Incidencia de hipertensión ocular y glaucoma agudo por bloqueo pupilar tras implante de lente intraocular fáquica tipo ICL. Resultados anatómicos y funcionales a corto y medio plazo. Resultados preliminares

L'implant d’una lent intraocular fàquica tipus ICL (Implantable Collamer Lens) pot produir glaucoma agut per tancament angular degut a un bloqueig pupil•lar amb el consegüent augment de la pressió intraocular, el mecanisme i epidemiologia del qual no són ben coneguts. Aquest estudi preliminar pretén avaluar la incidència d'hipertensió ocular i glaucoma agut per tancament angular degut a bloqueig pupil·lar després de l'implant d'una lent posterior fàquica tipus ICL i plantejar hipòtesis sobre el seu mecanisme fisiopatològic.

Reducing the Risk: A Strategic Approach - The Report of the Task Force on Sudden Cardiac Death

The Minister for Health and Children established the Task Force on Sudden Cardiac Death (SCD) in the Autumn of 2004, with the following terms of reference:1) Define SCD and describe its incidence and underlying causes in Ireland.2) Advise on the detection and assessment of those at high risk of SCD and their relatives.3) Advise on the systematic assessment of those engaged in sports and exercise for risk of SCD.4) Advise on maximizing access to basic life support (BLS) and automated external defibrillators (AEDs) and on:- appropriate levels of training in BLS and use of AEDs, and on the maintenance of that training- priority individuals and priority groups for such training- geographic areas and functional locations of greatest need- best practice models of first responder scheme and public access defibrillation, and- integration of such training services.5) Advise on the establishment and maintenance of surveillance systems, including a registry of SCD and information systems to monitor risk assessment, and training and equipment programmes.6) Advise and make recommendations on other priority issues relevant to SCD in Ireland.7) Outline a plan for implementation and advise on monitoring the implementation of recommendations made in the Task Force’s report. In undertaking its work the Task Force was mindful of national health policy, relevant national strategies and of the recently reformed structures for health service delivery in Ireland. Read the Report (PDF, 1.66mb)

La mort subite: de l' épidémiologie à la prévention [Sudden cardiac death: epidemiology and modern therapy].

Sudden Cardiac Death (SCD) has become an important public health challenge in the Western World. In Switzerland near 10,000 people suffer each year from SCD. The survival from SCD to hospital discharge is discouraging (near 5%). Large majority of events occur unexpectedly in the out-of-hospital environment and are not predicted with great accuracy by risk profiling. Because the majority of SCD occur by the mechanism of ventricular fibrillation, community-based defibrillation strategies have emerged as one approach to SCD problem. Newer strategies of defibrillation designed to respond faster to out-of-hospital cardiac arrest, including public access defibrillation, as well as aggressive primary and secondary prevention of coronary artery disease appears as the best approach for successful management of SCD.

AgilITIL : creación de una wiki semántica de soporte a los procesos de control

Este trabajo tiene como objetivo crear una Wiki Semántica que sirva de soporte para un modelo de gestión de servicios ágil, colaborativo y fácilmente implantable en las organizaciones denominadas pymes. En este tipo de organizaciones el posicionamiento inicial, ante la adopción de políticas como las sugeridas en ITIL, suele ser de rechazo, por la cantidad de trabajo añadido que previsiblemente genera. La Web Semántica aporta al conjunto la capacidad para establecer reglas de gestión del conocimiento, factor determinante para el crecimiento de una organización. El marco de recomendaciones ITIL es muy extenso y en este trabajo se pretende dar respuesta a los procesos de control pertenecientes a la fase del ciclo de vida denominada "Transición del Servicio". Estos procesos son: la gestión de la configuración, la gestión del cambio y la gestión de la entrega y despliegue.

On-pump beating heart coronary surgery for high risk patients requiring emergency multiple coronary artery bypass grafting.

BACKGROUND: Cardiopulmonary bypass (CPB) with aortic cross-clamping and cardioplegic arrest remains the method of choice for patients requiring standard myocardial revascularization. Therefore, very high-risk patients presenting with acute coronary syndrome, unstable angina, onset of cardiac decompensation and requiring emergency multiple myocardial revascularization, can have a poor outcome. The on-pump beating heart technique can reduce the mortality and the morbidity in such a selected group of patients and this report describes our clinical experience. METHODS: Out of 290 patients operated for CABG from January 2005 to January 2006, 25 (8.6%) selected high-risk patients suffering from life threatening coronary syndrome (mean age 69 +/- 7 years) and requiring emergency multiple myocardial revascularization, underwent on-pump beating heart surgery. The mean pre-operative left ventricle ejection fraction (LVEF) was 27 +/- 8%. The majority of them (88%) suffered of tri-vessel coronary disease and 6 (24%) had a left main stump disease. Nine patients (35%) were on severe cardiac failure and seven among them (28%) received a pre-operative intra-aortic balloon pump. The pre-operative EuroScore rate was equal or above 8 in 18 patients (73%). RESULTS: All patients underwent on-pump-beating heart coronary revascularization. The mean number of graft/patient was 2.9 +/- 0.6 and the internal mammary artery was used in 23 patients (92%). The mean CPB time was 84 +/- 19 minutes. Two patients died during the recovery stay in the intensive care unit, and there were no postoperative myocardial infarctions between the survivors. Eight patients suffered of transitorily renal failure and 1 patient developed a sternal wound infection. The mean hospital stay was 12 +/- 7 days. The follow-up was complete for all 23 patients survived at surgery and the mean follow-up time was 14 +/- 5 months. One patient died during the follow-up for cardiac arrest and 2 patients required an implantable cardiac defibrillator. One year after surgery they all had a standard trans-thoracic echocardiogram showing a mean LVEF rate of 36 +/- 11.8%. CONCLUSION: Standard on-pump arrested heart coronary surgery has higher mortality and morbidity in emergencies. The on-pump beating heart myocardial revascularization seems to be a valid alternative for the restricted and selected cohort of patients suffering from life threatening coronary syndrome and requiring multiple emergency CABG.

Ombres et lumières de l'accès public a la défibrillation [Public access defibrillation]

La stratégie d'accès public à la défibrillation (APD) comprend l'installation de défibrillateurs automatiques externes (DAE) dans les lieux publics et l'entraînement de sauveteurs non professionnels à la réanimation cardio pulmonaire et à la défibrillation (RCP-D). Cette approche est recommandée pour le traitement des arrêts cardiaques (ACR) dans les lieux publics. Beaucoup d'études d'observation, mais peu d'études randomisées s'intéressant à cette approche ont été publiées. Cet article résume les différentes approches proposées dans le cadre d'APD. A notre avis, l'installation de DAE dans des lieux publics ou le choix d'une stratégie alternative doivent être précédés d'une étude de la démographie locale des ACR et de l'entraînement du plus grand nombre possible de laïcs à la reconnaissance des signes précurseurs d'ACR et au massage cardiaque externe. Placement of automated external defibrillators (AED) in public facilities and training of the lay persons in basic life support-defibrillation (BLS-D) was recommended by the American Heart Association for the treatment of out-of-hospital cardiac arrest (OHCA). Immediate use of AED result in increase of survival to hospital discharge. Many observation and much less randomized trials describe clinical efficacy of this approach. However, "negative" trials have also been published and some recent data suggest that public access defibrillation (PAD) will have a minimal impact on population survival. In this article various PAD strategies were briefly reviewed. In our opinion installation of AED in public places should be based on the long-term study of local OHCA demography and preceded by widespread BLS training of lay population.

Assessment of the teaching-learning process in students of the health area: cardiopulmonary resuscitation maneuvers

OBJECTIVETo evaluate the skills and knowledge of undergraduate students in the health area on cardiopulmonary resuscitation maneuvers with the use of an automatic external defibrillator.METHODThe evaluation was performed in three different stages of the teaching-learning process. A theoretical and practical course was taught and the theoretical classes included demonstration. The evaluation was performed in three different stages of the teaching-learning process. Two instruments were applied to evaluate the skills (30-items checklist) and knowledge (40-questions written test). The sample comprised 84 students.RESULTSAfter the theoretical and practical course, an increase was observed in the number of correct answers in the 30-items checklist and 40-questions written test.CONCLUSIONAfter the theoretical class (including demonstration), only one of the 30-items checklist for skills achieved an index ≥ 90% of correct answers. On the other hand, an index of correct answers greater than 90% was achieved in 26 (86.7%) of the 30 items after a practical training simulation, evidencing the importance of this training in the defibrillation procedure.

Remote control of pulmonary blood flow: a dream comes true.

The indication for pulmonary artery banding is currently limited by several factors. Previous attempts have failed to produce adjustable pulmonary artery banding with reliable external regulation. An implantable, telemetrically controlled, battery-free device (FloWatch) developed by EndoArt SA, a medical company established in Lausanne, Switzerland, for externally adjustable pulmonary artery banding was evaluated on minipigs and proved to be effective for up to 6 months. The first human implant was performed on a girl with complete atrioventricular septal defect with unbalanced ventricles, large patent ductus arteriosus and pulmonary hypertension. At one month of age she underwent closure of the patent ductus arteriosus and FloWatch implantation around the pulmonary artery through conventional left thoracotomy. The surgical procedure was rapid and uneventful. During the entire postoperative period bedside adjustments (narrowing or release of pulmonary artery banding with echocardiographic assessment) were repeatedly required to maintain an adequate pressure gradient. The early clinical results demonstrated the clinical benefits of unlimited external telemetric adjustments. The next step will be a multi-centre clinical trial to confirm the early results and adapt therapeutic strategies to this promising technology.

Home care: a safe and attractive alternative to inpatient administration of intensive chemotherapies.

OBJECTIVE: The objective of this study was to evaluate feasibility, safety, perception, and costs of home care for the administration of intensive chemotherapies. METHODS: Patients receiving sequential chemotherapy in an inpatient setting, living within 30 km of the hospital, and having a relative to care for them were offered home care treatment. Chemotherapy was administered by a portable, programmable pump via an implantable catheter. The main endpoints were safety, patient's quality of life [Functional Living Index-Cancer (FLIC)], satisfaction of patients and relatives, and costs. RESULTS: Two hundred days of home care were analysed, representing a total of 46 treatment cycles of intensive chemotherapy in 17 patients. Two cycles were complicated by technical problems that required hospitalisation for a total of 5 days. Three major medical complications (heart failure, angina pectoris, and major allergic reaction) could be managed at home. Grades 1 and 2 nausea and vomiting occurring in 36% of patients could be treated at home. FLIC scores remained constant throughout the study. All patients rated home care as very satisfactory or satisfactory. Patient benefits of home care included increased comfort and freedom. Relatives acknowledged better tolerance and less asthenia of the patient. Home care resulted in a 53% cost benefit compared to hospital treatment (420 ± 120/day vs. 896 ± 165/day). CONCLUSION: Administration of intensive chemotherapy regimens at home was feasible and safe. Quality of life was not affected; satisfaction of patients and relatives was very high. A psychosocial benefit was observed for patients and relatives. Furthermore, a cost-benefit of home care compared to hospital treatment was demonstrated.

Patients avec syndrome de Brugada et défibrillateur implanté : suivi clinique

Introduction :¦Le syndrome de Brugada (SB) se définit par une élévation du segment ST dans les dérivations précordiales droites (V1-V3) associée à une incidence élevée de mort subite par arythmies chez des patients sans cardiopathie structurelle. La prévention de la mort subite repose sur la pose d'un défibrillateur automatique implantable (DAI).¦Matériel et méthode :¦Cette étude est une analyse rétrospective de tous les patients avec SB implantés d'un DAI au CHUV entre 1998 et 2010. Le profil des patients, les complications, ainsi que les thérapies appropriées et inappropriées délivrées par le défibrillateur ont été évaluées. Une thérapie appropriée est définie par l'action appropriée du DAI (choc ou stimulation anti-tachycardie = ATP) en réponse à une TV ou une FV correctement détectée. La thérapie inappropriée est définie comme une thérapie délivrée par l'appareil en l'absence d'une arythmie ventriculaire.¦Résultats :¦Durant la période étudiée (01.01.1998 - 31.12.2010) nous avons collecté au total 23 patients soit 19 hommes (83%) et 4 femmes (17%) âgés de 12 à 60 ans (41 13 ans). Le rapport hommes/femmes est de 4.75. Le suivi quant à lui porte sur 21 patients: un patient, après échec de primo-implantation au CHUV, a été implanté d'un défibrillateur dans un autre canton et un second patient a été perdu de vue entre l'implantation et le premier contrôle prévu. Le suivi moyen des 21 patients restants est de 8432 mois (37-149 mois, médiane : 78 mois). Il y a eu au total 45 thérapies délivrées : 12 appropriées (8 chocs; 4 ATP) et 33 inappropriées. 18% des patients ont eu ≥ 1 thérapie appropriée alors que 43% ont eu ≥ 1 choc inapproprié. 14 des 23 patients (61%) ont eu ≥ 1 complication (9 avec chocs inappropriés, 7 avec complications opératoires après primo-implantations ou ré-interventions, 6 avec dysfonction de sonde ventriculaire et 1 avec explantation).¦Conclusion :¦Le profil de ce petit collectif de patients avec SB implantés d'un DAI au CHUV est comparable à celui décrit dans la littérature. Durant un suivi moyen de 7 ans après la primo-implantation, l'incidence d'arythmies ventriculaires malignes est faible, avec un taux annuel de 2.6%. Le taux de complication est quant à lui élevé (8.7%/an). Près des trois-quarts des thérapies délivrées par le DAI sont inappropriées et les patients avec thérapies inappropriées sont 2.4x plus fréquents que les patients avec thérapies appropriées.

High activity of Fosfomycin and Rifampin against methicillin-resistant staphylococcus aureus biofilm in vitro and in an experimental foreign-body infection model.

Increasing antimicrobial resistance reduces treatment options for implant-associated infections caused by methicillin-resistant Staphylococcus aureus (MRSA). We evaluated the activity of fosfomycin alone and in combination with vancomycin, daptomycin, rifampin, and tigecycline against MRSA (ATCC 43300) in a foreign-body (implantable cage) infection model. The MICs of the individual agents were as follows: fosfomycin, 1 μg/ml; daptomycin, 0.125 μg/ml; vancomycin, 1 μg/ml; rifampin, 0.04 μg/ml; and tigecycline, 0.125 μg/ml. Microcalorimetry showed synergistic activity of fosfomycin and rifampin at subinhibitory concentrations against planktonic and biofilm MRSA. In time-kill curves, fosfomycin exhibited time-dependent activity against MRSA with a reduction of 2.5 log10 CFU/ml at 128 × the MIC. In the animal model, planktonic bacteria in cage fluid were reduced by <1 log10 CFU/ml with fosfomycin and tigecycline, 1.7 log10 with daptomycin, 2.2 log10 with fosfomycin-tigecycline and fosfomycin-vancomycin, 3.8 log10 with fosfomycin-daptomycin, and >6.0 log10 with daptomycin-rifampin and fosfomycin-rifampin. Daptomycin-rifampin cured 67% of cage-associated infections and fosfomycin-rifampin cured 83%, whereas all single drugs (fosfomycin, daptomycin, and tigecycline) and rifampin-free fosfomycin combinations showed no cure of MRSA cage-associated infections. No emergence of fosfomycin resistance was observed in animals; however, a 4-fold increase in fosfomycin MIC (from 2 to 16 μg/ml) occurred in the fosfomycin-vancomycin group. In summary, the highest eradication of MRSA cage-associated infections was achieved with fosfomycin in combination with rifampin (83%). Fosfomycin may be used in combination with rifampin against MRSA implant-associated infections, but it cannot replace rifampin as an antibiofilm agent.

The appropriate use of neurostimulation: avoidance and treatment of complications of neurostimulation therapies for the treatment of chronic pain.

INTRODUCTION: The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes. METHODS: The Neuromodulation Appropriateness Consensus Committee (NACC) reviewed the world literature in English by searching MEDLINE, PubMed, and Google Scholar to evaluate the evidence for ways to reduce risks of neurostimulation therapies. This evidence, obtained from the relevant literature, and clinical experience obtained from the convened consensus panel were used to make final recommendations on improving safety and reducing risks. RESULTS: The NACC determined that the ability to reduce risk associated with the use of neurostimulation devices is a valuable goal and possible with best practice. The NACC has recommended several practice modifications that will lead to improved care. The NACC also sets out the minimum training standards necessary to become an implanting physician. CONCLUSIONS: The NACC has identified the possibility of improving patient care and safety through practice modification. We recommend that all implanting physicians review this guidance and consider adapting their practice accordingly.

Polyanalgesic Consensus Conference-2012: Recommendations to Reduce Morbidity and Mortality in Intrathecal Drug Delivery in the Treatment of Chronic Pain.

Introduction:  Targeted intrathecal drug infusion to treat moderate to severe chronic pain has become a standard part of treatment algorithms when more conservative options fail. This therapy is well established in the literature, has shown efficacy, and is an important tool for the treatment of both cancer and noncancer pain; however, it has become clear in recent years that intrathecal drug delivery is associated with risks for serious morbidity and mortality. Methods:  The Polyanalgesic Consensus Conference is a meeting of experienced implanting physicians who strive to improve care in those receiving implantable devices. Employing data generated through an extensive literature search combined with clinical experience, this work group formulated recommendations regarding awareness, education, and mitigation of the morbidity and mortality associated with intrathecal therapy to establish best practices for targeted intrathecal drug delivery systems. Results:  Best practices for improved patient care and outcomes with targeted intrathecal infusion are recommended to minimize the risk of morbidity and mortality. Areas of focus include respiratory depression, infection, granuloma, device-related complications, endocrinopathies, and human error. Specific guidance is given with each of these issues and the general use of the therapy. Conclusions:  Targeted intrathecal drug delivery systems are associated with risks for morbidity and mortality that can be devastating. The panel has given guidance to treating physicians and healthcare providers to reduce the incidence of these problems and to improve outcomes when problems occur.

Brugada syndrome unmasked by accidental inhalation of gasoline vapors.

Loss-of-function mutations in the gene SCN5A can cause Brugada syndrome (BrS), which is an inherited form of idiopathic ventricular fibrillation. We report the case of a 46-year-old patient, with no previous medical history, who had ventricular fibrillation after accidental inhalation of gasoline vapors. His electrocardiogram (ECG) showed a typical type-1 BrS pattern that persisted after the acute event. Genetic investigations allowed the identification of a novel SCN5A mutation leading to a frame-shift and early termination of the channel protein. Biochemical and cellular electrophysiology experiments confirmed the loss-of-function of the mutant allele. The patient was implanted with a cardioverter/defibrillator.

Pacemaker therapy in patients with neurally mediated syncope and documented asystole: Third International Study on Syncope of Uncertain Etiology (ISSUE-3): a randomized trial.

BACKGROUND: The efficacy of cardiac pacing for prevention of syncopal recurrences in patients with neurally mediated syncope is controversial. We wanted to determine whether pacing therapy reduces syncopal recurrences in patients with severe asystolic neurally mediated syncope. METHODS AND RESULTS: Double-blind, randomized placebo-controlled study conducted in 29 centers in the Third International Study on Syncope of Uncertain Etiology (ISSUE-3) trial. Patients were ≥40 years, had experienced ≥3 syncopal episodes in the previous 2 years. Initially, 511 patients, received an implantable loop recorder; 89 of these had documentation of syncope with ≥3 s asystole or ≥6 s asystole without syncope within 12 ± 10 months and met criteria for pacemaker implantation; 77 of 89 patients were randomly assigned to dual-chamber pacing with rate drop response or to sensing only. The data were analyzed on intention-to-treat principle. There was syncope recurrence during follow-up in 27 patients, 19 of whom had been assigned to pacemaker OFF and 8 to pacemaker ON. The 2-year estimated syncope recurrence rate was 57% (95% CI, 40-74) with pacemaker OFF and 25% (95% CI, 13-45) with pacemaker ON (log rank: P=0.039 at the threshold of statistical significance of 0.04). The risk of recurrence was reduced by 57% (95% CI, 4-81). Five patients had procedural complications: lead dislodgment in 4 requiring correction and subclavian vein thrombosis in 1 patient. CONCLUSIONS: Dual-chamber permanent pacing is effective in reducing recurrence of syncope in patients ≥40 years with severe asystolic neurally mediated syncope. The observed 32% absolute and 57% relative reduction in syncope recurrence support this invasive treatment for the relatively benign neurally mediated syncope. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359203.