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|Spanish to English translations [PRO]|
|Spanish term or phrase: encefalopatia anoxica-sindrone de pre-excitacion|
|It's a cause of death|
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Anoxic encephalopathy: pre-excitation syndrome
encefalopatia anoxica-sindrone de pre-excitacion
->Anoxic encephalopathy: pre-excitation syndrome
Atrial Fibrillation Follow-up
Investigation of Rhythm
Management (AFFIRM) (2)
The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM)
Study is a randomized evaluation of treatment of AF by 1 of 2 strategies:
ventricular rate control and anticoagulation versus rhythm control and
anticoagulation. The primary end point is total mortality, analyzed by intention-to-
treat. Secondary end points are composite end points (total mortality, disabling
intracranial bleed [subdural and/or subarachnoid hemorrhage], stroke [embolus,
thrombosis, hemorrhage], disabling anoxic encephalopathy, cardiac arrest, major
noncentral nervous system bleed), cost of therapy, and quality of life. AFFIRM
randomized 4060 patients and followed them for an average of 3.5 years at 213
sites in the United States and Canada.
The Anticoagulation and Risk
Factors In Atrial Fibrillation Study
The Anticoagulation and Risk Factors In Atrial Fibrillation Study (ATRIA) sought to
determine the prevalence of AF in the United States. The hypothesis was that the
prevalence of AF in the United States could be projected for the years 1995 to
2050 by age- and sex-specific prevalence calculations and US census data. A
cross-sectional study of adults aged 20 years or older who were enrolled in a large
health maintenance organization in California was performed to identify all cases
of AF. The age- and sex-specific prevalence calculations of AF in the study
population were applied to 1995 United States census data to estimate the number
of US adults with this condition in 1995. Given the anticipated growth of the
population in the United States, the number of adults who will have diagnosed AF
was projected by directly applying age- and sex-specific prevalence estimates from
the study to US census projections for each adult age and sex category through
the year 2050. The study confirms that AF is common among older adults and
provides a contemporary basis for estimates of prevalence in the United States.
The number of patients with AF is likely to increase 2.5-fold during the next 50
years, reflecting the growing proportion of elderly individuals...
"Conditions characterized by activation of the whole or some part of the ventricle by the atrial impulse earlier than would be expected if the impulse reached the ventricle by way of the normal specific conduction system only."
In the pre-excitation syndrome there is early depolarization of a portion of the ventricles followed by normal activation of the remainder. The early depolarization may be constant or intermittent. This syndrome was described by Wolff, Parkinson and White, and has been called the WPW syndrome, characterized by a short P-R interval 0.12 sec or less, and an initial slurring of the QRS complex called a delta wave. The QRS is lengthened to the same degree that the P-R interval is shortened. The P-J time (beginning of the P to the end of QRS) is the same when an individual has the condition as it is when there is normal conduction (Fig.87).
There are a number of possible explanation for the pre-excitation syndrome, all must assume that the AV node is bypassed so that a portion of the myocardium is depolarized early. This preexited area is stimulated by an impulse which traver around the AV node at the same time the impulse is traversing the AV node Purkinje system and, finally, the ventricles.
The resulting QRS complex is a fusion beat with the initial portion referred as a delta wave, representing early depolarization, and the remainder, normal depolarization. How much of the depolarization is carried out through the bypass, and how much in the normal fashion, depends on the relative conduction times of the AV node and the bypass. If the AV node is blocked, then the entire QRS become a delta wave; or if the transmission through the AV node is relatively enhanced there may be no delta wave with variation in between. (This will be discussed a later chapter on the His bundle electrogram.)
The bypass of the AV node may occur through a group of fibers called the bundle of Kent. These communications between the atrial and ventricle are probably embryonic remainders which where not interrupted in fetal life when the atriovenrticular fibrous tissue developed. Pathways have been found in the lateral wall of the right and left ventricles as well as in the septum by anatomical and electrophysiological studies. The impulse may be transmitted over the posterior James pathway bypass the AV node, and then through a group of fibers to the ventricle.
Secondary S-T segment and T wave abnormalities may be associated when large part of the ventricular depolarization occurs through the bypass.
Pre-excitation may be seen in otherwise normal individuals, an incidence of above 1.5 per 1.000, and may be only intermittently present. Pre-excitation may be associated with congenital heart disease such as Ebstein's anomaly, atrial septum defect, ventricular septal defect or, in cardiomyopathy, mitral valve-prolapse and occasionally, in coronary artery disease.
Atrial arrhythmias occur in 12 to 80% of individuals with the pre-excitation syndrome. This depends on the population sampled. Lamb found that less that 12% of clinically healthy individuals with WPW gave a history, or were found to have, a paroxysmal arrhythmia. The incidence is much higher in a hospital and in other clinical settings.
Of these arrhythmias, about 80% are paroxysmal atrial tachycardia, 15% atrial fibrilation, 4% atrial flutter, 1% are other arrhythmias (ventricular tachycardia and ventricular fibrilation).
Figure 87B shows, diagrammatically, the pathways of the impulse from the AV node to the ventricles, which may go through the AV communication, bundle of Kent, or by way of the posterior James bundle bypassing the AV node and then through the Mahaim fibers to the ventricles.
The delta wave expressed as a vector may be directed ahead or back. If the wave is directed ahead, there is a tall R wave at V1 initially thought may be due to insertion of the bypass in the left ventricle. This is called Type A. If the delta vector is directed back, a QRS complex is written at V1 and is classified as Type B, initially thought to indicate a right ventricular bypass. In a third classification, Type C, the delta wave is directed to right either ahead or back.
More recently, it has been shown that bypass tracts are widely distributed and transmit impulses at any point around the AV ring or in the septum. The latter may result in delta waves directed ahead or back. The location of bypass cannot be accomplished accurately by the usual surface ECG but requires intracardiac and epicardial mapping.
The delta vector may be located downward to the left, downward to the right, or above to the left. Any of these delta vectors may be directed ahead or back (Type A or B).
In Fig. 88, in the frontal plane, the delta vector is usually directed leftward and down causing a positive delta wave in Leads I, II, aVL, V5, and V6. In the transverse plane, the delta wave may be either ahead or back directed resulting in either tall R waves in V1 (Type A) or QS complex in V1 (Type B).
The Type A may be confused with true posterior infarction or right ventricular hypertrophy and the Type B with anterior septal infarction. Careful measurement of the P-R interval and close inspection of the QRS will avoid this confusion.
When the vector is directed toward the right and down, q wave of abnormal duration are seen in Leads I and aVL suggesting lateral wall infarction. An up oriented delta vector causes an abnormal q wave to appear in Leads I, II, III, aVF and may be confused with inferior myocardial infarction.
In the VCG there is slowing of the initial forces for the first 20 to 40 msec as indicated by the close proximity of the dashes. On occasions this is very helpful, particularly when the delta wave is small and difficult to identify on the scalar ECG.
Hiss bundle studies have denostrated that a portion of the left ventricle is activeted before the Hiss bundle depolarization occurs, proving that a bypass exists. If a delay in transmission at the AV node is produced (by rapid atrial pacing or by an early atrial systole) then more and more of the depolarization wave is carried through the bypass so that finally the entire QRS results from depolarization by means of the bypass and becomes a delta wave. This may explain why some individuals have a large and other a small delta wave. When the delta wave progressively increase, this indicates progressive decreased conduction through the AV node and increased conduction through the bypass. Figure 91 illustrates two examples of the ECG seen in the WPW syndrome.
Pre-excitation may also occur without the presence of the delta wave as described by Lown, Ganong, and Levine and called the LGL syndrome. In this case the P-R interval is short, and the QRS is normal in duration, probably resulting from bypass of the AV node to the Hiss bundle through the posterior James tract. LGL syndrome is also often associated with paroxysmal tachy arrhythmias.
On rare occasions there is a delta wave associated with a normal P-R interval probably due to early depolarization of the ventricles by the Mahaim fibers after the impulse is transmitted over the AV node with normal delay.
WPW may be confused with myocardial infarction, right or left ventricular enlargement, or bundle branch block, if the P-R interval is not carefully measured. A false positive exercise test may occur in individuals with the WPW syndrome.
Arrhythmias in Pre-excitation
Paroxysmal supraventricular tachycardia is the most common arrhythmia seen in the WPW syndrome, accounting for about 80% of the rhythm disturbances that occur. This particular arrhythmia may be precipitated by an atrial or a ventricular premature impulse. The atrial premature impulse usually traverses the AV node in an antegrade fashion causing normal, narrow QRS complexes, then goes retrograde through the bypass and down the AV node again.
If the impulse goes through the bypass to the ventricle, the QRS is wide because of the delta wave. The circus movement is then retrograde through the AV node and back down again through the bypass. A ventricular premature beat may also precipitate supraventricular tachycardia with a normal or abnormal QRS.
CONDITION: PRE-EXCITATION SYNDROMES
I. Overview. The anomaly of concern is an accessory pathway of conduction from atria to ventricles. A portion of the electrical impulse “bypasses” the AV node (hence the term bypass tract) and depolarizes (excites) the ventricles prematurely (pre-excitation). In Wolff-Parkinson-White (WPW), the most common pre-excitation syndrome, the aberrant pathway links an atrium and ventricle. In Lown-Ganong-Levine (LGL) it links the atrium with the bundle of His. WPW is the only pre-excitation condition truly diagnosable by 12-lead electrocardiogram (ECG). Others may be suspected by ECG but are typically diagnosed only during an electrophysiologic study performed for documented/suspected tachyarrhythmia. Radiofrequency ablation is potentially curative for supraventricular tachycardia (SVT) associated with an accessory pathway. Please refer to the SVT and Ablation waiver guides for further guidance. This waiver guide addresses only the WPW ECG pattern.
WPW ECG pattern is the classic ECG findings of short PR interval and delta wave (slurred, widened QRS onset) but without documented or suspected SVT. The ECG findings are often only intermittently present. WPW syndrome is the ECG findings plus suspected or documented SVT. About 30% of all SVTs involve an accessory pathway. According to the general cardiac literature, the WPW ECG pattern occurs in 1-3 per 1,000 of the population and an estimated 30-35% will develop SVT over the next 10 years after diagnosis of the ECG pattern. Sudden death occurs in 1-6% over 10 years. Atrial fibrillation with rapid ventricular response and deterioration to ventricular fibrillation is considered the likely cause of sudden death and some studies have reported atrial fibrillation in up to 40% of WPW subjects. But it is not possible to identify which patients will develop SVT, atrial fibrillation, or sudden death.
The SVT mechanism is a macro reentrant circuit involving the normal AV node pathway and the accessory pathway. In 80-85% of WPW syndromes, the impulse travels atria-to-ventricles down the AV node and ventricles-to-atria up the accessory pathway, resulting in a normal QRS pattern SVT. In the other cases the impulse travels in the opposite direction, resulting in a wide-QRS complex SVT (100% pre-excited), which may be mistaken for ventricular tachycardia.
II. Aeromedical Concerns. Sudden cardiac death is the most compelling concern but is rare (0.1-0.6% per year). This is felt to be due to atrial fibrillation with a rapid ventricular response across the accessory pathway, deteriorating into ventricular fibrillation. The more likely event is SVT (up to 3.5% per year for at least 10 years after diagnosis) with possible hemodynamic symptoms.
III. Information Required for Waiver Submission. ACS review is required for waiver recommendation. Submit an aeromedical summary and originals or good quality copies of available ECGs. Additional local cardiac testing is not routinely required but may be requested in individual cases. Copies of reports and tracings of any other cardiac tests are required for ACS review. ACS evaluation may also be required, depending on the flying class or for specific concerns in an individual case.
IV. Waiver Considerations. WPW pattern is disqualifying for all classes of flying duties. Waiver is not recommended for FCI/IA unless successful radiofrequency ablation is performed. Please refer to the ablation waiver guide for further guidance. Unrestricted waiver may be recommended for FCII/III after ACS review/evaluation. FCII requires ACS evaluation. FCIII will usually receive a waiver recommendation after ACS review, but without formal ACS evaluation. However, concerns about an individual case may require ACS evaluation. FCII or FCIII waiver will generally be valid for three years with ACS reevaluation/review at that time for waiver renewal. The initial waiver recommendation will specify requirements for waiver renewal.
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Anoxic Encephalopathy - Wolf Parkinson White Syndrome
http://neuro-www.mgh.harvard.edu/forum/TraumaticBrainInjuryF... & Anoxic Encephalopathy)
This article submitted by Thame Chapman on 12/15/97.
Email Address: zIpPeRhEaD@texasonline.net
(I know this may not be the right forum for this question: so if someone could point me in the right direction. - Thank you.)
About 20 months ago I had an allergic re-action to some cold medicine. It left me in a coma for a week and I was hospitalized for 4 months. I was left with extreme weakness in my extremities and a severe speech impediment. My current diagnosis is anoxic encephalopathy but when I was in the hospital I was diagnosed with acute illness polyneuropathy.
And lots of info on the subject on the Internet.
Note added at 55 mins (2004-07-14 13:54:39 GMT)
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