• Factors predicting incremental administration of antihypertensive boluses during deep brain stimulator placement for Parkinson’s disease

      Rajan, Shobana; Deogaonkar, Milind; Kaw, Roop; Nada, Eman MS; Hernández, Adrian V.; Ebrahim, Zeyd; Avitsian, Rafi (Elsevier B.V., 2014-11-28)
      Hypertension is common in deep brain stimulator (DBS) placement predisposing to intracranial hemorrhage. This retrospective review evaluates factors predicting incremental antihypertensive use intraoperatively. Medical records of Parkinson’s disease (PD) patients undergoing DBS procedure between 2008–2011 were reviewed after Institutional Review Board approval. Anesthesia medication, preoperative levodopa dose, age, preoperative use of antihypertensive medications, diabetes mellitus, anxiety, motor part of the Unified Parkinson’s Disease Rating Scale score and PD duration were collected. Univariate and multivariate analysis was done between each patient characteristic and the number of antihypertensive boluses. From the 136 patients included 60 were hypertensive, of whom 32 were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), told to hold on the morning of surgery. Antihypertensive medications were given to 130 patients intraoperatively. Age (relative risk [RR] 1.01; 95% confidence interval [CI] 1.00–1.02; p = 0.005), high Joint National Committee (JNC) class (p < 0.0001), diabetes mellitus (RR 1.4; 95%CI 1.2–17; p < 0.0001) and duration of PD >10 years (RR 1.2; 95%CI 1.1–1.3; p = 0.001) were independent predictors for antihypertensive use. No difference was noted in the mean dose of levodopa (p = 0.1) and levodopa equivalent dose (p = 0.4) between the low (I/II) and high severity (III/IV) JNC groups. Addition of dexmedetomidine to propofol did not influence antihypertensive boluses required (p = 0.38). Intraoperative hypertension during DBS surgery is associated with higher age group, hypertensive, diabetic patients and longer duration of PD. Withholding ACEI or ARB is an independent predictor of hypertension requiring more aggressive therapy. Levodopa withdrawal and choice of anesthetic agent is not associated with higher intraoperative antihypertensive medications.
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    • Impaired Functional Capacity Predicts Mortality in Patients with Obstructive Sleep Apnea

      Nisar, Shiraz A.; Muppidi, Raghunandan; Duggal, Sumit; Hernández, Adrian V.; Kalahasti, Vidyasagar; Jaber, Wael; Minai, Omar A. (The American Thoracic Society, 2014-12-16)
      Background: Obstructive sleep apnea (OSA) is associated with increased mortality, for which impaired functional capacity (IFC) has been established as a surrogate. We sought to assess whether IFC is associated with increased mortality in patients with OSA and whether IFC is predictive of increased mortality after accounting for coronary artery disease. Methods: Patients with OSA who underwent both polysomnography testing and exercise stress echocardiogram were selected. Records were reviewed retrospectively for demographics, comorbidities, stress echocardiographic parameters, and polysomnography data. Univariable and multivariable logistic regression analysis was used to evaluate the association between IFC and overall mortality. We then evaluated the variables associated with IFC in the overall population and in the subgroup with normal Duke treadmill score (DTS). Results: In our cohort, 404 (26%) patients had IFC. The best predictors of IFC were female sex, history of smoking, ejection fraction less than 55, increased body mass index, presence of comorbidities, abnormal exercise echocardiogram, abnormal heart rate recovery, and abnormal DTS. Compared with those without IFC, patients with IFC were 5.1 times more likely to die (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.5–10.5; P , 0.0001) by univariate analysis and 2.7 times more likely to die (OR, 2.7; 95% CI, 1.2–6.1; P = 0.02) by multivariate analysis, when accounting for heart rate recovery, DTS, and sleep apnea severity. Among those without coronary artery disease, patients with IFC were at significantly increased risk of mortality (OR, 4.3; 95% CI, 1.35–13.79; P = 0.0088) compared with those with preserved functional capacity. Conclusions: In our OSA population, IFC was a strong predictor of increased mortality. Among those with normal DTS, IFC identified a cohort at increased risk of mortality.
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    • Inferior vena cava filters and postoperative outcomes in patients undergoing bariatric surgery: a meta-analysis

      Kaw, Roop; Pasupuleti, Vinay; Overby, D.Wayne; Deshpande, Abhishek; Craig I. Coleman Pharm; John P.A. Ioannidis; Hernández, Adrian V. (Elsevier B.V., 2014-06-09)
      Background: Pulmonary embolism (PE) accounts for almost 40% of perioperative deaths after bariatric surgery. Placement of prophylactic inferior vena cava (IVC) filter before bariatric surgery to improve outcomes has shown varied results. We performed a meta-analysis to evaluate postoperative outcomes associated with the preoperative placement of IVC filters in these patients. Methods: A systematic review was conducted by three investigators independently in PubMed, EMBASE, the Web of Science and Scopus until February 28, 2013. Our search was restricted to studies in adult patients undergoing bariatric surgery with and without IVC filters. Primary outcomes were postoperative deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative mortality. Meta-analysis used random effects models to account for heterogeneity, and Sidik-Jonkman method to account for scarcity of outcomes and studies. Associations are shown as Relative Risks (RR) and 95% Confidence Intervals (CI). Results: Seven observational studies were identified (n=102,767), with weighted average incidences of DVT (0.9%), PE (1.6%), and mortality (1.0%) for a follow-up ranging from 3 weeks to 3 months. Use of IVC filters was associated with an approximately 3-fold higher risk of DVT and death that was nominally significant for the former outcome, but not the latter (RR 2.81, 95%CI 1.33-5.97, p=0.007; and RR 3.27, 95% CI 0.78-13.64, p=0.1, respectively); there was no difference in the risk of PE (RR 1.02, 95%CI 0.31-3.77, p=0.9). Moderate to high heterogeneity of effects was noted across studies. Conclusions: Placement of IVC filter before bariatric surgery is associated with higher risk of postoperative DVT and mortality. A similar risk of PE in patients with and without IVC filter placement cannot exclude a benefit, given the potential large imbalance in risk at baseline. Randomized trials are needed before IVC placement can be recommended.
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    • Propuesta de oferta inmobiliaria dirigida a cubrir el déficit de vivienda para personas entre 25 y 35 años del sector socioeconómico B - Caso de estudio distrito de Yanahuara - Arequipa

      Bonelli Alzamora, Roberto; Medina Alcázar, Fiorella Manuela; Borja Paredes, José Alberto (Universidad Peruana de Ciencias Aplicadas (UPC), 2019-11-01)
      El presente trabajo de investigación está enfocado en un proyecto inmobiliario dirigido a un mercado actualmente desatendido en Arequipa que está conformado por personas entre 25 y 35 años del sector socioeconómico B en el distrito de Yanahuara, que inician o que ya se encuentran en el mercado laboral, que tienen la capacidad de ahorrar, que pueden acceder a un crédito hipotecario y así adquirir su primera vivienda. Se realizó un análisis de las características, gustos y preferencias de nuestros mercado objetivo tomando como referencia el estudio realizado por Arellano de los estilos de vida para así poder identificar los criterios de diseño y estilo de vivienda que requieren. Adicional a esto también se analizó la oferta y la demanda del distrito basado en los estudios de CAPECO (2016, IV Estudio: El Mercado de Edificaciones Urbanas Arequipa) e INE (Censos Nacionales 2017) y los datos arrojados de estos análisis fueron filtrados a través de una encuesta de elaboración propia para poder identificar nuestra demanda efectiva. Se determinó que la oferta actual de departamentos en Arequipa es de 80.00 m2 y en el distrito de Yanahuara es de 111.00 m2 por lo que el costo de estos es muy superior a lo que podría pagar nuestro mercado objetivo, partiendo de esto nuestra propuesta apunta a la construcción de departamentos más pequeños reduciendo el metraje a un promedio de 40.63 m2 de tal forma que puedan ser accesibles económicamente y que a través de un adecuado diseño cumpla con sus estándares y características de vida. Finalmente a través de un estudio financiero se determinó la vialidad y factibilidad económica del proyecto inmobiliario. Se pudo obtener un Valor Actual Neto (VAN) de $ 198,824.55 y la tasa interna de retorno (TIR) de 18.10%.
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    • Rural and small libraries: The tribal experience

      Jenkins, Jennifer L.; Quiroga, Guillermo; Quiballo, Kari; Peterson, Herman A.; Sorrell, Rhiannon (Emerald Group Publishing Ltd., 2017-01-01)
      This chapter discusses some of the challenges faced by tribal libraries. Considering the information provided throughout the rest of this volume, it is clear that some of the core issues-such as poor broadband availability, difficulties in achieving economies of scale, and barriers to collaboration-are shared between tribal institutions and rural libraries throughout the United States. The chapter presents a brief review of the literature on tribal libraries, establishing how they compare with rural public libraries in the United States. The remainder of the chapter is designed as a conversation piece, with responses from interviews with librarians from two tribal libraries detailing how the challenges faced by these outlets parallel those faced by America's rural libraries. • Tribal libraries face obstacles that are common among nontribal rural public libraries, such as poor broadband Internet availability, lack of funding, and geographic barriers that limit patron access. • Although public libraries exist in some tribal communities, other forms of libraries and cultural heritage institutions often fill the service roles that public libraries occupy in nontribal communities. • Public-oriented information institutions in tribal communities commonly preserve and promote tribal heritage, often as one of their primary purposes. Considering that this is often achieved on limited budgets, further documentation of these efforts could be useful for guiding nontribal rural public libraries that wish to do more to preserve and promote their local cultural heritage. This study creates bridges between rural public libraries in the United States and tribal libraries, which are commonly studied as two separate phenomena. Although the authors document how these types of institutions differ from each other in significant ways, barriers of broadband access, geographic isolation, and lack of funding are common across both rural and tribal libraries. The information provided in this chapter shows that both types of institutions need solutions for similar problems.
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    • Serelaxin: insights into its haemodynamic, biochemical, and clinical effects in acute heart failure

      Hernández, Adrian V. (Oxford University Press, 2014-07-03)
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