Mitral regurgitation secondary to infective endocarditis of the mitral valve in a patient with cor triatriatum sinistrum

The present essay begins by adapting the metaphor of Nassim Taleb, The Black Swan to the phenomenon of tourism in order to inquire the effects that terrorism acts have on the world´s tourist behaviour. This article was finished on June 2016 and is consistent with the unpredictability of subsequent events. You won’t find an analysis of statistics based on tourism models or analysis methods; nonetheless it presents a deductive approximation based on news reviews and social network publications that circulate about tourism. On the one hand, the news related to the impacts of terrorist attacks disturb the world at global scale making an impact on tourism destinations and on the other hand, there are cities with a parallel reality, one that shows an idyllic world, with positive and encouraging statistics of tourist visitors, travel promotion and circulation of travel experiences in social networks. Resembling the novel, the fiction of real characters. The sources triangulation, is not conclusive but indicative about the vast information that exists, the elaborated circulation of images and the broad literature of tourism; (some of them showing an interdisciplinary relation between terrorism and tourism) however, some of it lacks research and do not contribute to the knowledge of this phenomenon in social and economic aspects, beyond the marketing, a thematic highly privilege by the production of texts. The current swan disturbs, but the reaction of the travel industry is to settle.El presente ensayo parte de asimilar la metáfora de El cisne negro de Nassim Taleb con el fenómeno del turismo para indagar sobre los efectos del terrorismo en el comportamiento difícil de pronosticar de las hordas de turistas que viajan por el planeta. Su escritura concluyó en junio de 2016 y es consecuente con lo impredecible de los acontecimientos a posteriori. Aquí no se recogen ni analizan estadísticas de turismo bajo modelos o métodos de análisis; de lo que se trata es de hacer una aproximación deductiva con base en la observación de las noticias y publicaciones sobre turismo que circulan en redes sociales. Por una parte, están las noticias en torno a las consecuencias de los atentados terroristas que perturban al mundo a nivel global y que impactan los destinos turísticos; por otra, aquellas que circulan en la otra realidad paralela, la del mundo idílico de cifras exitosas y alentadoras para el turismo global, la promoción de los viajes y la circulación de experiencias de viajeros en las redes sociales. Como en la novela de Taleb, la ficción de personajes reales. El ejercicio de triangulación de fuentes no llega a ser concluyente, pero sí indicativo de la existencia de una vasta información, de una prolija circulación de imágenes y de la amplia existencia de literatura sobre el turismo (alguna con interesantes aproximaciones interdisciplinarias al fenómeno de la relación entre terrorismo y turismo), que ve reducido su ámbito de difusión por cuenta de un mar de escritos, en buena medida carentes de estudios profundos que permitan conocer más a fondo este fenómeno como un fenómeno social y económico, más allá del marketing, una temática altamente privilegiada por la producción de textos. El cisne de momento perturba, pero como reacción, la industria de los viajes y el turismo se acomoda

Systolic Anterior Motion of the Mitral Valve and Three-Dimensional Echocardiography

AnesthesiologyCardiac & Cardiovascular SystemsRespiratory SystemPeripheral Vascular DiseaseSCI(E)[email protected]

Demonstration and Performance Evaluation of Two Novel Algorithms for Removing Artifacts From Automated Intraoperative Temperature Data Sets: Multicenter, Observational, Retrospective Study

BackgroundThe automated acquisition of intraoperative patient temperature data via temperature probes leads to the possibility of producing a number of artifacts related to probe positioning that may impact these probes’ utility for observational research. ObjectiveWe sought to compare the performance of two de novo algorithms for filtering such artifacts. MethodsIn this observational retrospective study, the intraoperative temperature data of adults who received general anesthesia for noncardiac surgery were extracted from the Multicenter Perioperative Outcomes Group registry. Two algorithms were developed and then compared to the reference standard—anesthesiologists’ manual artifact detection process. Algorithm 1 (a slope-based algorithm) was based on the linear curve fit of 3 adjacent temperature data points. Algorithm 2 (an interval-based algorithm) assessed for time gaps between contiguous temperature recordings. Sensitivity and specificity values for artifact detection were calculated for each algorithm, as were mean temperatures and areas under the curve for hypothermia (temperatures below 36 °C) for each patient, after artifact removal via each methodology. ResultsA total of 27,683 temperature readings from 200 anesthetic records were analyzed. The overall agreement among the anesthesiologists was 92.1%. Both algorithms had high specificity but moderate sensitivity (specificity: 99.02% for algorithm 1 vs 99.54% for algorithm 2; sensitivity: 49.13% for algorithm 1 vs 37.72% for algorithm 2; F-score: 0.65 for algorithm 1 vs 0.55 for algorithm 2). The areas under the curve for time × hypothermic temperature and the mean temperatures recorded for each case after artifact removal were similar between the algorithms and the anesthesiologists. ConclusionsThe tested algorithms provide an automated way to filter intraoperative temperature artifacts that closely approximates manual sorting by anesthesiologists. Our study provides evidence demonstrating the efficacy of highly generalizable artifact reduction algorithms that can be readily used by observational studies that rely on automated intraoperative data acquisition

Combined Epidural-General Anesthesia vs General Anesthesia Alone for Elective Abdominal Aortic Aneurysm Repair.

Importance: Epidural analgesia (EA) is used as an adjunct procedure for postoperative pain control during elective abdominal aortic aneurysm (AAA) surgery. In addition to analgesia, modulatory effects of EA on spinal sympathetic outflow result in improved organ perfusion with reduced complications. Reductions in postoperative complications lead to shorter convalescence and possibly improved 30-day survival. However, the effect of EA on long-term survival when used as an adjunct to general anesthesia (GA) during elective AAA surgery is unknown. Objective: To evaluate the association between combined EA-GA vs GA alone and long-term survival and postoperative complications in patients undergoing elective, open AAA repair. Design, Setting, and Participants: A retrospective analysis of prospectively collected data was performed. Patients undergoing elective AAA repair between January 1, 2003, and December 31, 2011, were identified within the Vascular Society Group of New England (VSGNE) database. Kaplan-Meier curves were used to estimate survival. Cox proportional hazards regression models and multivariable logistic regression models assessed the independent association of EA-GA use with postoperative mortality and morbidity, respectively. Data analysis was conducted from March 15, 2015, to September 2, 2015. Interventions: Combined EA-GA. Main Outcomes and Measures: The primary outcome measure was all-cause mortality. Secondary end points included postoperative bowel ischemia, respiratory complications, myocardial infarction, dialysis requirement, wound complications, and need for surgical reintervention within 30 days of surgery. Results: A total of 1540 patients underwent elective AAA repair during the study period. Of these, 410 patients (26.6%) were women and the median (interquartile range) age was 71 (64-76) years; 980 individuals (63.6%) received EA-GA. Patients in the 2 groups were comparable in terms of age, comorbidities, and suprarenal clamp location. At 5 years, the Kaplan-Meier-estimated overall survival rates were 74% (95% CI, 72%-76%) and 65% (95% CI, 62%-68%) in the EA-GA and GA-alone groups, respectively (P \u3c .01). In adjusted analyses, EA-GA use was associated with significantly lower hazards of mortality compared with GA alone (hazard ratio, 0.73; 95% CI, 0.57-0.92; P = .01). Patients receiving EA-GA also had lower odds of 30-day surgical reintervention (odds ratio [OR], 0.65; 95% CI, 0.44-0.94; P = .02) as well as postoperative bowel ischemia (OR, 0.54; 95% CI, 0.31-0.94; P = .03), pulmonary complications (OR, 0.62; 95% CI, 0.41-0.95; P = .03), and dialysis requirements (OR, 0.44; 95% CI, 0.23-0.88; P = .02). No significant differences were noted for the odds of wound (OR, 0.88; 95% CI, 0.38-1.44; P = .51) and cardiac (OR, 1.08; 95% CI, 0.59-1.78; P = .82) complications. Conclusions and Relevance: Combined EA-GA was associated with improved survival and significantly lower HRs and ORs for mortality and morbidity in patients undergoing elective AAA repair. The survival benefit may be attributable to reduced immediate postoperative adverse events. Based on these findings, EA-GA should be strongly considered in suitable patients

Variation in propofol induction doses administered to surgical patients over age 65

Background/ObjectivesAdvanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery.DesignRetrospective observational study using the Multicenter Perioperative Outcomes Group data set.SettingThirty‐six institutions across the United States.ParticipantsA total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018.InterventionNone.MeasurementsTotal induction bolus dose of propofol administered.ResultsThe mean (SD) weight‐adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6–65.0), varying from 73.8% among patients aged 65–69 to 45.8% among patients aged 80 and older.ConclusionThe present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.See related editorial by Devinney et al. in this issue.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/169351/1/jgs17139_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/169351/2/jgs17139-sup-0001-Supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/169351/3/jgs17139.pd

Variation in propofol induction doses administered to surgical patients over age 65

Background/ObjectivesAdvanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery.DesignRetrospective observational study using the Multicenter Perioperative Outcomes Group data set.SettingThirty‐six institutions across the United States.ParticipantsA total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018.InterventionNone.MeasurementsTotal induction bolus dose of propofol administered.ResultsThe mean (SD) weight‐adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6–65.0), varying from 73.8% among patients aged 65–69 to 45.8% among patients aged 80 and older.ConclusionThe present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.See related editorial by Devinney et al. in this issue.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/169351/1/jgs17139_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/169351/2/jgs17139-sup-0001-Supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/169351/3/jgs17139.pd

Early Cellular Changes in the Ascending Aorta and Myocardium in a Swine Model of Metabolic Syndrome

<div><p>Background</p><p>Metabolic syndrome is associated with pathological remodeling of the heart and adjacent vessels. The early biochemical and cellular changes underlying the vascular damage are not fully understood. In this study, we sought to establish the nature, extent, and initial timeline of cytochemical derangements underlying reduced ventriculo-arterial compliance in a swine model of metabolic syndrome.</p><p>Methods</p><p>Yorkshire swine (n = 8 per group) were fed a normal diet (ND) or a high-cholesterol (HCD) for 12 weeks. Myocardial function and blood flow was assessed before harvesting the heart. Immuno-blotting and immuno-histochemical staining were used to assess the cellular changes in the myocardium, ascending aorta and left anterior descending artery (LAD).</p><p>Results</p><p>There was significant increase in body mass index, blood glucose and mean arterial pressures (p = 0.002, p = 0.001 and p = 0.024 respectively) in HCD group. At the cellular level there was significant increase in anti-apoptotic factors p-Akt (p = 0.007 and p = 0.002) and Bcl-xL (p = 0.05 and p = 0.01) in the HCD aorta and myocardium, respectively. Pro-fibrotic markers TGF-β (p = 0.01), pSmad1/5 (p = 0.03) and MMP-9 (p = 0.005) were significantly increased in the HCD aorta. The levels of pro-apoptotic p38MAPK, Apaf-1 and cleaved Caspase3 were significantly increased in aorta of HCD (p = 0.03, p = 0.04 and p = 0.007 respectively). Similar changes in coronary arteries were not observed in either group. Functionally, the high cholesterol diet resulted in significant increase in ventricular end systolic pressure and–dp/dt (p = 0.05 and p = 0.007 respectively) in the HCD group.</p><p>Conclusion</p><p>Preclinical metabolic syndrome initiates pro-apoptosis and pro-fibrosis pathways in the heart and ascending aorta, while sparing coronary arteries at this early stage of dietary modification.</p></div

Expression of neurovascular markers in the myocardium.

<p>(A) The slides from myocardial sections from normal (ND) and high cholesterol diet (HCD)-treated swine for PGP9.5. (B) PGP9.5 quantification showing a significant decrease in sympathetic nerves in the high cholesterol diet treated pigs. (*p-value<0.05).</p