ABSTRACT
Up to 20 % of patients presenting with acute heart failure and cardiogenic shock have a structural etiology. Despite efforts in timely management, mortality rates remain alarmingly high, ranging from 50 % to 80 %. Surgical intervention is often the definitive treatment for structural heart disease; however, many patients are considered high risk or unsuitable candidates for such procedures. Consequently, there has been a paradigm shift towards the development of novel percutaneous management strategies and temporizing interventions. This article aims to provide a comprehensive review of the pathophysiology of valvular and structural heart conditions presenting in cardiogenic shock, focusing on the evolving landscape of mechanical circulatory support devices and other management modalities.
Subject(s)
Heart-Assist Devices , Shock, Cardiogenic , Humans , Shock, Cardiogenic/therapy , Shock, Cardiogenic/etiology , Perioperative Care/methods , Heart Diseases , Cardiac Surgical Procedures/methods , Cardiac Surgical Procedures/adverse effects , Heart Failure/physiopathology , Heart Failure/therapy , Heart Failure/surgeryABSTRACT
Curricular development and modification involve first identifying a problem and then performing a needs assessment, which can guide the design of curricular components. Pedagogical changes, coupled with reductions in curricular time for gross anatomy, pose challenges and impose restrictions within medical school curricula. In order to make anatomy education effective and efficient, it is important to determine the anatomy considered essential for medical education through a targeted needs assessment. In this study, 50 adult primary care resident physicians in family medicine (FM) and internal medicine (IM) were surveyed to assess the importance of 907 anatomical structures, or groups of structures, across all anatomical regions from a curated list based on the boldface terms in four primary anatomy texts. There were no statistically significant differences in the ratings of structures between the two groups for any anatomical region. In total, 17.0% of structures, or groups of structures, were classified as essential, 58.0% as more important, 24.4% as less important, and 0.7% as not important. FM residents rated tissues classified as skeleton, nerves, fasciae, anatomical spaces, blood vessels, lymphatics, and surface anatomy (p < 0.0001) significantly higher than IM residents, but there were no differences in the rating of muscles or organs (p > 0.0056). It was notable that 100.0% of cranial nerves were classified as essential, and 94.5% of surface anatomy structures were classified as essential or more important. It is proposed that results of this study can serve to inform curricular development and revision.
Subject(s)
Anatomy , Physicians , Humans , Adult , Needs Assessment , Anatomy/education , Curriculum , Primary Health CareABSTRACT
Background Prior studies have shown an association between myocardial injury after noncardiac surgery (MINS) and all-cause mortality in patients following noncardiac surgery. However, the association between preoperative risk assessments, Revised Cardiac Risk Index and American College of Surgeons National Surgical Quality Improvement Program, and postoperative troponin elevations and long-term mortality is unknown. Methods and Results A retrospective chart review identified 548 patients who had a troponin I level drawn within 14 days of noncardiac surgery that required an overnight hospital stay. Patients aged 40 to 80 years with at least 2 cardiovascular risk factors were included, while those with trauma, pulmonary embolism, and neurosurgery were excluded. Kaplan-Meier survival and odds ratio (OR) with sensitivity/specificity analysis were performed to assess the association between preoperative risk and postoperative troponin elevation and all-cause mortality at 1 year. Overall, 69%/31% were classified as low-risk/high-risk per the Revised Cardiac Risk Index and 66%/34% per American College of Surgeons National Surgical Quality Improvement Program. Comparing the low-risk versus high-risk groups, preoperative risk assessment was not associated with either postoperative troponin elevation or 1-year mortality. MINS portended a 1-year mortality of OR, 3.9 (95% CI, 2.44-6.33) in the total population. Patients classified as low risk preoperatively with MINS had the highest risk of 1-year mortality (OR, 9.6; 95% CI, 4.27-24.38), with a low prevalence of statin use. Conclusions Current preoperative risk stratification tools do not prognosticate the risk of postoperative troponin elevation and all-cause mortality at 1 year. Interestingly, patients classified as low risk preoperatively with MINS had a markedly higher 1-year mortality risk compared with the general population, and most of them are not taking a statin. Our results suggest that evaluating preoperatively low-risk patients for MINS presents an opportunity for prognostication, risk reclassification, and initiating therapies such as statins to mitigate long-term risk.
Subject(s)
Myocardial Ischemia/diagnosis , Myocardial Ischemia/mortality , Postoperative Complications/diagnosis , Postoperative Complications/mortality , Adult , Aged , Aged, 80 and over , Female , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Male , Middle Aged , Myocardial Ischemia/blood , Ohio , Postoperative Complications/blood , Retrospective Studies , Risk Assessment , Risk Factors , Troponin I/bloodABSTRACT
María Montessori se destaca en la historia de la educación como la iniciadora del movimiento mundial de descubrimiento del niño. El pensamiento clave en el método Montessori es que el adulto enfrenta al niño, lo vive como algo que no es todavía, como una cara amorfa o, en el mejor de los casos, como una vida incompleta. No tiene historia, derechos, ni sindicatos que lo defiendan. Ni ciudades, ni casa, ni sillas a su medida. Por eso considera necesario crear para el niño un medio adecuado a sus exigencias de desarrollo, de experimentación, en vez de llenarlo de órdenes, enseñanzas o discursos que lo confundan
ABSTRACT
María Montessori se destaca en la historia de la educación como la iniciadora del movimiento mundial de descubrimiento del niño. El pensamiento clave en el método Montessori es que el adulto enfrenta al niño, lo vive como algo que no es todavía, como una cara amorfa o, en el mejor de los casos, como una vida incompleta. No tiene historia, derechos, ni sindicatos que lo defiendan. Ni ciudades, ni casa, ni sillas a su medida. Por eso considera necesario crear para el niño un medio adecuado a sus exigencias de desarrollo, de experimentación, en vez de llenarlo de órdenes, enseñanzas o discursos que lo confundan
ABSTRACT
El objetivo perseguido en esta indagacion, es el de lograr mayores conocimientos sobre los vinculos existentes entre la politica de salud, como politica sustantiva, y los procesos politico-administrativos por los que pasan esas politicas, en el transito que va desde la gestacion hasta la implementacion de las mismas. La tarea investigativa se centra en los mecanismos decisorios, en las formas de realizacion entre decision y ejecucion, en los actores intervinientes, en el proceso general de diseno e implementacion de las politicas, y no en la evaluacion de los resultados de las politicas sustantivas
