Severe pulmonary arterial hypertension associated with congenital cardiac shunts: evolution under specific treatment.

Objective: The aim of this study was to compare the effects of Sildenafil, Bosentan and combined therapy in patients with congenital cardiac shunts associated pulmonary artery hypertension (CCS-PAH). Design: Prospective observational study (February 2011 - January 2014) with a historical control group (January 2009 - January 2011). Setting: "CC Iliescu" Institute for Emergency Cardiovascular Diseases of Bucharest, a tertiary university-affiliated center. Patients: All cases with CCS-PAH. Interventions: Specific vasodilatory therapy: Sildenafil, Bosentan or combined therapy. Outcome Measures: The primary outcome was the overall survival at 24 months. Results: Out of 108 patients with pulmonary arterial hypertension, there were 79 patients with CCS-PAH, 55 presenting a severe form of the disease. The mean age of the patients was 34.42±21.15 years, with 37 (67,3%) female patients. 23 patients received specific vasodilatory treatment (thirteen Sildenafil, seven Bosentan, three combined treatment), with 32 patients in the control group, without specific vasodilatory therapy. The specific vasodilatory therapy was associated with improved WHO/ NYHA functional class (p=0.025), oxygen saturation at the end of the six-minute walk test (p=0.011), decreased pulmonary artery systolic (p=0.002) and diastolic (p=0.004) pressures, and an increased S' wave in Tissue Doppler Imaging (p=0.008). Conclusions: Despite the complexity of CCS-PAH, with a complex constellation of underlying congenital heart defects, there are short-term benefits of a specific vasodilatory therapy.

The adaptation of health care marketing to the digital era.

The purpose of health care marketing is to learn and understand the needs and desires of prospective patients in order to be able to meet those necessities at the highest standards. A big advantage is the targeting capability of the electronic media that has led to its being used by managers of marketing in medical institutions as means of advertisement when they develop the marketing strategies. Regarding social media, it is safe to say that there are communication platforms that can promote certain behaviours thus influencing decision-making. Through social media, people stay in touch with other people and they can provide a mean for medical institutions to permanently communicate with the existing patients or with the potential ones. In addition, social media can be used in advertising and promoting strategies, by posting information about discounts, offers and advantages of accessing the products provided by a certain institution. A study was conducted on 126 patients of a dental clinic in Bucharest. 126 new patients were selected on a period of 22 months from January 2015 until October 2016. The patients never had any treatment in this clinic and were influenced by the Internet to seek for dental care services. The purpose of this study was to evaluate the digital methods of promoting medical services, bringing new patients to a clinic. The results of the study demonstrated the need for digital methods of promoting medical care services in order to expand a business. A strategic way of thinking in this case implied attracting new patients and offering them quality health care services, which ensured their satisfaction and the probability of their recommending the health facility further. This study revealed an important role of social networking sites in promoting. This high response was probably responsible due to targeted promoting services. Almost all the new patients who completed the form will remain patients of this clinic in future.

Diabetes and collision risk. A meta-analysis and meta-regression.

AIMS: The main objective of this study was to see whether diabetes is associated with an increased collision risk and to test the effect of age and gender on the overall collision risk for diabetes drivers. MATERIALS AND METHODS: Twenty-eight studies were included in meta-analysis, using mean age, gender, continent and the prevalence of fatal road incidents as covariates. RESULTS: The collision risk for diabetes drivers was small and not statistically significant - RR = 1.11 (1.01-1.23) with a prediction interval (PI) or 0.77-1.65. Age and gender were not associated with an increased overall risk. Insulin-dependent diabetes patients had a slightly increased effect size compared with the overall diabetes population, but the effect was not statistically significant. European diabetes drivers had a lower collision risk compared with their North American counterparts, the main cause being the difference of collision risk in the countries in which the studies were performed. CONCLUSIONS: Overall, diabetes patients do not have a statistically significant increased risk for unfavourable traffic events. Old age and insulin-dependent patients tend to have a higher risk. Advances in diabetes care, associated with advances in road safety regulations, and automotive industry have not decreased significantly the collision risk in the last 50 years for drivers with diabetes.

Idiopathic venous thromboembolism and thrombophilia.

During the past decade idiopathic venous thromboembolism has become a separate entity, a chronic illness which has required prolonged anticoagulation and other prevention strategies to avoid recurrences. This article reviews recent developments regarding unprovoked venous thromboembolism and its relation with thrombophilia. In the beginning, the latest definition of idiopathic venous thromboembolism is presented. The article continues with statistics about thrombophilia, related venous thromboembolism, and a classification of major thrombophilic factors according to their intrinsic risk of thrombosis and of thrombotic recurrences. Great interest is given to the predictors of recurrence and the importance of prolonged anticoagulation is underlined. The antiphospholipid antibody syndrome, the most common acquired thrombophilia, is presented separately. The revised diagnosis criteria are discussed. Some characteristics of the antiphospholipid syndrome are worth presenting: the risk of both venous and arterial thrombosis, the high risk of thrombotic recurrence and the diversity of antiphospholipid antibodies. Patients experiencing idiopathic venous thromboembolic event have a great risk of recurrence, and highly benefit from long time anticoagulation. Natural coagulation inhibitors deficiencies, homozygous factor V Leiden and prothrombin G20210A and the antiphospholipid syndrome, increase the risk of first venous thrombosis and their recurrences and require adequate prevention.

Can subclinical hypothyroidism explain some sudden deaths due to pulmonary embolism without evident risk factors?

Thyroid pathology is rarely involved in the pathogenesis of sudden death in young people, and usually, when this is the case, is associated with acute changes of thyroid hormone blood levels. Three main thyroid causes of sudden death are known and used in tanathologic chains: thyrotoxicosis, myxedematous coma and, as of recently, lymphocytic thyroid infiltration. Coagulation disorders associated with thyroid disease are usually mild and not associated with sudden death. There are some studies showing an increased risk for unprovoked deep venous thrombosis in patients with hypothyroidism but there is none, to our knowledge, showing a correlation between hypothyroidism, deep venous thrombosis and sudden death. Our article suggests that subclinical hypothyroidism can lead to coagulation disorders and deep venous thrombosis which can explain some cases of sudden death associated with pulmonary embolism without other significant risk factors.

Morphological changes associated with hemodynamically significant myocardial bridges in sudden cardiac death.

UNLABELLED: Although myocardial bridging (MB) is a common coronary anomaly, its cardiovascular consequences are still disputed. A positive link between sudden cardiac death (SCD) and myocardial bridging has not yet been definitively proved, even though many case reports and small scale studies support this association. For myocardial bridging to be associated with sudden cardiac death it must exhibit certain specific characteristics involving coronary or myocardial changes sufficient to explain a terminal cardiac event. In this study we aimed to analyze the morphological changes (both myocardial and coronary) associated with hemodynamically significant myocardial bridging and the morphological differences between hemodynamically significant MB and MB considered to be non-hemodynamically significant. MATERIAL AND METHOD: We analyzed 53 cases of sudden cardiac death, of which 21 cases had hemodynamically significant myocardial bridging, 14 had non-hemodynamically significant myocardial bridging and 20 cases suffered sudden cardiac death without myocardial bridging, using a morphological score with seven histological parameters. RESULTS: Myocardial fibrosis and interstitial edema were found to be highly correlated with hemodynamically significant myocardial bridging (HSMB), as were interstitial edema and interstitial fibrosis. CONCLUSIONS: Hemodynamically significant myocardial bridging can be discovered during heart dissection by analyzing a series of morphological markers (width, distribution of atherosclerosis, distal hypoplasia). Our study showed that MB was associated with increased myocardial fibrosis and edema, both of which have an increased risk of electrical instability. Compared to non-hemodynamically significant myocardial bridging, HSMB shows a distinct histological pattern, with increased myocardial fibrosis and edema. The main cause of SCD in association with HSMB seems to be electrical due to increased electrical myocardial heterogeneity, but large scale studies are needed to test this.