Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA).

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries.

Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA).

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programmes that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of 'assisting only'. In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its 'Seal of Approval' for the sustainability of endorsed programmes in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programmes could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Making a Difference: 5 Years of Cardiac Surgery Intersociety Alliance (CSIA).

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based non-governmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Making a difference: 5 years of Cardiac Surgery Intersociety Alliance (CSIA).

Informed by the almost unimaginable unmet need for cardiac surgery in the developing regions of the world, leading surgeons, cardiologists, editors in chief of the major cardiothoracic journals as well as representatives of medical industry and government convened in December 2017 to address this unacceptable disparity in access to care. The ensuing "Cape Town Declaration" constituted a clarion call to cardiac surgical societies to jointly advocate the strengthening of sustainable, local cardiac surgical capacity in the developing world. The Cardiac Surgery Intersociety Alliance (CSIA) was thus created, comprising The Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), the Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS), the European Association for Cardio-Thoracic Surgery (EACTS) and the World Heart Federation (WHF). The guiding principle was advocacy for sustainable cardiac surgical capacity in low-income countries. As a first step, a global needs assessment confirmed rheumatic heart disease as the overwhelming pathology requiring cardiac surgery in these regions. Subsequently, CSIA published a request for proposals to support fledgling programs that could demonstrate the backing by their governments and health care institution. Out of 11 applicants, and following an evaluation of the sites, including site visits to the 3 finalists, Mozambique and Rwanda were selected as the first Pilot Sites. Subsequently, a mentorship and training agreement was completed between Mozambique and the University of Cape Town, a middle-income country with a comparable burden of rheumatic heart disease. The agreement entails regular video calls between the heart teams, targeted training across all aspects of cardiac surgery, as well as on-site presence of mentoring teams for complex cases with the strict observance of "assisting only." In Rwanda, Team Heart, a US and Rwanda-based nongovernmental organization (NGO) that has been performing cardiac surgery in Rwanda and helping to train the cardiac surgery workforce since 2008, has agreed to continue providing mentorship for the local team and to assist in the establishment of independent cardiac surgery with all that entails. This involves intermittent virtual conferences between Rwandan and US cardiologists for surgical case selection. Five years after CSIA was founded, its "Seal of Approval" for the sustainability of endorsed programs in Mozambique and Rwanda has resulted in higher case numbers, a stronger government commitment, significant upgrades of infrastructure, the nurturing of generous consumable donations by industry and the commencement of negotiations with global donors for major grants. Extending the CSIA Seal to additional deserving programs could further align the international cardiac surgical community with the principle of local cardiac surgery capacity-building in developing countries.

Last twenty-years activity of cardiovascular tissue banking in Barcelona.

The Barcelona Tissue Bank was established from the merge of two previous multi-tissue banks. Potential donors are screened by Donor Center staff and multi-tissue retrieval is performed by specialized own teams. Tissue processing and preservation is performed in clean room facilities by specialised personnel. After quality control of both donor and all tissues results, the heart valves and vascular segments are stored until medical request. The aim of this report is to present the cardiovascular tissue activity and retrospectively evaluate the outcomes of the changes performed in last 20 years. Cardiovascular tissue from 4088 donors was received, specifically 3115 hearts and 2095 vascular segments were processed and evaluated. A total of 48% of the aortic valves, 68% of the pulmonary valves and 75% of the vascular segments were suitable for transplant. The main reason for discarding tissue was macroscopic morphology followed by microbiological results, for both valves and arteries. Altogether, 4360 tissues were distributed for transplantation: 2032 (47%) vascular segments, 1545 (35%) pulmonary valves and 781 (18%) aortic valves. The most common indication for aortic valve surgery was the treatment of endocarditis, while for pulmonary valves, it was congenital malformation reconstruction. Vascular segments were mainly used for reconstruction after ischemia. During this period, a number of changes were made with the goal of enhancing tissue quality, safety and efficacy. These improvements were achieved through the use of a new antibiotic cocktail, increasing of donor age criteria and changing the microbiological control strategy.

Creation of a brand model through SEM to predict users' loyalty and recommendations regarding a public sports service.

Brand perception is a key element in achieving business success: how a brand is perceived by current and potential users determines what they think and their disposition towards the brand. The users' perception also determines whether they will perceive the sports service as offering a greater quality or value than other services, whether they will be more loyal, or whether they will recommend the service. This paper analyses the brand perception of users of a public sports service, creating a model of structural equations that analyses how credibility and trust influence a user's congruence with the brand and the generation of positive attitudes towards the brand and how these variables influence loyalty levels and recommendations. The results indicate that the proposed model can explain the variables of trust, congruence, attitudes, loyalty and word of mouth by more than 60%. The study finds that credibility influences trust but that credibility in itself does not cause a congruence with the brand, whereas trust does. Similarly, trust does not generate attitudes towards the brand but credibility and congruence do. Congruence generates loyalty but attitudes do not, and congruence, attitudes and loyalty influence recommendation to a similar extent, with congruence having the highest influence.

Effect of a lysine depletion-repletion protocol on the compensatory growth of growing-finishing pigs.

The effect of Lys restriction followed by a repletion period on the performance of growing pigs was studied during 3 feeding phases, each lasting 28 d. A total of 47 castrated male pigs (G Performer 8.0 × Fertilis 25 pigs; Genetiporc Inc., Saint-Bernard, QC, Canada; initial BW of 26.7 ± 2.7 kg) were given each d 70% or 100% of their Lys requirements according to 1 of the following 5 sequences: 70-70-70, 70-70-100, 70-100-70, 70-100-100, or 100-100-100 (for each sequence, numbers indicate the Lys supply percentage in phase 1, 2, and 3, respectively). Individual Lys requirements were estimated daily on the basis of each pig's actual BW and feed intake and BW gain patterns obtained by regression using each pig's historical data. At the end of phase 1, the pigs given 100% of their Lys requirements had higher ADFI ( = 0.01), ADG ( < 0.01), and average daily protein deposition ( < 0.01) than did the pigs given 70% of their requirements. Similar results were observed during phases 2 and 3. At the end of phase 2, the pigs in the 70-100 sequence did not display any compensatory response, given that their ADFI, ADG, and average daily protein deposition did not differ from those of the pigs in the 100-100 sequence. Similar results were observed during phase 3. Although no compensatory growth was observed during the growing phases, the fact that the pigs in the 70-100-100 treatment were able to catch up in terms of BW and body protein mass to the pigs in the 100-100-100 sequence could indicate that a small degree of compensation did occur; these research results cannot ascertain that any compensatory growth occurred.

Precision feeding can significantly reduce lysine intake and nitrogen excretion without compromising the performance of growing pigs.

This study was developed to assess the impact on performance, nutrient balance, serum parameters and feeding costs resulting from the switching of conventional to precision-feeding programs for growing-finishing pigs. A total of 70 pigs (30.4±2.2 kg BW) were used in a performance trial (84 days). The five treatments used in this experiment were a three-phase group-feeding program (control) obtained with fixed blending proportions of feeds A (high nutrient density) and B (low nutrient density); against four individual daily-phase feeding programs in which the blending proportions of feeds A and B were updated daily to meet 110%, 100%, 90% or 80% of the lysine requirements estimated using a mathematical model. Feed intake was recorded automatically by a computerized device in the feeders, and the pigs were weighed weekly during the project. Body composition traits were estimated by scanning with an ultrasound device and densitometer every 28 days. Nitrogen and phosphorus excretions were calculated by the difference between retention (obtained from densitometer measurements) and intake. Feeding costs were assessed using 2013 ingredient cost data. Feed intake, feed efficiency, back fat thickness, body fat mass and serum contents of total protein and phosphorus were similar among treatments. Feeding pigs in a daily-basis program providing 110%, 100% or 90% of the estimated individual lysine requirements also did not influence BW, body protein mass, weight gain and nitrogen retention in comparison with the animals in the group-feeding program. However, feeding pigs individually with diets tailored to match 100% of nutrient requirements made it possible to reduce (P<0.05) digestible lysine intake by 26%, estimated nitrogen excretion by 30% and feeding costs by US$7.60/pig (-10%) relative to group feeding. Precision feeding is an effective approach to make pig production more sustainable without compromising growth performance.

Evaluation of a method estimating real-time individual lysine requirements in two lines of growing-finishing pigs.

The implementation of precision feeding in growing-finishing facilities requires accurate estimates of the animals' nutrient requirements. The objectives of the current study was to validate a method for estimating the real-time individual standardized ileal digestible (SID) lysine (Lys) requirements of growing-finishing pigs and the ability of this method to estimate the Lys requirements of pigs with different feed intake and growth patterns. Seventy-five pigs from a terminal cross and 72 pigs from a maternal cross were used in two 28-day experimental phases beginning at 25.8 (±2.5) and 73.3 (±5.2) kg BW, respectively. Treatments were randomly assigned to pigs within each experimental phase according to a 2×4 factorial design in which the two genetic lines and four dietary SID Lys levels (70%, 85%, 100% and 115% of the requirements estimated by the factorial method developed for precision feeding) were the main factors. Individual pigs' Lys requirements were estimated daily using a factorial approach based on their feed intake, BW and weight gain patterns. From 25 to 50 kg BW, this method slightly underestimated the pigs' SID Lys requirements, given that maximum protein deposition and weight gain were achieved at 115% of SID Lys requirements. However, the best gain-to-feed ratio (G : F) was obtained at a level of 85% or more of the estimated Lys requirement. From 70 to 100 kg, the method adequately estimated the pigs' individual requirements, given that maximum performance was achieved at 100% of Lys requirements. Terminal line pigs ate more (P=0.04) during the first experimental phase and tended to eat more (P=0.10) during the second phase than the maternal line pigs but both genetic lines had similar ADG and protein deposition rates during the two phases. The factorial method used in this study to estimate individual daily SID Lys requirements was able to accommodate the small genetic differences in feed intake, and it was concluded that this method can be used in precision feeding systems without adjustments. However, the method's ability to accommodate large genetic differences in feed intake and protein deposition patterns needs to be studied further.

The impact of feeding growing-finishing pigs with daily tailored diets using precision feeding techniques on animal performance, nutrient utilization, and body and carcass composition.

The impact of moving from conventional to precision feeding systems in growing-finishing pig operations on animal performance, nutrient utilization, and body and carcass composition was studied. Fifteen animals per treatment for a total of 60 pigs of 41.2 (SE = 0.5) kg of BW were used in a performance trial (84 d) with 4 treatments: a 3-phase (3P) feeding program obtained by blending fixed proportions of feeds A (high nutrient density) and B (low nutrient density); a 3-phase commercial (COM) feeding program; and 2 daily-phase feeding programs in which the blended proportions of feeds A and B were adjusted daily to meet the estimated nutritional requirements of the group (multiphase-group feeding, MPG) or of each pig individually (multiphase-individual feeding, MPI). Daily feed intake was recorded each day and pigs were weighed weekly during the trial. Body composition was assessed at the beginning of the trial and every 28 d by dual-energy X-ray densitometry. Nitrogen and phosphorus excretion was estimated as the difference between retention and intake. Organ, carcass, and primal cut measurements were taken after slaughter. The COM feeding program reduced (P < 0.05) ADFI and improved G:F rate in relation to other treatments. The MPG and MPI programs showed values for ADFI, ADG, G:F, final BW, and nitrogen and phosphorus retention that were similar to those obtained for the 3P feeding program. However, compared with the 3P treatment, the MPI feeding program reduced the standardized ileal digestible lysine intake by 27%, the estimated nitrogen excretion by 22%, and the estimated phosphorus excretion by 27% (P < 0.05). Organs, carcass, and primal cut weights did not differ among treatments. Feeding growing-finishing pigs with daily tailored diets using precision feeding techniques is an effective approach to reduce nutrient excretion without compromising pig performance or carcass composition.

The impact of daily multiphase feeding on animal performance, body composition, nitrogen and phosphorus excretions, and feed costs in growing-finishing pigs.

The effect of feeding pigs in a three-phase feeding (3PF) system or a daily-phase feeding (DPF) system on growth performance, body composition, and N and P excretions was studied on 8 pens of 10 pigs each. Feeds for the 3PF and DPF treatments were obtained by mixing two feeds, one with a high nutrient concentration and the other with a low nutrient concentration. The DPF pigs tended (P=0.08) to consume more feed (+3.7%) than the 3PF pigs, but only during the first feeding phase. The DPF pigs consumed 7.3% less protein (P<0.01) but a similar amount of total P. For the whole growing period, the DPF pigs tended (P=0.08) to gain more weight (+2.4%) than the 3PF pigs, mainly because of faster growth (P=0.02) during the first feeding period. At the end of the experiment, total body protein mass was similar in the two treatment groups, but the DPF pigs had 8% more body lipids (P=0.04) than the 3PF pigs. Daily multiphase feeding reduced N excretion by 12% (P<0.01) but did not significantly reduce P excretion. In addition, feed costs, nutrient intake and nutrient excretion under the two feeding strategies were simulated and compared after different approaches were used to formulate complete feeds for each phase of the 3PF system, as well as the two feeds used in the DPF program. Simulated feed intake and growth was similar to those observed in the animal experiment. In comparison with the simulated 3PF system, the feed cost for the DPF pigs was reduced by 1.0%, the simulated N and P intakes were reduced by 7.3% and 4.4%, respectively, and the expected N and P excretions were reduced by 12.6% and 6.6%, respectively. The concomitant adjustment of the dietary concentration of nutrients to match the evaluated requirements of pig populations can be an efficient approach to significantly reduce feeding costs and N and P excretions in pig production systems.

Towards loss compensated and lasing terahertz metamaterials based on optically pumped graphene.

We evidence by numerical calculations that optically pumped graphene is suitable for compensating inherent loss in terahertz (THz) metamaterials. We calculate the complex conductivity of graphene under optical pumping and determine the proper conditions for terahertz amplification in single layer graphene. It is shown that amplification in graphene occurs up to room temperature for moderate pump intensities at telecommunication wavelength λ = 1.5 µm. Furthermore, we investigate the coupling between a plasmonic split ring resonator (SRR) metamaterial and optically pumped graphene at a temperature T = 77 K and a pump intensity I = 300 mW/mm(2). We find that the loss of a SRR metamaterial can be compensated by optically stimulated amplification in graphene. Moreover, we show that a hybrid material consisting of asymmetric split-ring resonators and optically pumped graphene can emit coherent THz radiation at minimum output power levels of 60 nW/mm(2).

Interrupciones por llamadas telefónicas en la consulta del médico de familia en 2 centros de salud de Zaragoza / Telephone interruptions in family doctor clinics in two health centres in Saragossa

Objetivos. Analizar las interrupciones por llamadas telefónicas en las consultas de atención primaria, sus motivos y distribución en las jornadas laborales. Diseño. Estudio descriptivo y transversal. Ámbito. El estudio se lleva a cabo en atención primaria, en 2 centros de salud urbanos del sector II de Zaragoza. Metodología. Siete médicos de atención primaria registraron todas las llamadas telefónicas pasadas o no desde el servicio de admisión, a consulta, su origen y características, a lo largo de 5,5 meses. Resultados. La media global de llamadas por día para cada médico ha sido de 1,39 (DE 1,5), siendo de 1,66 (DE 1,53) en San José Norte y de 1,22 (DE 1,46) en San José Centro (p=0,000), con una diferencia entre 0,2 y 0,68 llamadas por consulta y día. La media de llamadas por consulta y día en las consultas de horario de mañana es de 1,37 (DE 1,53) y en las de horario de tarde de 1,44 (DE 1,41), no existiendo una diferencia significativa (p=0,62). Las llamadas originadas por los propios pacientes para hablar directamente con sus médicos constituyen el motivo más frecuente en los horarios de mañana y de tarde (28,5 y 26,5%). La distribución del horario de las llamadas, se centra entre las 10,30 y las 13 h, y entre las 17 y 18 h. Conclusiones. Cuantificar las llamadas telefónicas que se producen durante la consulta del médico de familia, así como conocer su distribución y motivos, permite desarrollar estrategias para aprovechar las ventajas de la llamada telefónica, a la vez que minimizar la interrupción en la consulta (AU)

Objectives. To analyse disruptions due to telephone calls in primary care clinics, their reasons and distribution during the working day. Design. Cross-sectional descriptive study. Setting. The study was conducted in primary care, 2 urban Primary Care Health Centres in Area II of Zaragoza. Methodology. Seven primary care physicians recorded all calls, whether or not they were passed on from the admissions service to clinics, their origin and characteristics, over a period of 5.5 months. Results. The overall mean percentage of calls per day for each doctor was of 1.39 (SD 1.5), being 1.66 (SD 1.53) in San José Norte and 1.22 (SD 1.46) in San José Centro (P=.012), with a difference between 0.2 and 0.68 calls per day per clinic. The mean number of calls per day in the morning clinics and per clinic was 1.37 (SD 1.53) and 1.44 (SD 1.41) in the afternoon clinics, there being a significant difference (P=. 62). Calls originated by the patients themselves to speak directly with their doctors are more frequent in the morning than afternoon hours (28.5% and 26.5%). The distribution of calls is mainly from the 10.30 to 1 p.m., and between the 17:00 and 18:00hours. Conclusions. Quantifying the telephone calls that occur during the family physician clinics, as well as determining their distribution and reasons, allows strategies to be developed to take advantage of the phone calls, as well as minimising disruption in the clinics (AU)

Development of sustainable precision farming systems for swine: estimating real-time individual amino acid requirements in growing-finishing pigs.

The objective of this study was to develop and evaluate a mathematical model used to estimate the daily amino acid requirements of individual growing-finishing pigs. The model includes empirical and mechanistic model components. The empirical component estimates daily feed intake (DFI), BW, and daily gain (DG) based on individual pig information collected in real time. Based on DFI, BW, and DG estimates, the mechanistic component uses classic factorial equations to estimate the optimal concentration of amino acids that must be offered to each pig to meet its requirements. The model was evaluated with data from a study that investigated the effect of feeding pigs with a 3-phase or daily multiphase system. The DFI and BW values measured in this study were compared with those estimated by the empirical component of the model. The coherence of the values estimated by the mechanistic component was evaluated by analyzing if it followed a normal pattern of requirements. Lastly, the proposed model was evaluated by comparing its estimates with those generated by the existing growth model (InraPorc). The precision of the proposed model and InraPorc in estimating DFI and BW was evaluated through the mean absolute error. The empirical component results indicated that the DFI and BW trajectories of individual pigs fed ad libitum could be predicted 1 d (DFI) or 7 d (BW) ahead with the average mean absolute error of 12.45 and 1.85%, respectively. The average mean absolute error obtained with the InraPorc for the average individual of the population was 14.72% for DFI and 5.38% for BW. Major differences were observed when estimates from InraPorc were compared with individual observations. The proposed model, however, was effective in tracking the change in DFI and BW for each individual pig. The mechanistic model component estimated the optimal standardized ileal digestible Lys to NE ratio with reasonable between animal (average CV = 7%) and overtime (average CV = 14%) variation. Thus, the amino acid requirements estimated by model are animal- and time-dependent and follow, in real time, the individual DFI and BW growth patterns. The proposed model can follow the average feed intake and feed weight trajectory of each individual pig in real time with good accuracy. Based on these trajectories and using classical factorial equations, the model makes it possible to estimate dynamically the AA requirements of each animal, taking into account the intake and growth changes of the animal.

Tricuspid valve surgery.

INTRODUCTION: The tricuspid valve has been taken as a non-critical valve in terms of acute or late mortality in a number of conditions. Tricuspid functional regurgitation is a cause of late operations with an increased morbidity. A number of techniques have been described and used in clinical practice in the past forty years and include simple suture techniques and the use of support for annuloplasty with the use of different types of prosthetic rings. The experience accumulated over the years indicates that tricuspid annuloplasty is mandatory to improve late results, which are superior, in general, to replacement of the valve. METHODS: The role of echocardiography in defining surgical planning, intraoperative results and follow-up is reviewed as echocardiography is a fundamental tool in cardiac surgery. Surgery for isolated lesions of the tricuspid valve has not received much attention and herein we report the results of the follow-up of a limited series of patients undergoing isolated tricuspid surgery. RESULTS: The correlation between echocardiographic measurements and surgical measurements was confirmed and was helpful at the time of the confirmation of repair (r=0.53). Forty-seven patients (18 repair, 29 replacement) underwent isolated surgery. Results of isolated tricuspid repair seemed to be superior when compared to those of tricuspid replacement. Survival was 20.7% for tricuspid valve replacement (N=18) and 50% for tricuspid valve repair (N=29) (p=0.04). Freedom from reoperation was 94.4±5.4% for repair and 67.3±12.1% for replacement (p= 0.0011). CONCLUSIONS: The tricuspid valve continues to be a surgical challenge.

[Telephone interruptions in family doctor clinics in two health centres in Saragossa]. / Interrupciones por llamadas telefónicas en la consulta del médico de familia en 2 centros de salud de Zaragoza.

OBJECTIVES: To analyse disruptions due to telephone calls in primary care clinics, their reasons and distribution during the working day. DESIGN: Cross-sectional descriptive study. SETTING: The study was conducted in primary care, 2 urban Primary Care Health Centres in Area II of Zaragoza. METHODOLOGY: Seven primary care physicians recorded all calls, whether or not they were passed on from the admissions service to clinics, their origin and characteristics, over a period of 5.5 months. RESULTS: The overall mean percentage of calls per day for each doctor was of 1.39 (SD 1.5), being 1.66 (SD 1.53) in San José Norte and 1.22 (SD 1.46) in San José Centro (P=.012), with a difference between 0.2 and 0.68 calls per day per clinic. The mean number of calls per day in the morning clinics and per clinic was 1.37 (SD 1.53) and 1.44 (SD 1.41) in the afternoon clinics, there being a significant difference (P=. 62). Calls originated by the patients themselves to speak directly with their doctors are more frequent in the morning than afternoon hours (28.5% and 26.5%). The distribution of calls is mainly from the 10.30 to 1 p.m., and between the 17:00 and 18:00 hours. CONCLUSIONS: Quantifying the telephone calls that occur during the family physician clinics, as well as determining their distribution and reasons, allows strategies to be developed to take advantage of the phone calls, as well as minimising disruption in the clinics.

Fully valley-polarized electron beams in graphene.

We propose a device to break the valley degeneracy in graphene and produce fully valley-polarized currents that can be either split or collimated to a high degree in a experimentally controllable way. The proposal combines two recent seminal ideas: negative refraction and the concept of valleytronics in graphene. The key new ingredient lies in the use of the specular shape of the Fermi surface of the two valleys when a high electronic density is induced by a gate voltage (trigonal warping). By changing the gate voltage in a n-p-n junction of a graphene transistor, the device can be used as a valley beam splitter, where each of the beams belong to a different valley, or as a collimator. The result is demonstrated through an optical analogy with two-dimensional photonic crystals.

CarboMedics Mitroflow pericardial aortic bioprosthesis - performance in patients aged 60 years and older after 15 years.

BACKGROUND: The purpose of this study was to carry out a current assessment of the Mitroflow pericardial bioprosthesis (model 11) according to the durability of the prosthesis after 15 years in patients aged 60 years or older. METHODS: This bioprosthesis was implanted in 161 patients (mean age 69.5 +/- 6.3 years; range 60 - 94 years) undergoing aortic valve replacement (AVR) between 1982 and 1992. There were 84 patients aged 60 - 69 years (mean 64.5 +/- 3.1years) and 77 patients aged 70 years or older (mean 74.8 +/- 4.3 years). Of the total population, concomitant procedures were performed in 63 patients (39.1 %); of these, coronary artery bypass grafting was performed in 39 (24.2 %). RESULTS: Early mortality was 4.8 % (4 patients) in the 60 - 69 year age group and 10.4 % (8) in patients aged 70 years or older ( P = 0.290). Late mortality was 4.5 %/patient-year (35) for those aged 60 - 69 years and 8.1 %/patient-year (49) for those aged 70 years or older ( P = 0.007). Patient survival at 15 years of patients aged 60 - 69 years was 47.6 +/- 6.3 % and of patients aged 70 years or older was 20.9 +/- 5.4 % ( P = 0.003) ( ). Freedom from valve-related mortality for patients in the 60 - 69 year age group was 92.1 +/- 3.5 % at 15 years (0.6 %/patient-year [5]), and in the patient group aged 70 years or older it was 84.4 +/- 5.3 % (1.3 %/patient-year [8]; P = 0.194). Freedom from reoperation for patients in the 60 - 69 year age group was 73.9 +/- 5.0 % (2.6 %/patient-year [20]), and for patients aged 70 years or older it was 91.4 +/- 3.4 % (1.0 %/patient-year [6]; P = 0.029). The structural valve deterioration (SVD) rate for patients in the 60 - 69 year age group was 2.4 %/patient-year (19), and for patients aged 70 years or older it was 1.0 %/patient-year (6) ( P = 0.041). Actuarial freedom from structural valve deterioration at 15 years for patients aged 60 - 69 years was 62.0 +/- 7.3 %, and 80.8 +/- 7.9 % for patients aged 70 years and older ( P = 0.049) (actual freedom 73.9 +/- 5.2 % and 91.4 +/- 3.4 %, respectively). CONCLUSIONS: The Mitroflow pericardial bioprosthesis can still be recommended for aortic valve replacement in patients 70 years and older.

Clinical implications of late mitral valve regurgitation appearance in the follow-up of heart transplantation.

BACKGROUND: Tricuspid regurgitation is frequently observed after orthotopic heart transplantation (OHT), in association with severe pulmonary hypertension. However, the incidence of left-sided valvular disease has not been addressed. AIM: We analyzed the incidence and prognostic implications of left-sided valve disease in 141 patients after OHT. METHODS: Echocardiography was performed with every endomyocardial biopsy during the first year after OHT and every 6 months thereafter. Mitral regurgitation (MR) grade II or III was considered significant. Graft vasculopathy was assessed using coronary angiography. RESULTS: Eight patients (6%) developed significant left-sided valvular disease, namely, MR in 6 (4%) and aortic regurgitation (AR) in 2 (1.4%). The 2 cases with AR were diagnosed the first week after OHT, whereas significant MR was diagnosed at mean follow- up of 34 +/- 6 months. Mean regurgitant orifice and volume were 34 +/- 14 mm2 and 41 +/- 15 mL/beat, respectively. Patients with significant MR had experienced a greater number of acute rejection episodes >or=3A, (1.8 +/- 1.7 vs 0.8 +/- 1.05; P = .02) and were associated with allograft vasculopathy in 83% vs 6% among unaffected patients (P = .0001). Four of 6 patients with significant MR died during follow-up (67%) and 1 of the living patients underwent reparative mitral valve surgery. The probability of survival using Kaplan-Meier curves was significantly lower when patients developed late significant MR (54% vs 76%; P = .0001). CONCLUSIONS: The incidence of significant left-sided valvular disease after OHT was low. MR was associated with a higher degree of previous acute rejection, of graft vasculopathy, and mortality. The presence of moderate or severe MR of late appearance identified a group of OHT patients with poor outcomes.