Common bile duct calculi: updated experience with dissolution with methyl tertiary butyl ether

The authors describe their experience with methyl tertiary butyl ether (MTBE) in a larger series of patients than previously reported in order to acquaint physicians with both its effectiveness for dissolution of common bile duct calculi and the limitations of its use. Ten patients with 13 biliary calculi underwent percutaneous stone dissolution treatment with the experimental cholesterol solvent, MTBE. Three stones completely dissolved within 30 minutes, seven were reduced in size, and three were visibly unaffected. All stones not completely dissolved were easily extracted by means of a stone basket except for one in a patient taken to surgery. Although MTBE perfusion is an effective technique for management of biliary calculi, practitioners should be aware that its use is quite time consuming and its odor difficult to control.     

Informant ratings of cognitive decline of elderly people: relationship to longitudinal change on cognitive tests

Formal assessment of cognitive decline with cognitive tests can be difficult, requiring either two measurement points or a comparison of 'hold' with 'don't hold' tests. Informant-based assessment provides an alternative approach because informants can adopt a longitudinal perspective and directly rate cognitive change. A study was carried out to assess the validity of informant ratings collected by means of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). A community sample of 500 subjects aged 74 or over underwent four cognitive tests on two occasions 3½ years apart. On the second occasion, informants filled out the IQCODE. Subjects rated as having moderate or severe decline were found to have greater change on the cognitive tests. These findings support the validity of informant ratings of cognitive decline.     

Função Diastólica e Biomarcadores de Participantes de Caminhada de Longa Distância

Background:The effects of long-distance walking on the cardiovascular system have been little studied.Objectives:The general objective of this study was to verify these effects on the behavior of diastolic function and the cardiac biomarkers CK-MB (mass), troponin T, and NT-proBNP, in amateur athletes.Method:This longitudinal study, conducted in 2015, evaluated participants during the following 5 stages: E0 (baseline) before starting the trajectory and the others, E1, E2, E3, and E4, at the end of each day, totaling 244.7 km. At all stages, the biomarkers NT-proBNP, CK-MB (mass), and troponin T were measured. Echocardiogram was performed to analyze the E, A and E'' waves. P < 0.05 was adopted as significant.Results:The study evaluated 25 participants, with an average age of 46 ± 10.5 years and body mass index of 20.2 ± 2.3 kg/m2. Increased values were found for NT-proBNP from E0 to E1, E2, E3, and E4 (p < 0.001), CK-MB (mass) from E0 to E2 (p < 0.001), and E'' wave from E0 to E1, E2, E3, and E4 (p < 0.001). Positive correlations were identified between the following: CK-MB (mass) and troponin T (E1: r = 0.524, p = 0.010; E4: r = 0.413, p = 0.044); CK-MB (mass) and NT-proBNP (E4: r = 0.539, p = 0.006); and E/A and E'' (E0: r = 0.603, p < 0.001; E1: r = 0.639, p < 0.001; E4: r = 0.593, p = 0.002). A negative correlation was found between CK-MB (mass) and E/A (E1: r = −0.428, p = 0.041).Conclusion:The effects of intense, prolonged, and interspersed physical activity were verified based on significant variations in the behavior of CK-MB (mass), NT-proBNP, and the E'' wave. Notwithstanding the alterations found, there were no criteria suggestive of myocardial damagePalavras-chave: Walking, Biomarkers, Biological, Blood Pressure, Troponin-T, Natriuretic Peptide Brain, Athletes, Echocardiography, Doppler/methods     

Respiratory muscle weakness and normal ventilatory drive in dilative cardiomyopathy

BACKGROUND: In dilative cardiomyopathy several factors influence dyspnoea.Patients with chronic heart failure may demonstrate impairmentof breathing pattern, ventilatory drive and respiratory musclestrength, as well as reduction of ventilatory efficiency. Thepurpose of this study was to evaluate whether dilative cardiomyopathyis accompanied by changes in breathing pattern, respiratorymuscle weakness and ventilatory neural drive. METHODS: We investigated 47 patients (36 men, mean age=47·8±11·2years) with chronic heart failure due to dilative cardiomyopathy,and 30 healthy subjects (10 men, mean age=35·4±11·7years) served as controls. Patients and controls underwent evaluationof left ventricular ejection fraction by 2D echocardiography,spirometry, body plethysmography, mouth occlusion pressure andrespiratory muscle strength, as well as by submaximal treadmillexercise testing with gas exchange measurements. The patients'results were compared to controls and predicted standard normalvalues, and evaluated for differences according to the degreeof severity of functional impairment. RESULTS: Patients with dilative cardiomyopathy demonstrated a slightreduction in lung volumes (15% of the patients with obstructiveand 15% with restrictive lung function pattern) and diffusioncapacity (20·4±6·8 vs 15·4±6·7ml. min^–1 . kPa^–1; P<0·01). In neuraldrive, as assessed by mouth occlusion pressure, there was nosignificant difference between patients and controls. Therewas a slight but significant reduction in respiratory musclestrength, as assessed by measuring maximal inspiratory pressurein patients with dilative cardiomyopathy (6·7±2·4kPavs 8·6±3·5kPa; P<0·01). The observedchanges were more pronounced in the severe chronic heart failurepatients (with a reduction in ventilatory efficiency) whereasno relationship among indices of cardiac or respiratory functionwas found. CONCLUSION: Patients with chronic heart failure due to dilative cardiomyopathydevelop respiratory muscle weakness without changes in neuralventilatory drive, and slight changes in breathing pattern relatedto the severity of the disease.     

Targeting the Use of Pooled HIV RNA Screening to Reduce Cost in Health Department STD Clinics: New York City, 2009–2011

Objective

Staff at public New York City sexually transmitted disease (STD) clinics screen patients for acute HIV infection (AHI) using pooled nucleic acid amplification tests. AHI screening is expensive but important for populations at high risk of acquiring HIV. We analyzed if targeting AHI screening in STD clinics could reduce program costs while maintaining AHI case detection.

Methods

From January 2009 through May 2010, we screened all patients with negative rapid HIV tests for AHI. Using risk information on cases detected during this universal screening period, we developed criteria for targeted AHI screening and compared case yields and testing costs during 12 months of universal screening (June 2009 through May 2010) vs. 12 months of targeted screening (June 2010 through May 2011).

Results

During the defined period of universal screening, we identified 40 AHI cases, and during targeted screening, we identified 35 AHI cases. Because of targeting efforts, the number needed to test to find one AHI case dropped from 1,631 to 254. With targeted screening, it cost an average of $4,535 per case detected and 39.3 cases were detected per 10,000 specimens; using universal screening, $29,088 was spent per case detected and 6.1 cases were detected per 10,000 specimens processed.

Conclusion

Targeted screening identified similar numbers of AHI cases as when screening all clinic patients seeking HIV testing, but at one-seventh the cost.During the acute phase of human immunodeficiency virus (HIV) infection (AHI), infected people are often unaware of their condition, as AHI symptoms—which include fever, sore throat, fatigue, myalgia, lymphadenopathy, rash, joint pain, night sweats, and diarrhea—are nonspecific.¹ During AHI, patients are highly viremic (and, thus, highly infectious), and antibodies to HIV have not yet developed.² This stage of infection, therefore, is not detected by traditional antibody tests. Detecting AHI requires nucleic acid amplification or antigen tests and enables infected people to adopt safer behaviors and be linked to earlier treatment and care, all of which may reduce HIV transmission.^3,4 A multisite study conducted in 14 clinics in New York City (NYC); Los Angeles, California; and four counties in Florida from 2006 to 2008 found that AHI screening, when added to point-of-care rapid testing, increased HIV detection by 8.2% across all sites; in three NYC clinics, 24% more HIV infections were detected using AHI screening than with HIV detection using rapid antibody tests alone (seven cases detected by nucleic acid amplification testing [NAAT]; 22 cases detected by rapid test).⁵ NAAT is an important tool for identifying AHI, and NAAT pooling methods (pNAATs) help to contain the costs of screening.⁶ By 2009, the NYC Department of Health and Mental Hygiene (NYC DOHMH) had implemented routine AHI screening via pNAAT for all patients with negative rapid HIV tests in all of its sexually transmitted disease (STD) clinics. At that time, the NYC DOHMH joined just a handful of state and local health departments in the United States that were routinely using pNAAT.⁷While AHI screening increased HIV detection in NYC STD clinics, it came at a considerable cost. Annualized other-than-personnel costs of this screening were more than $1 million, or approximately $30,000 per new diagnosis, which was as much as 16 times greater than the average cost of routine opt-out HIV screening in health-care facilities in the U.S.⁸ We present our evaluation of a strategy to reduce program costs while maintaining a high level of AHI case detection among clinic patients.     

Unilateral Direct Carotid Cavernous Fistula Causing Bilateral Ocular Manifestation

Unilateral carotid cavernous fistula presents with ipsilateral ocular findings. Bilateral presentation is only seen in bilateral fistulas, usually associated with indirect (dural) carotid cavernous fistulas. Direct carotid cavernous fistulas are an abnormal communication between the internal carotid artery and the cavernous sinus. They typically begin with a traumatic disruption in the artery wall into the cavernous sinus, presenting with a classic triad of unilateral pulsatile exophthalmos, cranial bruit and episcleral venous engorgement. We report the case of a 38-year-old male with traumatic right carotid cavernous sinus fistula and bilateral ocular presentation successfully treated by interventional neuroradiology.Key Words: Exophthalmos, Papilledema, Carotid artery injury, Carotid cavernous sinus fistula, Endovascular procedure, Therapeutic embolization