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Biomedical subjects

E Winkel

Publications and source records attributed to E Winkel.

At least 19 recordsLinked to original sources
PubMed2001

Hypotension, acidosis, and vasodilatation syndrome post-heart transplant: prognostic variables and outcomes.

BACKGROUND: In recent years a syndrome characterized by hypotension, acidosis, and vasodilatation, which we have designated HAV syndrome, has been reported to occur more frequently after heart transplantation (HT), but its pathogenesis is unknown. METHODS: We analyzed consecutive patients undergoing HT between January 1994 and June 1998 (aged 50 +/- 8 years; 87% male; 40% African American; ischemia time, 190 +/- 20 minutes; given triple immunosuppression without anti-lymphocyte antibodies) in 2 groups: 38 (54%) who developed HAV (systemic vascular resistance < or = 800 dines x sec x cm(-5) and serum bicarbonate < or = 20 mEq/liter) and 32 (46%) who did not. To identify causes of HAV, we compared 113 pre-HT donor and recipient variables, 28 peri-HT variables, and 46 post-HT variables between groups. We used Mann-Whitney, Fisher exact, and chi-squared tests to compare variables and to determine significance. RESULTS: Univariate analysis showed that HAV patients had significantly greater recipient and donor weight (p = 0.000007 and 0.0017, respectively), longer ischemia times (p = 0.0052), pre-HT use of beta-blockers (p = 0.009), and longer waiting times for HT (p = 0.018). African-American patients had less HAV than Caucasians (p = 0.047). Patients with pre-HT mechanical circulatory assistance had less HAV than pharmacologically treated patients (p = 0.014). Multivariate analysis showed that recipient (p = 0.0004) and donor weight (p = 0.0394) and ischemia time (p = 0.0015) independently predicted HAV and correlated with HAV severity. Deaths at < or =30 days of HT occurred more in patients with (33%) than in those without (15%) HAV. CONCLUSIONS: (1) Hypotension, acidosis, and vasodilatation after HT are associated with high mortality. (2) Recipient and donor weights and ischemia time are independent risk factors for HAV. (3) Pre-HT mechanical circulatory assistance and African-American race confer protection against HAV. (4) Because HAV risk factors can be altered, prevention may be possible. Further study is needed to identify the cellular and humoral mediators of HAV.

Acidosis↗
PubMed2000

Myocarditis.

Myocarditis and its sequela, dilated cardiomyopathy (DCM), cause substantial morbidity and mortality, especially in children and young adults. Physicians should include myocarditis in the differential diagnosis of all patients who have new symptoms of heart failure, arrhythmia, or chest pain syndromes of unclear cause, and should strongly consider performing endomyocardial biopsy (EMB) to establish the diagnosis. It may be necessary to perform multiple or serial biopsies to increase sensitivity. Patients with myocarditis and symptomatic heart failure, chest pain, or arrhythmias need hospitalization for evaluation and treatment. Patients with symptomatic left ventricular dysfunction should be treated with conventional heart failure therapy, including angiotensin-converting enzyme (ACE) inhibitors, digitalis, diuretics, and beta-blockers. Patients with arrhythmias or syncope may require electrophysiologic evaluation. In addition to conventional therapy, physicians should consider a course of immunosuppressive therapy in selected patients. The clinical course, response to therapy, and left ventricular function need close monitoring. Patients with myocarditis and rapidly progressive heart failure or cardiogenic shock should be referred early to an advanced heart failure center for implantation of a ventricular assist device and consideration for cardiac transplantation.

Journal Article↗
PubMed2000

Differences in the composition of the subgingival microbiota of two periodontitis populations of different geographical origin. A comparison between Spain and The Netherlands.

The purpose of this study was to compare the subgingival microbiota of two geographically distinct patient populations using identical clinical and bacteriological methods. Adult patients with a diagnosis of periodontitis were consecutively selected according to pre-defined clinical criteria. Microbiological samples were taken from the deepest four sites with bleeding. The samples were plated on blood agar plates, for the determination of the total anaerobic counts and identification of specific bacterial pathogens, and on TSBV and McConkey for isolation of Actinobacillus actinomycetemcomitans and enteric rods, respectively. Thirty-one patients in Spain and 30 patients in The Netherlands were selected. Both patient groups showed similar clinical characteristics, both in terms of age, gender and periodontal clinical variables. A. actinomycetemcomitans was significantly more prevalent (23.3% vs. 3.2%) in the Dutch group, while Porphyromonas gingivalis was significantly more prevalent (64.5% vs. 36.7%) in the Spanish group. Bacteroides forsythus and most commensal periodontal pathogens showed similar prevalences, except Peptostreptococcus micros that was significantly more frequent in the Dutch group (96.7% vs. 74.2%). In summary, the subgingival microbiota from the Spanish group was characterised by a high prevalence of P. gingivalis and low of A. actinomycetemcomitans, while the flora from the Dutch group was characterised by a high prevalence of A. actinomycetemcomitans and P. micros.

Aggregatibacter actinomycetemcomitans↗
PubMed1999

Chronic Heart Failure.

Physicians must aggressively treat heart failure in the early stages to prevent disease progression and improve survival. Early treatment implies early diagnosis of left ventricular (LV) dysfunction, before the onset of symptoms. Patients with risk factors for the development of heart failure, especially coronary disease or hypertension, should undergo echocardiography to evaluate LV function. Patients with LV systolic dysfunction should be further evaluated to determine the type of cardiac dysfunction, uncover correctable etiologic factors, determine prognosis, and guide treatment. Angiotensin-converting enzyme (ACE) inhibitors and beta-adrenergic blocking drugs improve survival and are integral to the treatment plan. Physicians should prescribe an ACE inhibitor as initial therapy for all patients with LV systolic dysfunction unless there are specific contraindications. The combination of hydralazine and isosorbide dinitrate is an acceptable alternative therapy for patients who cannot take ACE inhibitors. Diuretics should be used if there are signs or symptoms of volume overload. Beta-adrenergic blocking drugs should be added to therapy in stable patients with mild to moderate heart failure after optimal treatment with ACE inhibitors, diuretics, or other vasodilators. Digoxin should be used routinely in patients with severe heart failure and should be added to therapy in patients with mild to moderate heart failure who remain symptomatic despite optimal doses of ACE inhibitors and diuretics. Spironolactone should be added, but electrolytes should be closely monitored. Warfarin anticoagulation should be considered in patients with a left ventricular ejection fraction (LVEF) of 35% or less. Until survival data exist, angiotensin receptor blockers (ARBs) should not be used as initial therapy or as sole therapy but can be used for ACE-intolerant patients or can be added to standard heart failure therapy. Outpatient use of intravenous inotropic therapy should be avoided. Patients with severe heart failure should have peak oxygen consumption measured to quantify functional impairment, determine prognosis, and identify the need for advanced heart failure therapy. Patients who remain symptomatic while receiving optimal standard therapy should be referred early to a specialized heart failure center.

Journal Article↗
PubMed1999

Radiofrequency catheter ablation of atrial flutter after orthotopic heart transplantation: insights into the redefined critical isthmus.

We report a case of successful radiofrequency catheter ablation of recurrent atrial flutter in a heart transplant recipient and discuss technical aspects of the procedure. A counterclockwise flutter circuit was defined during endocardial mapping of the donor atrium. Termination of atrial flutter was achieved by creating lines of radiofrequency lesions from the tricuspid ring to the suture line between donor and recipient atria. Creation of bidirectional conduction block in the tricuspid ring-suture line isthmus resulted in abolition of atrial flutter.

Atrial Flutter↗
PubMed1998

Pathological epididymal obstruction unrelated to vasectomy: results with microsurgical reconstruction.

PURPOSE: We determine the success of end-to-side epididymovasostomy in patients presenting with obstructive azoospermia from primary epididymal obstruction and identify prognostic factors that could predict a successful outcome. MATERIALS AND METHODS: Of 256 consecutive patients undergoing end-to-side epididymovasostomy 49 had primary epididymal obstruction unrelated to prior vasectomy. Patients were excluded from study if they had a history of vasectomy, microsurgical reconstruction or ejaculatory duct obstruction. RESULTS: Followup was available in 43 of the 49 patients (88%). Patency rates were 87% in the bilateral epididymovasostomy group, 69% in the unilateral group and 81% overall. Pregnancy rates were 43% in the bilateral and 23% in the unilateral group. While higher patency rates were observed for proximal anastomoses, higher pregnancy rates were observed for distal anastomoses. Intraoperative epididymal fluid quality correlated with patency, that is motile sperm in the epididymal aspirate correlated with postoperative patency (p <0.05). There was no correlation between fluid quality and pregnancy rates. Postoperative semen analyses demonstrated higher sperm density and higher motility in the pregnant versus nonpregnant groups. CONCLUSIONS: Epididymovasostomy may be performed in patients with obstructive azoospermia unrelated to vasectomy with high patency and good pregnancy rates. Intraoperative epididymal fluid quality can be predictive of patency. There was a trend towards higher pregnancy rates for distal anastomosis. There were no pregnancies when anastomosis was at the caput epididymis on both sides.

Adult↗
PubMed1998

Outpatient inotropic therapy in heart transplant candidates: should its use influence waiting list priority status?

BACKGROUND: The use of outpatient intravenous inotropic therapy in heart transplant candidates is contentious. In addition to concerns about morbidity and mortality rates, the current United Network for Organ Sharing (UNOS) heart allocation system presently grants no waiting list priority status benefit to candidates who receive intravenous inotropic therapy in the outpatient setting (UNOS status 2), whereas identical therapy given in an intensive care unit setting does increase priority status (UNOS status 1). The goal of this study was to determine whether an increase in UNOS waiting list priority status is justified in heart transplant candidates receiving outpatient intravenous inotropic therapy by comparing the waiting list mortality of UNOS status 2 candidates on such therapy with that of UNOS status 2 candidates maintained on oral heart failure agents alone. METHODS: This is a retrospective analysis of the pretransplantation outcomes of heart transplant candidates initially listed as UNOS status 2, comparing 29 candidates receiving intravenous outpatient inotropic therapy (group 1) to 109 candidates maintained on oral heart failure agents alone (group 2). RESULTS: The waiting list mortality was not significantly different between the two groups (group 1=7% vs group 2=20%, p=.18); however, group 1 patients had greater morbidity rates while awaiting transplantation than group 2 patients. A greater percentage of group 1 than group 2 patients clinically deteriorated to UNOS status 1 while awaiting transplantation (45% vs 11%), resulting in more group 1 patients undergoing transplantation overall, (59% vs 33%, p=.01) and more group 1 than group 2 patients undergoing transplantation at a higher priority status, UNOS status 1 (76% vs 33%, p=.003). Group 1 patients had more pretransplantation heart failure admissions (1.2 vs 0.6 admissions/total waiting period, p=.02) and longer hospital stays (26+/-39 vs 8.8+/-16 days, p=.03), spent a greater percentage of their total waiting time hospitalized (7% vs 2%, p=.003), and were more likely than group 2 patients to receive intravenous inotropic therapy during hospitalization (70% vs 25%, p=.001). CONCLUSION: This study suggests that heart transplant candidates who require maintenance outpatient intravenous inotropic therapy represent a subgroup of UNOS status 2 candidates with greater waiting list morbidity, but no greater waiting list mortality than candidates who can be maintained on oral heart failure agents alone. However, the current UNOS heart allocation system provides for this increased illness acuity by assigning a higher priority status when necessary. A larger, prospective study is necessary to determine whether a true difference in waiting list mortality rates exists and if an increase in priority status is justified for UNOS status 2 candidates requiring maintenance inotropic therapy.

Administration, Oral↗
PubMed1995

Candidate evaluation and selection for heart transplantation.

Because of the increasing discrepancy between the number of identified candidates for heart transplantation and available donor organs, appropriate selection of patients for heart transplantation is critical. The establishment of a cardiac prognosis that is significantly worse than that following heart transplant is central in the determination of candidacy for transplantation. However, with recent improvements in heart failure management, prognosis must be considered a dynamic state involving periodic reassessment to ensure an individual's ongoing suitability for transplantation. There have been many descriptions of prognostic indexes in heart failure, but care must be used when extrapolating observations collected from patients with a broad range of conditions to those with end-stage disease. The contraindications to heart transplantation have also evolved with the increasing success of the transplant process. Many conditions that precluded patients from heart transplant in the past are no longer regarded as absolute. Despite less stringent conditions for recipient candidacy, the need to achieve optimal results with an increasingly valuable donor resource will necessitate careful scrutiny of the posttransplant implications of the various conditions currently regarded as contraindications to heart transplant. Determination of heart transplantation candidacy therefore continues to remain a highly individualized process, requiring clinical judgment and experience.

Heart↗
PubMed1995

A Muslim perspective on female circumcision.

Western observers are unable to understand why women would want to practice clitoridectomy, just as they are perplexed at the vocal, if mostly inarticulate, rejection by many Muslims of the Cairo conference. The battle lines which get drawn have on one side public health professionals, development organizations, and feminists and on the other side conservative and "fundamentalist" Muslims who, if they are heard at all, sound impossibly antediluvian. Many Muslims, including myself, are uncomfortable with both sides. What is needed is an alternative to this polarization. The alternative I propose is the Islamic legal discourse, which might best be described as the discursive arena in which issues of societal importance get worked out. That positive change can come about from within--using the Islamic discourse--is possible because Islamic discursive systems are broad and nuanced enough to accommodate a wide variety of medical and public health endeavors. Meaningful social change and improved public health could come about by stimulating and recovering the many Islamic sunnah (exemplary) practices which are so conducive to physical and material well-being. By dealing change through existing, and proven, traditional formats, Muslims would be able to effect valuable and meaningful change in their communities. Muslim communities should not become dependent on and indentured to Western agencies and their own nation-states to solve the problems they face, including the tragic consequences of widely practiced infibulation and clitoridectomy; instead we need to apply our own traditional practices and to support an indigenous Islamic legal discourse.

Circumcision, Female↗