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Immunization: a global challenge for the 21st Century.

The 9th Canadian Immunization Conference was held on 5-8 December 2010 in Quebec City, Canada. Over 1000 academic, public health and vaccine industry scientists, nurses, pharmacists, physicians and policy makers attended the conference, which was organized by the Public Health Agency of Canada-Centre for Immunization Research and Respiratory Infectious Diseases in collaboration with the Canadian Association of Immunization Research and Evaluation, the Canadian Paediatric Society and the Canadian Public Health Association.

Fresh from the pandemic influenza A H1N1 2009-2010 experience, in which Canada experienced a smaller Spring 2009 wave followed by a Fall wave that stretched public health prevention and healthcare system resources, conference attendees were given the chance to reflect on lessons from the perspective of communication strategies, vaccine effectiveness, safety and program delivery techniques, in one of six program streams devoted to H1N1. The five other streams were immunization in a global community, vaccine safety, new technologies, vaccine-specific issues and clinical practice.

In this article, we summarize some of the key presentations from the six plenary sessions, 36 concurrent symposia and workshops, podium and poster presentations.

Successful Endovascular Repair of Two Ruptured Thoracic Aortic Aneurysms in Nonagenarians.

Ruptured thoracic aortic aneurysm (rTAA) is a catastrophic and mortal event. Thoracic endoVascular aortic repair (TEVAR) has emerged as an alternative to open repair. We report the first two successful TEVAR performed for rTAA in nonagenarians.

METHODS AND RESULTS: Patient 1 was a 92-year-old man with multiple comorbidities with a 5.6 cm thoracic aortic aneurysm who was admitted for anticoagulation for pulmonary embolism. Twelve hours later, he was found to be hypotensive and the X-ray showed an opacified left hemithorax (Fig. 1). A 40 mm × 20 cm Gore TAG stent-graft (W. L. Gore & Associates, Inc., Flagstaff, AZ) was deployed to successfully exclude the rupture. The postoperative course was uncomplicated and on day 9, he was discharged to a skilled nursing facility. Patient 2 was a 94-year-old man with a history of multiple comorbidites and endovascular aneurysm repair for ruptured abdominal aortic aneurysm 3 years earlier, who presented to the emergency room in hemorrhagic shock. Computed tomography scan revealed hemomediastinum and left hemothorax suggesting thoracic aorta rupture (Fig. 2A). Emergently, a 34 mm × 30 cm Gore TAG stent-graft was deployed (Fig. 2B). A left chest tube was placed. Postoperative course was briefly complicated by acute renal failure and pneumonia and on day 14, he was discharged to a rehabilitation center.

CONCLUSION: TEVAR for rTAA is an effective option and advanced age alone should not deter definitive repair of the thoracic aorta.

Therapeutic effects of percutaneous vertebroplasty for vertebral metastases.

We have performed percutaneous vertebroplasty (PV) using polymethylmethacrylate (PMMA) for patients with vertebral metastases since 2002. This study investigated the therapeutic effects of PV on vertebral metastases.

How I manage venous thromboembolism in pregnancy.

In pregnancy, the combination of altered coagulation factors, stasis and vascular damage heightens the thrombotic risk and venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality.

In women presenting with pregnancy-related VTE, the wellbeing of both mother and fetus must be considered, necessitating a multidisciplinary approach. The risk of VTE is present throughout the pregnancy and is maximal during the postpartum period. Diagnosis may be difficult because the symptoms might mimic those of pregnancy and prospectively validated diagnostic protocols are lacking. Compression ultrasound is the test of choice for deep vein thrombosis and perfusion scan and computerized tomography pulmonary angiography are the imaging options for diagnosis of pulmonary embolism. Low molecular weight heparin does not cross the placenta and is a safe and effective treatment for the majority of cases of pregnancy-related VTE.

This review provides a practical approach to diagnosis and treatment of VTE in pregnancy.

Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test.

Aims In patients with acute pulmonary embolism (PE), right ventricular dysfunction at echocardiography is associated with increased in-hospital mortality.

The aims of this study in patients with acute PE were to identify a sensitive and simple criterion for right ventricular dysfunction at multidetector computed tomography (MDCT) using echocardiography as the reference standard and to evaluate the predictive value of the identified MDCT criterion for in-hospital death or clinical deterioration.

Methods and results Right ventricular dysfunction at MDCT was defined as the right-to-left ventricular dimensional ratio and was centrally assessed by a panel unaware of clinical and echocardiographic data. A right-to-left ventricular dimensional ratio ≥0.9 at MDCT had a 92% sensitivity for right ventricular dysfunction [95% confidence interval (CI) 88-96]. Overall, 457 patients were included in the outcome study: 303 had right ventricular dysfunction at MDCT. In-hospital death or clinical deterioration occurred in 44 patients with and in 8 patients without right ventricular dysfunction at MDCT (14.5 vs. 5.2%; P< 0.004). The negative predictive value of right ventricular dysfunction for death due to PE was 100% (95% CI 98-100). Right ventricular dysfunction at MDCT was an independent predictor for in-hospital death or clinical deterioration in the overall population [hazard ratio (HR) 3.5, 95% CI 1.6-7.7; P= 0.002] and in haemodynamically stable patients (HR 3.8, 95% CI 1.3-10.9; P= 0.007).

Conclusion In patients with acute PE, MDCT might be used as a single procedure for diagnosis and risk stratification. Patients without right ventricular dysfunction at MDCT have a low risk of in-hospital adverse outcome.

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