•We analyze general and specific deforestation reduction policies using a systematic approach.•Monitoring population and agriculture through intensification of livestock and arable production systems ...are promising solutions.•Setting of logging quotas, specifications of tasks inter alia are also promising.•Reducing deforestation reduces CO2 emissions, GDP and employment.•REDD+ offers options that absorb the shocks of reducing deforestation.
This study advances measures that can combat deforestation in Cameroon. It also looks at possible carbon dioxide (CO2) emission reductions and the effects on gross domestic product (GDP) and employment based on selected baseline scenarios based on reductions in deforestation. A systematic approach of analyzing the drivers, agents, socio-economic context, political context, spatial context of deforestation and specific and general deforestation reduction policies is used. The final step of the approach is to verify the repercussions of deforestation reduction on CO2 emissions, employment and GDP. Monitoring population growth and arable production through intensification of production is promising. The general policies that this study postulates are enforcement, legal adherence, specification of tasks and quotas, collaboration, forest licensing and monitoring. More specific policies could be within the reduction of emissions from deforestation and forest degradation mechanism (REDD+) as well as diversification of livelihoods, mechanization, use of fertilizers and intensive cattle farming inter alia. Reductions in deforestation will reduce atmospheric CO2, employment in the forestry sector and the share of forestry's contribution to GDP.
Performance of tricuspid annuloplasty (TA) in patients undergoing mitral valve surgery is recommended based on the degree of tricuspid regurgitation and tricuspid annulus size, but is often ...underused.
To evaluate the impact of combined TA on in-hospital outcome in patients undergoing mitral valve replacement (MVR).
We selected all consecutive patients who underwent MVR for native valve disease. Clinical, echocardiographic and in-hospital complications were obtained from chart review.
We identified 287 patients (mean age 62±17 years; 44% men). Combined TA was performed in 165 patients (57%), who had more rheumatic disease (71% vs. 24%; P<0.0001) and mitral stenosis (55% vs. 22%; P<0.0001), but less endocarditis (4% vs. 31%; P<0.0001), were more often in atrial fibrillation (54% vs. 22%; P<0.0001), were more severely symptomatic (80% vs. 57%; P<0.0001), presented with a higher systolic pulmonary artery pressure (SPAP) (53±16 vs. 45±15mmHg; P=0.0002) and were less likely to have required emergency surgery (17% vs. 38%; P<0.0001). Despite this higher risk profile, in-hospital mortality was slightly lower (5% vs. 13%; P=0.02) and complication rates were similar (redo surgery 22% vs. 16% P=0.18 and tamponade 20% vs. 15% P=0.15). After adjustment for age, sex, functional class, SPAP, emergency surgery and concomitant coronary artery bypass graft or aortic valve replacement surgery, combined TA was not associated with an increased rate of in-hospital death (P=0.08) or major complications (P=0.89).
In a consecutive series of patients who underwent MVR, TA did not seem to have a negative impact on immediate outcome. Hence, additional performance of TA at the time of MVR should not be declined on the basis of an increased surgical risk.
Si une annuloplastie tricuspide (AT) est indiquée chez les patients devant bénéficier d’une chirurgie mitrale en cas de fuite tricuspide significative ou de dilatation de l’anneau tricuspide, elle reste sous-utilisée.
Le but de la présente étude est d’évaluer l’impact d’une AT réalisée lors d’un remplacement valvulaire mitral (RVM) sur la morbi-mortalité hospitalière.
Nous avons recensé tous les patients consécutifs ayant bénéficiés d’un RVM sur une période de 2 ans dans notre institution et colligés les données cliniques, échographiques et les complications postopératoires.
Nous avons identifié 287 patients (62±17 ans ; 44 % homme). Les patients chez qui une AT a été réalisée (n=165, 57 %) présentaient plus souvent une étiologie rhumatismale (71 % vs 24 % ; p<0,0001), une sténose mitrale (55 % vs 22 % ; p<0,0001) mais moins fréquemment une endocardite (4 % vs 31 % ; p<0,0001) était plus souvent en fibrillation auriculaire (54 % vs 22 % ; p<0,0001), plus sévèrement symptomatiques (80 % vs 57 % ; p<0,0001) et présentaient une pression artérielle pulmonaire (PAPS) plus élevée (53±16mmHg vs 45±15mmHg ; p=0,0002). Malgré une présentation plus sévère, la mortalité hospitalière était discrètement inférieure (5 % vs 13 % ; p=0,02) et le taux de complication non significativement diffèrent (ré-intervention 22 % vs 16 % p=0,18 ou tamponade 20 % vs 15 % p=0,15). Après ajustement pour l’âge, le sexe, la classe fonctionnelle, la PAPS, le degré d’urgence de la chirurgie et la réalisation d’un pontage ou d’un remplacement valvulaire aortique associé, la réalisation d’un AT n’était ni associée à une augmentation de la mortalité (p=0,08) ni à un taux plus élevé de complications sévères (p=0,89).
Dans cette série consécutive de patients opérés pour RVM, la réalisation d’un AT n’était pas associée à une augmentation du risque de complications post-opératoires. Ces résultats montrent que la crainte d’une augmentation du risque opératoire ne doit pas conduire a récuser la réalisation d’une AT si celle-ci est indiquée.
Background: Infective endocarditis (IE) due to gram-negative bacilli (GNB) is rare. However, several studies described a change in the epidemiological profile of patients within the past few years. ...Methods: We reviewed all cases diagnosed and followed in the infectious diseases ward of a French teaching hospital in Paris between 2009 and 2014, inclusive. Results: Among the 17 patients with definite GNB-IE (11 male, mean age 54 years), 12 (70%) were due to non-HACEK GNB and 5 (30%) to HACEK group GNB. A prosthetic valve was involved in 10 cases (8 in non-HACEK and 2 in HACEK group). Escherichia coli (4/12 patients) and Pseudomonas aeruginosa (3/12 patients) were the most common pathogens in the first group; all the pathogens in the second group were Haemophilus spp. One-third of the patients with non-HACEK GNB had nosocomial IE, whereas injection drug use-related infections were rare (2/12). All patients with HACEK infection had at least one complication (intracardiac abscess, stroke or other systemic embolization). All patients were treated by antibiotic combination therapy during a median time of 42 days (interquartile range (IQR) = 42-42) and 10 (59%) underwent cardiac surgery. One death at 9 months was observed in the non-HACEK group. Conclusions: Regarding HACEK IE, this report supports the frequent association with vascular complications. Regarding non-HACEK GNB IE, this report supports the increasing proportion of nosocomial infections. We reported a high proportion of surgery in the therapeutic management of both HACEK and non-HACEK groups associated with no in-hospital mortality.
Celotno besedilo
Dostopno za:
DOBA, IJS, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Cardiac implantable electronic devices (CIEDs) chronic infection diagnosis is challenging because the clinical presentation is frequently misleading and echocardiography may be inconclusive. The aim ...of this study was to evaluate the diagnostic value of
F-fluorodeoxyglucose positron emission tomography/computed tomography (CT) and radiolabeled white blood cells single photon emission CT/CT in a cohort of patients who underwent both scans for suspicion of CIED infection and inconclusive routine investigations.
Forty-eight consecutive patients with suspicion of CIED infection who underwent both
F-fluorodeoxyglucose positron emission tomography/CT and white blood cell single photon emission CT/CT in a time span ≤30 days were retrospectively included. The final diagnosis of CIED infection by the endocarditis expert team was based on the modified Duke-Li classification at the end of follow-up.
F-Fluorodeoxyglucose positron emission tomography/CT and white blood cell single photon emission CT/CT scans were independently analyzed blinded to the patients' medical record.
In the overall study population, the diagnostic sensitivity, specificity, positive predictive value, and negative predictive value were respectively 80%, 91%, 80%, and 91% for
F-fluorodeoxyglucose positron emission tomography/CT and 60%, 100%, 100%, and 85% for white blood cell single photon emission CT/CT. Addition of a positive nuclear imaging scan as a major criterion markedly improved the Duke-Li classification at admission. Semiquantitative parameters did not allow to discriminate between definite and rejected CIED infection. Prolonged antibiotic therapy before imaging tended to decrease the sensitivity for both techniques.
Nuclear imaging can improve the diagnostic performances of the Duke-Li score at admission in a selected population of patients with suspected CIED infection, particularly when the infection was initially graded as possible. Whenever possible, imaging should be performed before or early after antibiotic initiation.
The use of heparin exposes patients to heparin-induced thrombocytopenia, which is a challenging issue for both diagnosis and patient management. We sought to describe the clinical presentation, ...management and outcome of a series of patients diagnosed with heparin-induced thrombocytopenia after heart valve surgery.
All consecutive patients diagnosed with heparin-induced thrombocytopenia during the postoperative period of heart valve surgery over a 6-year period were prospectively enrolled in a single-centre registry. Clinical and biological data were collected. In-hospital and mid-term outcomes were assessed. Information regarding the occurrence of all medical events including death, recurrence of thromboembolic events and/or thrombocytopenia was collected.
We identified 93 patients (incidence proportion = 2.8%). Most patients (82%) were asymptomatic with isolated thrombocytopenia at the time of diagnosis. The other main circumstance of diagnosis was the occurrence of thromboembolic events in 17 patients (6 strokes, 10 prosthetic valve thrombosis and 1 peripheral embolic event). The in-hospital mortality rate was 1%. No thrombolysis, interventional procedure or redo surgery was performed. Danaparoid sodium was used as heparin replacement therapy in most cases (96%) and leading to complete and uneventful thrombus resolution in all cases with only one possibly related major bleeding complication. During a mean follow-up of 36 ± 20 months, no patient presented recurrence of any heparin-induced thrombocytopenia-related complication.
In this contemporary series of patients, heparin-induced thrombocytopenia incidence was low and isolated thrombocytopenia was the most frequent presentation. Conservative management with early diagnosis and substitutive anticoagulation therapy introduction was associated with a low rate of clinical events and a remarkably good outcome with a low mortality rate.
With the emergence of transcatheter mitral valve replacement, it appears crucial to provide contemporary references with which this new technology can be compared. At our institution, ...transoesophageal echocardiography is systematically performed before discharge after surgical mitral valve replacement.
To evaluate the rate and determinants of paravalvular regurgitation after surgical mitral valve replacement.
We collected medical history, indication, type of surgery and in-hospital outcome in all consecutive patients who underwent a mitral valve replacement in the past 2 years at our institution. Paravalvular regurgitation was assessed semiquantitatively using transoesophageal echocardiography before discharge.
We enrolled 399 patients (mean age 61±16 years; 58% women; 27% with a history of cardiac surgery). Mitral valve replacement was performed mainly for rheumatic disease (44%). Most patients were severely symptomatic (70% in New York Heart Association class III/IV). A mechanical prosthesis was implanted in 60% and a bioprosthesis in 40%. In-hospital mortality was 10%. Transoesophageal echocardiography was performed in 310 patients (77%); the main reasons for not performing transoesophageal echocardiography were frailty (n=40, 10%), early death (n=19, 5%) and contraindication for transoesophageal echocardiography (n=10, 3%). The overall rate of paravalvular regurgitation was 8% (n=25); a grade ≥2 was observed in five patients (2%), and two patients had to be reoperated on. Mitral annular calcification was the main factor associated with paravalvular regurgitation (P=0.01).
Surgical mitral valve replacement was associated with significant in-hospital mortality and morbidity. Using systematic transoesophageal echocardiography assessment, paravalvular regurgitation was not uncommon (8%), and was significantly linked to mitral annulus calcification. However, clinically significant leakage (≥grade 2) was rare (2%).
Avec le développement du remplacement valvulaire mitral percutané, il devient indispensable de fournir des référentiels pour évaluer les nouvelles techniques. Dans notre hôpital, une échographie trans-œsophagienne est systématiquement réalisée avant la sortie de l’hôpital chez les patients ayant bénéficié d’un remplacement valvulaire mitral chirurgical.
Évaluer la fréquence et les déterminants des fuites para prothétiques après une chirurgie de remplacement valvulaire mitral.
Nous avons collecté les antécédents, l’indication et le type de chirurgie, les résultats de la chirurgie chez tous les patients ayant bénéficié d’un remplacement valvulaire mitral au cours des deux dernières années dans notre hôpital. Les fuites paravalvulaire ont été évaluées semi quantitativement par le biais de l’échographie trans-œsophagienne réalisée avant la sortie.
Nous avons inclus 399 patients (âge moyen 61±16 ans ; 58 % de femmes ; 27 % ayant un antécédent de chirurgie cardiaque). La pathologie mitrale principale était le rhumatisme articulaire aigu (44 %). La majorité des patients étaient très symptomatiques (70 % des patients stade II/IV de la NYHA). Une prothèse mécanique a été implantée dans 60 % des cas contre 40 % pour les prothèses biologiques. La mortalité intra-hospitalière était de 10 %. L’échographie trans-œsophagienne a pu être pratiquée chez 310 patients (77 %), les raisons principales de ne pas faire l’examen étaient la fragilité (n=40, 10 %), le décès précoce (n=19, 5 %) et la présence de contre-indication (n=10, 3 %). Le taux de fuite paraprothétique était de 8 % (n=25) ; un grade ≥2 était présent chez 5 patients (2 %), deux patients ont dû être réopérés. Les calcifications de l’anneau mitral étaient le principal facteur associé à la survenue d’une fuite para prothétique (p=0,01).
Le remplacement valvulaire mitral chirurgical est associé à une morbi-mortalité intra-hospitalière significative. Par le biais d’une évaluation échographique trans-œsophagienne, les fuites paraprothétiques ne sont pas exceptionnelles (8 %) et leur survenue est liée dans notre étude à la présence de calcification de l’anneau mitral. Cependant les fuites cliniquement parlantes (≥grade 2) restent rares (2 %).
Background
Bleeding originating in the gastrointestinal (
GI
) tract is one of the most common adverse events after left ventricular assist device (
LVAD
) implantation. In these patients,
GI
...bleeding appears to be the consequence of altered hemostasis on the one hand and alterations of the
GI
microvasculature on the other.
Case Report
We report the case of a patient who suffered repeated, severe
GI
bleeding early after implantation of a
HeartMate II
continuous‐flow
LVAD
.
Results
After failure of conventional treatment strategies,
GI
bleeding was controlled using repeated transfusions of a purified von
W
illebrand factor (
VWF
) concentrate, almost devoid of
F
actor
VIII
(
W
ilfactin,
LFB
). No episodes of pump thrombosis were noted. Subsequent to
VWF
transfusions, we observed a progressive normalization of circulating vascular endothelial growth factor levels.
Conclusions
Our data raise the possibility that, in addition to its hemostatic properties, transfusions of
VWF
might have acted as an antiangiogenic factor.
Les approches de gestion de l’eau par bassin versant sont variées autour de la planète et reposent sur un certain nombre de principes théoriques qui, eux aussi, varient d’un contexte à l’autre. Alors ...que ces approches se répandent grâce à l’adoption de politique nationale, les principes théoriques formels qui les définissent subissent un processus d’ajustement et reflètent les spécificités locales de mise en œuvre. Ainsi, une théorie effective de la gestion par bassin versant se situe à l’interface des volontés étatiques et des dynamiques sociales locales.En se basant sur le pragmatisme environnemental et sur l’analyse stratégique des organisations, de même que sur la réalisation de six études de cas, nous présentons l’ajustement subi par le modèle Québecois de gestion intégrée de l’eau par bassin versant depuis son adoption. Ce regard permet de constater que les repères théoriques formels subissent différentes évolutions en étant renforcés ou ignorés par les acteurs locaux, ou encore, en étant l’objet d’innovations qui visent à traduire les repères théoriques pour connecter aux contextes locaux.
Background
Heart failure is a major cause of mortality and morbidity, particularly among patients with advanced disease and no access to cardiac transplantation. LVAD implantation is not only a ...bridge-to-transplantation option for patients awaiting a heart donor, but is often used as bridge-to-destination therapy in patients unsuited for transplantation for various reasons. LVAD infection is considered the second-most common cause of death in patients who survive the initial 6 months on LVAD support. Few reports describe the indications for chronic suppressing antibiotic therapy, device exchange, methods for exchanging infected devices, post-exchange antimicrobial management status, and the outcomes of such patients.
Case presentation
This is the case of a 74-year-old male patient with numerous comorbidities who received urgent surgical management for severe heart failure with a HeartMate II. Six months later he developed an LVAD pump infection with methicillin-resistant Staphylococcus epidermidis, which was diagnosed with leucocyte scintigraphy. The patient received an omental graft over the LVAD and a chronic suppressive antibiotic regime. A marked leukocyte scintigraphy showed the infection's regression 6 months after the initiation of antibiotic treatment.
Discussion
We concisely reviewed the driveline infections and the main aspects of the LVAD pump infection. We reviewed options for conservative and nonconservative management and showed that conservative management of the LVAD pump infection is possible.
Conclusions
There are no defined recommendations for the management of LVAD pump infection. This case is among the few in the literature showing that conservative treatment of an LVAD pump infection is possible.
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