My Canadian Pharmacy: Sildenafil in Inoperable Chronic Thromboembolic Pulmonary Hypertension

Pulmonary Vascular Diseases UnitSubjects

Consecutive patients with distal CTEPH attending the Pulmonary Vascular Diseases Unit at Papworth Hospital between August 2004 and August 2007 were considered for the study. All had previously received a diagnosis of pulmonary hypertension at right-heart catheterization using standard diagnostic criteria. CTEPH was confirmed by ventilation perfusion scanning, CT pulmonary angiography, and either catheter-directed pulmonary angiography or magnetic resonance pulmonary angiography. All imaging had been reviewed by a panel of specialist physicians, radiologists, and surgeons to determine the distribution of disease. Patients with de novo distal CTEPH and patients with persistent pulmonary hypertension > 3 months post-PEA surgery were approached. Post-PEA subjects were re-imaged prior to enrollment both with CT pulmonary angiography and magnetic resonance pulmonary angiography to ensure no proximal disease remained. Subjects were excluded if they had received any pulmonary hypertension-specific therapy or nitrate therapy in the 6 months prior to enrollment. Subjects with a 6-min walking distance (6MWD) < 100 m or > 450 m were also excluded.

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Long-term Use of Sildenafil in Inoperable Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertensionChronic thromboembolic pulmonary hypertension (CTEPH) represents an uncommon consequence of acute pulmonary embolic disease. Untreated, it leads to progressive right ventricular dysfunction and death. In patients with predominantly “proximal” disease, surgical intervention (pulmonary endarterectomy [PEA]) can be effective. However, when hemodynamic compromise is disproportionate to the degree of surgically accessible disease, surgery is often inappropriate. In addition, a proportion of surgical patients have persistent pulmonary hypertension postoperatively as a result of residual inaccessible disease. Both groups of patients have “distal” disease, in which the majority of the disease lies beyond the subsegmental level.

There are currently no licensed therapies for these patients, and thus their long-term outcomes are typically poor.

Conversely, in idiopathic pulmonary arterial hypertension (IPAH), a range of licensed vasoactive therapies is available that significantly improves morbidity and mortality. Histopathologic studies suggest that the small-vessel changes seen in IPAH may also be common to CTEPH, coexisting with the more classically described obstructive lesions. These vasculopathic changes have predominantly been described in unobstructed beds and may represent a maladaptive response to elevated pressure and shear stress. Given this shared vasculopathic morphology, there has been considerable interest in using IPAH-specific vasoactive therapies in patients with distal CTEPH.

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My Canadian Pharmacy about Asthma in Puerto Rican Children

 multivariable analysisFigure 1 shows the schema for enrollment into the study by individual study site. Based on the sampling design, a total of 21,185 households were randomly selected for inclusion in the study; 20,681 households (97.6%) were successfully contacted. Of these 20,681 households, 1,853 households (9.0%) with 2,940 children were eligible for the study. However, 449 of 2,940 eligible children did not participate in the study because of parental refusal or repeated unavailability (three or more unsuccessful attempts). The final study population consisted of 2,491 children in 1,643 households. There were households with one (n = 1,009), two (n = 420), and three (n = 214) eligible children.

Table 1 summarizes the characteristics of the study population. The denominator indicates the number of participants who provided valid information; missing values and “don’t know” were excluded from the calculations. Site of residence and birthplace were highly correlated: 90.2% of participants living in the Bronx were born in the mainland United States, and 94.6% of those living in Puerto Rico were born in Puerto Rico. Children living in Puerto Rico were more likely to have four grandparents who were born in Puerto Rico than Puerto Rican children living in the South Bronx. Families of Puerto Rican children in Puerto Rico were more likely to have household incomes < $25,000 per year but less likely to receive public assistance in the past year than families of Puerto Rican children in the South Bronx. Mothers of Puerto Rican children in Puerto Rico were more likely to have completed high school (HS) or a general equivalency diploma (GED) and less likely to smoke during pregnancy than mothers of Puerto Rican children in the South Bronx. Premature birth was lower in Puerto Rican children in Puerto Rico than in Puerto Rican children in the Bronx.

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Studying of Area of Residence, Birthplace, and Asthma in Puerto Rican Children

mental illnessThis was a population-based prospective cohort study of the prevalence of antisocial behaviors and associated comorbid conditions (eg, asthma) among Puerto Rican children in each of two sites. Children in the South Bronx (New York) and the standard metropolitan areas of San Juan and Caguas (Puerto Rico) were enrolled from July 2001 through August 2003. The study was approved by the Institutional Review Boards of the New York State Psychiatric Institute and the University of Puerto Rico Medical School.

The study employed a multistage probability sample design described in detail elsewhere. Briefly, primary sampling units were randomly selected neighborhood clusters based on the 1990 US Census and subsequently adjusted to the 2000 census. Secondary sampling units were randomly selected households within each individual primary sampling unit. To contrast the prevalence of antisocial behaviors between island and mainland Puerto Rican children (the primary purpose of the original study), the sample size was calculated to be 1101 children per site in order to detect a risk ratio of 1.5 with 80% power at a p value <0.05.

A household was eligible if as follows: (1) at least one resident was a child between the ages of5 and 13 years who was identified by his/her parents/primary caretakers as being of Puerto Rican background, and (2) at least one of the child’s parents or primary caretakers in the household also self-identified as being of Puerto Rican background. In households with more than one eligible child, a maximum of three children were randomly selected to participate. Children were not eligible if they had mental retardation or developmental disabilities, or if they had not resided in the household for at least 9 months. Continue reading “Studying of Area of Residence, Birthplace, and Asthma in Puerto Rican Children”

Discussion of Area of Residence, Birthplace, and Asthma in Puerto Rican Children

asthma attacks In our study, Puerto Rican children from the South Bronx were more likely to be born prematurely, to have mothers who smoked during pregnancy, and to have families with lower SES than island Puerto Rican children. Surprisingly, however, children living in Puerto Rico were more likely to have asthma and to have been hospitalized for asthma than Puerto Rican children living in the South Bronx.

Previous studies have demonstrated a high prevalence of asthma among children in Puerto Rico. Two separate probability sampled, community-based studies of children in Puerto Rico found the lifetime prevalence of asthma to be > 30%. Perez-Perdomo et al found that parents of island Puerto Ricans who participated in the 2000 Behavioral Risk Factor Surveillance System reported a lifetime prevalence of asthma in their children of 33.2%. While many studies have shown a high burden of asthma in mainland US cities in which a large proportion of the Hispanic population is of Puerto Rican background, fewer studies have focused on Puerto Ricans specifically.

Poverty is a common condition among Puerto Ricans-; thus, most studies of asthma in the Puerto Rican population include participants from poor and disadvantaged backgrounds. It is unlikely, however, that the high prevalence of asthma in this population can be completely explained by issues related to SES. Ledogar at al found that the prevalence of asthma was higher in Puerto Ricans than in Dominicans or “other Latinos” living on the same streets and in the same buildings in Brooklyn, NY (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.0 to 3.6). Claudio et al conducted a study of 5,250 public elementary school children in New York City and found that Puerto Rican children had the highest 12-month prevalence of asthma (by parental report) of all ethnic groups, regardless of income level. Similarly, Ortega et al found no association between family income or maternal educational attainment and lifetime asthma prevalence, history of asthma attacks, or history of asthma hospitalization among children in Puerto Rico. Continue reading “Discussion of Area of Residence, Birthplace, and Asthma in Puerto Rican Children”

Area of Residence, Birthplace, and Asthma in Puerto Rican Children

AsthmaIn the United States, Puerto Ricans have higher asthma prevalence and have more morbidity and mortality from asthma than do whites, blacks, and other Hispanic subgroups. Using data from the National Health Interview Survey for from 1997 to 2001, Lara et al showed that Puerto Rican children had a higher lifetime prevalence of asthma (25.8%) than did white (12.7%), black (15.8%), Mexican (10.1%), Cuban (14.9%), and Dominican (14.9%) children living in the mainland United States. In addition, mainland Puerto Rican children had increased odds of an asthma attack in the past 12 months. According to the 2002 Behavioral Risk Factor Surveillance System the prevalence of current asthma was higher in adults living in Puerto Rico (11.6%) than in all US adults (7.3%) or Hispanic adults in the US mainland (5.5%). From 1990 to 1995, Puerto Ricans had the highest (40.9 per million) mortality rate due to asthma of all ethnic groups in the US mainland. Continue reading “Area of Residence, Birthplace, and Asthma in Puerto Rican Children”