We sought to investigate the effect of patient prosthesis mismatch on hemodynamic profile using dobutamine stress echocardiography, and to evaluate midterm survival of patients undergoing aortic ...valve replacement with 19-mm Perimount (Baxter Healthcare, Santa Ana, California) aortic prosthetic valves.
Between December 1, 1999, and August 17, 2005, 147 patients (mean age, 76.8 +/- 5.51 years) had aortic valves replaced with 19-mm Perimount prostheses. Dobutamine stress echocardiography was performed in a subgroup of 24 patients (mean age, 76.6 +/- 5.60 years). Univariable predictors of peak transprosthetic gradient (PTG) under maximum stress, adjusted for resting PTG, were investigated by regression. Survival in the whole cohort was described, and univariable predictors of survival were investigated by Cox regression.
In the stress echocardiography subgroup, cardiac output (p < 0.0001), PTG (p < 0.0001), and effective orifice area index increased significantly (p = 0.002) under stress. Peak transprosthetic gradient under stress was strongly associated with PTG at rest (p < 0.0001). After controlling for PTG at rest, no other variables were associated with PTG under stress. In the whole cohort, mean duration of follow-up was 2.21 years; 23 patients died. Neither body surface area nor effective orifice area index was significantly associated with survival.
The 19-mm Perimount aortic prosthesis has acceptable hemodynamic performance. Transvalvular gradients were within a clinically acceptable range, both at rest and under stress. These findings suggest that patient-prosthesis mismatch is unlikely to cause a clinically important problem when the prosthesis is used, which is consistent with survival experience in the whole cohort.
Medullary thick ascending limb (mTAL) cells in primary culture express the Ca(2+)-sensing receptor (CaR), a G protein-coupled receptor that senses changes in extracellular Ca(2+) (Ca(o)(2+)) ...concentration, resulting in increases of intracellular Ca(2+) concentration and PKC activity. Exposure of mTAL cells to either Ca(o)(2+) or the CaR-selective agonist poly-L-arginine increased TNF-alpha synthesis. Moreover, the response to Ca(o)(2+) was enhanced in mTAL cells transfected with a CaR overexpression vector. Transfection of mTAL cells with a TNF promoter construct revealed an increase in reporter gene activity after exposure of the cells to Ca(o)(2+), suggesting that intracellular signaling pathways initiated by means of activation of a CaR contribute to TNF synthesis by a mechanism that involves transcription of the TNF gene. Neutralization of TNF activity with an anti-TNF antibody attenuated Ca(2+)-mediated increases in cyclooxygenase-2 (COX-2) protein expression and PGE(2) synthesis, suggesting that TNF exerts an autocrine effect in the mTAL, which contributes to COX-2-mediated PGE(2) production. Preincubation with the PKC inhibitor bisindolylmaleimide I inhibited Ca(2+)-mediated TNF production. Significant inhibition of COX-2 protein expression and PGE(2) synthesis also was observed when cells were challenged with Ca(o)(2+) in the presence of bisindolylmaleimide I. The data suggest that increases in TNF production subsequent to activation of the CaR may be the basis of an important renal mechanism that regulates salt and water excretion.
Men who join militant Islamist networks often frame their participation in masculine terms, as protectors, warriors or brothers. While the role of masculinities in recruitment to jihadi groups has ...received increasing attention, their role in disengaging men from armed groups (and particularly men in the global south) have not. This paper explores the role of masculinities in shaping men's paths out of jihadi networks. Based on life history research with Indonesian former militant Islamist we suggest that men's pathways out of armed groups are defined by negotiating alternate masculinities, which reposition their gendered role in society from those associated with militancy.
Background
Obesity increases risk of venous thromboembolism (VTE) in obstetric patients regardless of delivery mode and for up to six weeks postpartum.
Aim
This study aimed to examine postpartum ...pharmacological VTE prophylaxis practices for obese women at an Australian tertiary referral hospital.
Materials and Methods
Medical records were retrieved for obese obstetric patients who delivered during May 2016–May 2017. Records were examined for demographic data, VTE risk factors, and LMWH (low‐molecular‐weight heparin) use. Due to lack of specific Australian or local guidelines, practice was evaluated using recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG‐UK). Patients with BMI (body mass index) <30, incomplete/unavailable medical records, and those discharged from other health services were excluded.
Results
One hundred and eight postpartum patients (70 caesareans, 38 vaginal deliveries) with a BMI ≥ 30 kg/m2 were reviewed. Of these patients, 53 (49.1%) had a BMI ≥ 40 kg/m2. Ninety‐eight of 108 (90.7%) patients had ≥2 VTE risk factors including a BMI ≥ 30 kg/m2. One hundred and three of 108 (95.4%) patients were indicated for postpartum VTE prophylaxis with LMWH, and 77 of 103 (74.8%) patients received it. Three of five patients meeting criteria for ≥6 weeks of LMWH thromboprophylaxis had it prescribed. Of the 72 patients whose weight exceeded 90 kg and who also received LMWH, 32 (44.4%) were prescribed a weight‐adjusted dose.
Conclusion
VTE prophylaxis practices using LMWH in obese postpartum patients, including weight‐adjusting doses and extended‐course prescribing, appear variable. Limited literature, recommendation discrepancies, and varied awareness of recommendations may be contributing factors. Further education and research regarding this high‐risk cohort are warranted.
Glomerular filtration rate (GFR) measured by Chromium-51-EDTA excretion (51Cr-GFR) is considered the gold standard of renal function assessment, but serum creatinine in the Cockcroft-Gault (CG) ...formula is routinely used to estimate GFR for carboplatin dosing. Serum creatinine measured by isotope-dilution-mass-spectrometry (IDMS) can generate spuriously high GFR estimates when used in the CG formula. We hypothesized that GFR calculated using IDMS-creatinine in the CG formula (CG-GFR) exposes patients to inaccurate carboplatin dosing.
This is a multicenter retrospective study of patients who had a 51Cr-GFR assessment for malignant or non-malignant indications, with a matched CG-GFR. Carboplatin dose based on 51Cr-GFR at AUC5 was used as the reference.
550 patients were analyzed, median age 62 (19–90), 64% female. Indication for GFR evaluation: malignancy (85%), assessment for live kidney donation (12%), other (3%). Median ratio of CG-GFR: 51Cr-GFR 1.04 (0.43–3.38); <0.8 in 72 patients (13%), >1.2 in 180 patients (33%). Despite capping of CG-GFR at 125 mL/min, dosing according to AUC6 would have resulted in 18% of patients being underdosed and 23% overdosed by >100 mg compared to 51Cr-GFR. Subgroup analysis identified BMI (>35, MPE 39%), gender (female MPE 15%), GFR indication (malignancy MPE 11%) as risk factors for overestimate of CG-GFR, and BMI < 20 for underestimate (MPE −3.5%).
The convention of considering AUC5 carboplatin based on 51Cr-GFR, and AUC6 carboplatin based on CG-GFR as equivalent is invalid and should be abandoned. When 51Cr-GFR is unavailable, capping CG-GFR at 125 mL/min is recommended.
•51Cr-GFR is considered the gold standard for renal function assessment.•The Cockroft-Gault formula can generate spuriously high GFR estimates.•AUC5 carboplatin based on 51Cr-GFR and AUC6 carboplatin based on CG-GFR are not equivalent.•Imprecise GFR estimates results in incorrect carboplatin dosing.•When 51Cr-GFR is unavailable, capping CG-GFR at 125 mL/min is recommended.
Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The ...study included 250 patients (males
= 101; females
= 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5 kg/m
,
< .001), and diabetes was more common in males (44 vs 42%,
= .012). The ejection fraction was higher in females (55 vs 50%,
< .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%,
= .003 and 44.30 vs 19.8%,
< .001, respectively). Mitral valve replacement was more common in females (
< .001), and they had lower concomitant coronary artery bypass grafting (
= .001). Bleeding and renal failure were lower in females (
= .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival HR (hazard ratio): 2.18;
= .024. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery.
To compare the clinical outcomes of immediate versus conventional delayed loading of four dental implants in edentulous mandibles with fixed prostheses.
A blinded, two-arm, parallel group, randomised ...controlled trial was conducted. A total of 42 patients were included, and each received four Brånemark System implants with a TiUnite surface. The patients were randomly assigned to two study arms: 1) immediate-loading arm (IL), in which the mandibular denture was converted into an interim implant-supported fixed prosthesis (ISFP) on the day of surgery, with a permanent ISFP being inserted at least 3 months postsurgery; 2) conventional-loading arm (CL), in which the mandibular removable prosthesis was relieved at the implant site and relined with a soft tissue conditioner. Only implants with a minimum insertion torque of ≥ 35 Ncm were included in the IL group. Implants were loaded 4 to 6 months postsurgery. Independent, blind investigators assessed the patients at 2, 6 and 12 months and at 10 years. The outcome measures were prosthesis and implant success rates, type and frequency of complications and changes in peri-implant marginal bone levels.
A total of 20 patients were allocated to the IL group and 22 to the CL group. However, one patient from the IL arm was excluded and three patients were reallocated to the CL arm. Two implants in one patient and one in another patient could not be placed with a ≥ 35 Ncm insertion torque, and a third patient developed severe sudden gag reflex and thus it was not possible to load the implants immediately. At a later stage, one of the patients who failed the initial stability test dropped out of the study. Therefore, initially, 24 patients were conventionally loaded and 16 patients were immediately loaded. At the 10-year follow-up, six patients dropped out from the IL arm and two from the CL arm. Also, at the 10-year-follow-up, the CL and IL study arms consisted of 22 and 10 participants, respectively, using the per-protocol (PP) analysis. Six implants failed in two patients of the CL arm (two implants in one patient and four implants in another patient), and three implants failed in three patients in the IL arm (PP analysis), respectively. The patient-level implant failure rate was 10% (intention-to-treat ITT analysis) and 14% (PP analysis) in the CL arm, and 25% (ITT) and 20% (PP) in the IL arm. The difference was not statistically significant (95% CI from -0.18 to 0.39, P = 0.65). The failure rate at the implant level was 8% (ITT) and 8% (PP) in the CL arm, and 6% (ITT) and 5% (PP) in the IL arm. The difference was not statistically significant (95% CI from -0.06 to 0.14, P = 0.44). Ten years after loading, patients in the IL arm lost an average of 0.55 ± 0.64 mm of peri-implant bone versus 0.41 ± 0.40 mm of peri-implant bone loss observed in the CL arm. The 10-year bone loss in both arms was statistically significant compared with the baseline (P < 0.001). However, there was no statistically significant difference between the two arms for peri-implant bone level changes (the difference between the arms was 0.14 mm ± 0.50 mm; 95% CI -0.23 to 0.52; P = 0.43). One prosthesis failed due to the loss of all four implants in one patient of the CL arm. Eight patients from the IL arm were affected by 13 complications (such as pain from fractures and inflammation) versus seven patients (10 complications) from the CL arm. The complication rate was 67% in the IL arm and 35% in the CL arm. The difference in complication proportions between the two arms was not statistically significant (difference in proportions = 0.32; 95% CI = -0.08 to 0.61; P = 0.14). All complications were managed successfully.
Long-term data of immediate loading of four dental implants with a mandibular fixed prosthesis revealed comparable clinical outcomes to conventional loading. Therefore, immediate loading should be considered in the treatment of edentulous patients.
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