M'liss Ilitch

In March, Perrigo Co. issued a voluntary recall of certain lots of its Gerber Good Start SoothePro Powder Infant Formula “out of an abundance of caution” due to the possible presence of Cronobacter sakazakii, a germ that can cause serious or deadly infections in infants.

The recall impacted Gerber Good Start formula manufactured between Jan. 2 and Jan. 18 at Perrigo’s Eau Claire, Wisconsin, facility. The recalled formula was sold in three different sizes at retailers nationwide, according to a March 17 recall notice.

Cooperative food wholesaler Associated Wholesale Grocers, however, distributed the 12.4-ounce version of the recalled product to its Nashville Division retailers after Perrigo’s initial recall notice was published.

As a result, the recalled product was distributed to supermarkets across Alabama, Georgia, Indiana, Kentucky, Ohio, Tennessee, Virginia and West Virginia, Associated Wholesale Grocers said Saturday.

The wholesaler is urging consumers who purchased Gerber Good Start formula at impacted locations to check their products. The recalled formula sold beyond the start of the recall can be identified by its lot codes and “use by” dates — which range from July 4, 2024, to July 12, 2024.

“Any consumers who purchased product with matching codes should discontinue use and dispose of the product,” Associated Wholesale Grocers’ Saturday notice reads, adding that consumers can request a refund by contacting the Gerber Parent Resource Center on behalf of Perrigo.

In a statement to The Associated Press on Tuesday, Perrigo said that the company informed all customers at the time of the March recall. The Saturday notice from Associated Wholesale Grocers, which Perrigo identifies as a customer, is “not directly associated with Perrigo and has no impact on the company,” Perrigo said.

The company also maintained that the March recall was initiated “out of an abundance of caution” — adding that “no Cronobacter sakazakii bacteria has been found in any product distributed for sale and no adverse events have been reported.”

The AP also reached out to Associated Wholesale Grocers for further comment Tuesday morning.

Infections caused by Cronobacter sakazakii are rare, but they can be life-threatening for newborns, the Centers for Disease Control and Prevention writes. The bacteria can cause sepsis and meningitis, according to the CDC.

Cronobacter sakazakii was the same germ that sparked Abbott Nutrition’s recall following a nationwide shortage of powdered infant formula last year. According to the FDA and CDC, Cronobacter sakazakii is found naturally in the environment and is “particularly good” at surviving in dry foods like infant formula — which can get contaminated at home or in processing facilities.

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Both acquired and genetic disorders share a common pathway that leads to intimal disruption. The mechanisms that weaken the layers of the aortic media eventually lead to increased stress on the arteriosclerotic wall, which can cause a variety of problems. The most frequent risk factor in aortic dissection is arterial hypertension, with chronic exposure of the aorta to high tensions that lead to thickening of the intima, fibrosis, calcification, and extracellular fatty acid deposits; the extracellular matrix can undergo accelerated degradation, apoptosis, and elastolysis, with final disruption of the intima, generally at the edges of atheromatous plaques1,6-8.

Acute aortic syndromes can be caused by some genetic diseases, such as Marfan syndrome. Dedifferentiation of the smooth muscle cells and increased elastolysis of the aortic wall components are some of the causes of these genetic disorders. A detailed family history is important to assess the need for systematic family screening in patients with acute aortic syndromes or sudden death.

There is limited knowledge of the incidence of aortic dissection.

There are studies that show an incidence of 2.6 to 3.5 cases per 100,000 person. A review of 464 patients from the International Registry of Acute Aortic Dissection (IRAD) found that two-thirds of the patients were male.

Women are more likely to be affected by acute aortic dissection than men, with a mean age of 67 years. The most common predisposing factors are arterial hypertension, a history of atherosclerosis, and previous cardiac surgery, which are summarized in Table 212-14. 5% of acute aortic dissections were considered to be related to Marfan syndrome and 4% to iatrogenic causes in the total IRAD registry. Younger patients were less likely to have a history of hypertension or atherosclerotic than older patients, but were more likely to find a syndrome Marfan, a bicuspid aortic valve, and/or previous aortic surgery.

AORTIC SYNDROME is a class of classes.

The types A and B are different. In type A, the dissection affects the ascending aorta, while in type B it only affects the descending aorta. The DeBakey classification divides the dissection into 3 different types: type I affects the entire aorta, type II only affects the ascending aorta, and type III avoids both the ascending aorta and the arch.

There are "variants" of dissection, such as intimal tears and penetrating aortic ulcers.

There is a fig. 1. The most common classifications are DeBakey and Stanford.

There is a fig. 2. There is a diagram of the dissection of the aorta.

Aortic dissection is a classic.

Acute aortic dissection is characterized by the rapid development of an intima flap that separates the true from the false.

The dissection can extend forward or backward from the intimal rupture and can cause problems. The data of persistent communication with the circulatory flow and patent false channel can be used to calculate the final risk of expansion.

There is an internal hematoma.

Aortic IH can be caused by the vasa vasorum being torn open and can lead to a secondary tear in the aortic media.

In up to 10% of cases, IH can extend, progress, or be reabsorbed. It is found frequently in the descending aorta. Although the clinical manifestations of IH resemble those of dissection, the process tends to be more segmental, so it's rare that pain to the head or legs is caused. Obtaining tomographic images in the appropriate clinical context is needed for the diagnosis of IH.

Penetrating atherosclerotic ulcer.

A dissection of the atherosclerotic aortic plaques can be caused by deep ulceration of the plaques. This entity can be difficult to diagnose and presents as an ulceroid image within the hematoma. In association with HI, a limited number of patients have documented the presence of penetrating atherosclerotic ulcers.

Symptomatic wounds with signs of deep erosion are prone to break. For such patients, it is becoming an attractive therapeutic option.

Natural history and evolution.

A dissection of theproximal.

Acute aortic dissection can be lethal and has a mortality that is between 1% and 2% per hour from the time of symptoms. Patients with pericardial tamponade or involvement of the coronary arteries have a higher risk of death. Age 70 years, arterial hypotension, and pulse deficit are some of the factors that can be used to predict increased in-hospital mortality.

Other less observed predisposing factors are previous cardiac and valve surgery, and iatrogenic dissection. Iatrogenic aortic dissection has a slightly higher mortality than non-iatrogenic. The data from the largest registry on acute aortic dissection showed that the mortality was associated with medical treatment, even if it wasn't immediately surgical repair. In-hospital mortality rates are 10% after the first day, 12% at 2 days, and almost 20% at 2 weeks, even with surgical repair. Aortic rupturing, cerebrovascular accident, and cardiac tamponade are the most common causes of death.

There is a fig. The IRAD Registry had

A dissection called type B.

Acute aortic dissection is associated with lower mortality. Patients with uncomplicated type B dissections have a mortality of 10% at 30 days. The mortality of patients with complications such asrenal failure, visceral ischemia, or contained rupture is 20% on day 2 and 25% on one month. As with type A dissection, advanced age, shock, and poor perfusion are strong predictors of early mortality. Patients with chronic use of crack are more likely to suffer from acute aortic dissection.

There is an internal hematoma.

The location of the IH is considered to be an independent predictor of progression to dissection, contained rupturing, or aneurysm formation, regardless of age, sex, or other factors. The findings are supported by the general experience in 454 cases of IH with an early mortality rate of 16%31,32,54-54. With timely surgical repair, IH is no longer associated with early death.

The early mortality of 45% with medical treatment, compared with 8% with surgical repair, is a reflection of the high risk of adopting a "wait and see" clinical attitude. The overall experience of the IRAD registry shows that there is a trend towards a better outcome after surgery for IH, taking into account the early mortality of 12% and the mortality rate of 24%.

There is a fig. 4. Mortality rates of hematoma are related to medical or surgical treatment.

Asian patients have low mortality rates in the IH even without surgery. Of the 22 patients with type A HI, 10 of them underwent surgical repair and 4 of them had medical treatment. 2 of 3 patients with type A IH who survived with medical treatment had tamponade.

8 patients with type A HI treated medically, of whom 7 survived, were not included in the analysis. In Korean patients with type A IH, only 1 in 18 died and 4 required surgery to correct the dissection. The Asian experience that an aorta of normal dimensions doesn't rule out progression in cases with 50mm of diameter is questionable. The Asian experience shows that the conclusions reached in the European mainstream can lead to serious problems.

The actuarial analysis shows that the clinical course achieved with oral beta-blocker therapy is better than without it.

Reducing wall tension, systolic blood pressure, and rate of change in blood pressure are all protected by the use of bia-blockers. The observation that a greater age at the time of initial diagnosis of IH carries a better long-term prognosis may be explained by a greater number of focal microscars along the aortic wall. Patients with IH who are over 65 years old present favorable results. If both the advanced aortosclerosis of old age and the lower risk of progression are considered, a conservative strategy could be justified in elderly patients with multimorbidity.

Penetrating the aortas.

A subset of high-risk patients are identified by the use of uiloid in the aortic segments. Penetrating atherosclerotic ulcers are caused by the erosion of the mural atheromatous plaque penetrating to the elastic lamina, which leads to separation of the media layers and the formation of adjacent hematoma. In the descending aorta, UAPs are seen more frequently than in the ascending aorta. UAP can cause problems such as pseudoaneurysm and dissection, or unpredictable rupture.

It is important to identify the diameter and depth of the ulcers, as the need for repair may be signaled by the width and depth of the ulcers.

The treatment of arteriosclerosis is a pharmactical treatment.

Patients with aortic dissection often present with chest or back pain that is penetrating and intense in nature. The most common presenting complaint was sudden onset of severe, sharp pain, which was not described as cutting, tearing, or migratory in the IRAD registry.

At the time of presentation, 4.5% of patients denied any pain. In patients with type A dissections, chest pain was more common than in type B dissections, while both back and abdominal pain were more common in type B12 dissection. Hypertension is the risk factor most frequently associated with aortic dissection, although it is less seen at presentation, especially in patients with type A proximal dissections. Acute dissections that affect the ascending aorta are considered to be surgical emergencies.

Unless the patient exhibits dissection progression, intractable pain, poor organ perfusion, or extra-aortic hemorrhage, dissections limited to the descending aorta are treated medically.

Initial medical treatment.

The main objective is to reduce the heart rate and thus limit the force of ejection of the left ventricle, since these are the main factors determining the dilation and rupture of the false light.

Blood pressure can be maintained between 100 and 120mmHg with a heart rate of 60 beats/min with a dose adjustment of the IV drugs. esmolol is a reasonable choice in patients with asthma, bradycardia, or signs of heart failure who may be tolerant to theblockers.

In order to control pain and blood pressure, a combination of drugs is needed. Dilaudid or verapamil can be used if theblockers are not safe.

It is possible to control mild hypertension with a combination of bia-blocker monotherapy and sodium nitroprusside at a starting dose of 0.2 g/kg per minute. Before administering fluids in patients with hypotensive or normotensive conditions, it is necessary to have an echocardiography to rule out blood loss, pericardial effusion, or heart failure. Patients with profound hemodynamic instability often need intubation and urgent bedside transesophageal echocardiography for confirmatory images.

In rare cases, the echocardiographic diagnosis of cardiac tamponade may justify immediate sternotomy and surgical access to the ascending aorta in order to prevent cardiovascular arrest, cardiogenic shock, and ischemic brain damage. Percutaneous pericardiocentesis is a temporary intervention that can cause bleeding and shock.

The ascending aorta is dissection.

Acute dissections of the ascending aorta should be treated as a surgical emergency, as they are at high risk of life-threatening consequences such as stroke, vas scrotum, and tamponade. The goal of surgery in type A is to prevent the occurrence of a pericardial effusion, which can lead to cardiac tamponade and death.

Similarly, the sudden onset of aortic regurgitation and coronary outflow obstruction requires urgent surgical attention with the goal of excising the region of the ruptured intimal flap in the dissection limited to the ascending aorta and replacing it with a mixed or interposed graft. (if the aortic leaflets are intact or can be resuspended). The complete intimal flap can't be removed when the dissection extends to the descending aorta. In a recent report, it was pointed out that removing or not uncovering intimal flaps in the descending thoracic arch is a problem that is seen in 20-30% of cases and leads to subsequent operation of the distal aorta62. In the treatment of arch or repair of open anastomosis63, there are measures that can be used such as deep hypothermic circulatory arrest andselective retrograde flow of head vessels.

Cerebral perfusion has recently gained acceptance due to improved outcomes with a 5-year survival of 73 6%, but it has failed to improve initial complications, survival and death rates. The 30-day, 1-year, and 5-year survival estimates were 81 2, 74 3, and 63 3%, respectively, and therefore did not differ from those of other techniques that use retrospective analyzes with propensity adjustments64. Immediate surgery is the key to success.

After the patient is maintained on extracorporeal circulation and antegrade cerebral perfusion, the aorta is mobilized to visualize the innominate arteries and the right atrium. In the case of intact leaflets, valve reconstruction using David or Yacoub resuspension techniques is more accepted than valve replacement.

The approach to an acute type A dissection is different. In these circumstances, a mixed sputum with an integrated valve is preferred in patients with Marfan syndrome. In urgent cases, valve-sparing operations are delicate and require extensive surgical expertise in centers with experience in elective cases. The ostium can be preserved if the dissection involves the left or right ostium. A button can be used to remove a ostium completely surrounded by a wall.

The layers are joined by tissue glue and double sutures after they are removed from the tube. A small, torn orifice is the only circumstance in which a bypass graft with saphenous vein segments can be used.

About 20% of patients don't have surgery after acute type A aortic dissections. The reasons cited to justify the preference for medical treatment have included morbidity with associated diseases, old age and patient refusal. The best treatment for an acute dissection of the aortic arch is still being worked on. A growing number of people agree that a dissection of the aortic arch should be done during hypothermic arrest.

In the absence of an intimal rupturing of the arch, an open anastomosis of the graft and junction of the aortic wall layers should be done. Up to 30% of patients with acute dissection have arch rupturings. When significant ruptures are found that extend beyond the junction between the transverse and descending aortic segments, or in cases with acute dissection of a previously aneurysmal arch, partial or total arch replacement may be necessary, with a new one. connection to the graft of some (or all) of the supra-aortic vessels during circulatory arrest in hypothermia and anterograde cerebral perfusion72.

The extension of the arch into the elephant trunk is one option described by Borst et al 73 in the case of non-dissecting aneurysms. Subsequent interventions on the descending aorta are greatly aided by this technique.

The former is allowed to float freely in the aortic lumen, instead of being stuck between the two. In a subsequent surgical procedure, the elephant trunk section of the graft may be connected directly to the distal descending aorta or extended by another tubular graft, or alternatively, a custom-made stent graft may be inserted and anastomosased. to the desired height of the descending aorta (fig. 5).

There is a fig.

Three-dimensional magnetic resonance imagery (MRI) reconstruction is done after a custom-made stent is used to connect a "elephant trunk" to the upper abdominal aorta to exclude an anneurysm that may have arisen at the end of the elephant's trunk. thrombus formation around the stent was successfully excluded from the circulation. Aneurysm is a self-expanding graft.

There is a role for endovascular procedures in type A dissection.

Conventional treatment of a dissection of the ascending aorta with complete or partial removal is called a De bakey type A dissection. Endovascular strategies have no clinical application except to alleviate critically poor perfusion prior to surgery of the ascending aorta, either by insertion of a self-expanding stent graft into the descending thoracic aorta, or by distal fenestration of the ascending aorta. rare cases of thoracoabdominal extension (De Bakey type I) with peripheral ischemic complications. The reestablishment of circulation in the branches could be accomplished with the help of the reconstruction of the true collapsed intravascular lumen.

The mortality rates in patients with acute peripheral infarction are similar to those in patients with poor perfusion syndrome, which is why most of them are good candidates for endovascular treatment.

There is a fig. The dissection of the B section of the aorta had poor blood flow.

The flow to the abdomen and lower extremities was restored after the insertion of a stent.

The dissection of the aortic valve.

At the present time, the most commonly adopted approach to treat complications of acute descending aortic dissection (type B) is stenting, as surgical repair has not shown any superiority over treatment in these cases. medical or interventional Patients with uncomplicated aortic dissections limited to the descending thoracic aorta (Stanford type B or DeBakey type III) currently receive medical treatment, but in the near future they may become candidates for endovascular treatment in selected cases. If necessary, medical treatment includes the administration of beta-blockers and vasodilators to maintain blood pressure.

Morphine sulfate analgesia is important in attenuating the sympathetic release of catecholamines caused by pain, with the resulting tachycardia and arterial hypertension. After the patient has been stable, treatment with antihypertensive drugs is continued under close follow-up with clinical evaluations at 6 months intervals. A series from the IRAD registry included a number of patients with type B dissections. The mortality of these patients was 10%.

Long-term survival with medical treatment is between 60 to 80% and between 40% and 45%. In patients with noncommunicating dissections, survival is better.

There is surgery in the type B.

At the present time, the indications for operative treatment in patients with acute type B (type III) aortic dissection are limited to the prevention or alleviation of life-threatening complications, such as refractory pain, an aortic diameter that rapidly increasing or signs of impending aortic rupture, although they can also be treated interventionally by inserting a self-expanding stent graft.

The onset of complications such as poor perfusion of the vital lateral arteries of the aorta warrants interventional treatment, with the insertion of a stent graft, in order to improve distal flow through the true lumen or, in rare cases, with catheter-guided fenestration of an occlusive intimal flap. If this approach doesn't produce rapid relief of symptoms, surgical intervention may be necessary. Surgery has not shown superiority over medical or interventional treatment in stable patients, so uncomplicated type B (type III) aortic dissections are managed conservatively. The concept of a stent is being explored in more complicated cases. The patients who are treated surgically are those with a complicated clinical course, which leads to higher short-term mortality than with medical treatment.

There is a type B dissection.

It is appealing that a stent can be inserted to repair a dissection. An increasing number of acute type B aortic dissections are repaired in this way, with little evidence of periprocedural morbidity, allowing treatment of poor perfusion, interruption of blood loss, and ultimately reconstruction of the aorta.

With experienced hands, stent insertion in complicated distal aortic dissection is associated with few peripheral or neurologic problems, which is better than with medical or surgical treatment in high-risk groups with a type B dissection.

Even in patients with life-threatening problems, the role of fenestration and stenting in a dissection is still evolving. The mortality rate of patients with mesenteric ischemia is greater than the mortality rate of patients with renal ischemia.

The in-hospital surgical mortality rate in ischemia of affected end organs reaches 89%, which makes it a viable option before or after definitive surgical treatment.

10 years ago, a group of patients with type B chronic aortic dissection who had at least one indication for surgery were compared to a group of patients with no indication for surgery. There were no deaths or serious adverse events associated with surgery for type B dissection.

In 19 patients with acute aortic dissection, the primary intimal break point was the place where the stents were inserted. Fourteen of the 19 patients had dissections that involved the aortic branches, and seven had dissections that involved multiple veins. All 19 patients had the stent inserted into the primary rupture. In 15 patients, complete thrombosis was achieved.

In 75% of the arteries, the ischemic branch vessel was successfully re-opened. Three of 19 patients died within 30 days, with no further deaths during a 13 month follow up.

The European Society of Cardiology on acute aortic dissection published its recommendations with the indications for fenestration 87.

In high-risk patients who are not candidates for surgery due to age, comorbidity, or personal preference, endovascular repair can be used to treat disease that might otherwise have been left to its natural course.

In the cases of type B dissection, the in-hospital mortality was 10%86 and the majority of the cases received medical treatment.

The long-term survival rate with medical treatment is between 60 and 80%. Patients with retrograde dissections have a better survival rate.