English literature, this was only the second case found in which extensive intravenous leiomyomatosis interfered with the tricuspid valve mechanism. In this report, the clinical picture, etiology, and treatment are discussed, along with the literature on this rare entity.

[Prosthetic heart valve thrombosis: a 3-year experience].

A series of 12 patients with 16 episodes of prosthetic heart-valve thrombosis over 3 years is presented. Most episodes affected mitral or tricuspid bileaflet prostheses. All patients were inadequately anticoagulated at the time of thrombosis. The clinical presentation was acute and severe in 6 patients, and subacute or chronic in the rest. Physical examination was suggestive of stuck valves in most cases. Transthoracic echocardiography revealed increased transvalvular gradients in most. However, clearer evidence of valve thrombosis was obtained from transesophageal echocardiography or fluoroscopy. 9 patients eventually had their valves re-replaced successfully, and the preoperative diagnosis was confirmed in all. 5 patients were operated as soon as the diagnosis was established. and an additional 4 were operated after failure of anticoagulation. In 4 patients the valve leaflets became completely mobile after a course of thrombolysis. Prosthetic valve thrombosis is a severe and potentially fatal complication in patients with mechanical heart valves. Alertness of physicians at all levels- the general practitioner, the internist and the cardiologist- to the possibility of valve thrombosis and to its clinical presentation may lead to prompt and earlier diagnosis and to comprehensive therapy.

Molecular mechanism of peroxisome proliferator-activated receptor α activation by WY14643: a new mode of ligand recognition and receptor stabilization.

Peroxisome proliferator-activated receptors (PPARs) are members of a superfamily of nuclear transcription factors. They are involved in mediating numerous physiological effects in humans, including glucose and lipid metabolism. PPARα ligands effectively treat dyslipidemia and have significant antiinflammatory and anti-atherosclerotic activities. These effects and their ligand-dependent activity make nuclear receptors obvious targets for drug design. Here, we present the structure of the human PPARα in complex with WY14643, a member of fibrate class of drug, and a widely used PPAR activator. The crystal structure of this complex suggests that WY14643 induces activation of PPARα in an unusual bipartite mechanism involving conventional direct helix 12 stabilization and an alternative mode that involves a second ligand in the pocket. We present structural observations, molecular dynamics and activity assays that support the importance of the second site in WY14643 action. The unique binding mode of WY14643 reveals a new pattern of nuclear receptor ligand recognition and suggests a novel basis for ligand design, offering clues for improving the binding affinity and selectivity of ligand. We show that binding of WY14643 to PPARα was associated with antiinflammatory disease in a human corneal cell model, suggesting possible applications for PPARα ligands.

Mixed infection with intestinal tape worms in sheep.

In a survey carried out during the period April 2001 to November 2002, the intestines of 3165 slaughtered sheep in the Fars province of Iran were examined for mixed infection with intestinal tape worms. Four point sixty eight percent of animals were found to be infected with one or more than one species of tape worms. The identified species included: Moniezia expansa, Moniezia benedeni, Thysaniezia giardi, Avitellina centripunctata and Stilesia globipunctata. Of all 148 infected sheep, 104 animals (70.3%) were infected with one species, 38 animals (25.7%) were infected with two species and 5 animals (3.4%) were infected with three species of tape worms. No animal was found to be infected with four species but one sheep (0.7%) was found to be infected with all five species of tape worms.

Modulation of myosin function by isoform-specific properties of Saccharomyces cerevisiae and muscle tropomyosins.

Tropomyosin is an extended coiled-coil protein that influences actin function by binding longitudinally along thin filaments. The present work compares cardiac tropomyosin and the two tropomyosins from Saccharomyces cerevisiae, TPM1 and TPM2, that are much shorter than vertebrate tropomyosins. Unlike cardiac tropomyosin, the phase of the coiled-coil-forming heptad repeat of TPM2 is discontinuous; it is interrupted by a 4-residue deletion. TPM1 has two such deletions, which flank the 38-residue partial gene duplication that causes TPM1 to span five actins instead of the four of TPM2. Each of the three tropomyosin isoforms modulates actin-myosin interactions, with isoform-specific effects on cooperativity and strength of myosin binding. These different properties can be explained by a model that combines opposite effects, steric hindrance between myosin and tropomyosin when the latter is bound to a subset of its sites on actin, and also indirect, favorable interactions between tropomyosin and myosin, mediated by mutually promoted changes in actin. Both of these effects are influenced by which tropomyosin isoform is present. Finally, the tropomyosins have isoform-specific effects on in vitro sliding speed and on the myosin concentration dependence of this movement, suggesting that non-muscle tropomyosin isoforms exist, at least in part, to modulate myosin function.

Atrial tumors--surgical experience of 9 cases.

Nine patients underwent surgical removal of intracardiac tumor during a 12-year period. The mean age of the five women and four men was 57 years (range 40 to 69). Eight of the nine patients were operated on in the last four years of the study period. The interval from onset of symptoms to surgery averaged 18.3 months. Clinical presentation varied significantly, reflecting mechanical, embolic and constitutional effects of the intracardiac mass. Echocardiography was the noninvasive procedure that contributed most to preoperative diagnosis, confirming presence of an intracardiac tumor in seven of the eight examined patients. Of the nine intracardiac tumors, seven were myxomas (6 left atrial and 1 right atrial), one was a primary left atrial liposarcoma and one a right atrial metastasis from an anaplastic carcinoma of the kidney. No patient died during or immediately after the operation. The two patients with malignant tumor died, two months and two years postoperatively, from progression of the basic disease. In neither case, however, was atrial recurrence of tumor found at autopsy. Of the seven surviving patients, five are symptom-free after observation periods averaging 34 months (range 2 months to 12 years). The other two still have signs of mild congestive heart failure. No recurrence of atrial myxoma has so far been detected.