Utility of the STOP-Bang and Epworth scales and the neck-to-height ratio to detect severe obstructive apnea-hypopnea syndrome in severe obesity

BackgroundObstructive sleep apnea–hypopnea syndrome (OSAHS) is present in 80% of patients evaluated for bariatric surgery (BS). Extensive evaluation is not widely available, but treatment is mandatory for severe cases. The Snore, Tiredness, Observed apneas and Pressure - Body mass index, Age, Neck circumference and Gender (STOP-Bang) and Epworth questionnaires and neck-to-height ratio (NHtR) are accessible clinical tools to screen for sleep and metabolic disturbances, but their utility to detect severe OSAHS in patients with severe obesity has not been determined.ObjectivesTo evaluate the cutoff point of those clinical tools that may predict severe OSAHS, confirmed by polysomnography in patients referred for BS.SettingTertiary referral center in Mexico City.MethodsWe applied the STOP-Bang and Epworth questionnaires, evaluated anthropometric characteristics, and collected samples for arterial gasometry and metabolic parameters from 68 patients with severe obesity, who were then referred for polysomnography before their evaluation for BS.ResultsOf the 68 patients participating in the study, 67.7% were female, with a median age of 43 years (35–49 years) and a body mass index (BMI) of 45.5 kg/m² (42.4–50.9 kg/m²; 28.3% had a BMI ≥ 50 kg/m²). A STOP-Bang cutoff >5 points had a sensitivity of 60% and specificity of 90% for detecting severe OSAHS (area under the curve [AUC] = .962); meanwhile, an NHtR >.25 had a sensitivity of 90% and specificity of 52.5% (AUC = .759). The Epworth scale score >11 points had a sensitivity of 57.1% and specificity of 83.3% (AUC = .802).ConclusionClinical data may be useful to detect severe sleep apnea in high-risk populations, allowing for rapid referral and better use of resources.     

Cost-effectiveness of using hepatitis C viremic hearts for transplantation into HCV-negative recipients

Outcomes following hepatitis C virus (HCV)-viremic heart transplantation into HCV-negative recipients with HCV treatment are good. We assessed cost-effectiveness between cohorts of transplant recipients willing and unwilling to receive HCV-viremic hearts. Markov model simulated long-term outcomes among HCV-negative patients on the transplant waitlist. We compared costs (2018 USD) and health outcomes (quality-adjusted life-years, QALYs) between cohorts willing to accept any heart and those willing to accept only HCV-negative hearts. We assumed 4.9% HCV-viremic donor prevalence. Patients receiving HCV-viremic hearts were treated, assuming $39 600/treatment with 95% cure. Incremental cost-effectiveness ratios (ICERs) were compared to a $100 000/QALY gained willingness-to-pay threshold. Sensitivity analyses included stratification by blood type or region and potential negative consequences of receipt of HCV-viremic hearts. Compared to accepting only HCV-negative hearts, accepting any heart gained 0.14 life-years and 0.11 QALYs, while increasing costs by $9418/patient. Accepting any heart was cost effective (ICER $85 602/QALY gained). Results were robust to all transplant regions and blood types, except type AB. Accepting any heart remained cost effective provided posttransplant mortality and costs among those receiving HCV-viremic hearts were not >7% higher compared to HCV-negative hearts. Willingness to accept HCV-viremic hearts for transplantation into HCV-negative recipients is cost effective and improves clinical outcomes.     

Safety and immunogenicity of adjuvanted recombinant subunit herpes zoster vaccine in lung transplant recipients

Lung transplant recipients are at high risk for herpes zoster and preventive measures are a significant unmet need. We investigated the safety and immunogenicity of two doses of a recombinant zoster vaccine (RZV) in lung transplant recipients (≥50 years). We enrolled 50 patients of which 49 received at least one vaccine dose. Anti-glycoprotein E (gE) antibody levels (n = 43) increased significantly compared to baseline (median optical density [OD] 1.96; interquartile range [IQR]: 1.17–2.89) after the first (median OD 3.41, IQR 2.54–3.81, p < .0001) and second vaccine dose (median OD 3.63, IQR 3.39–3.86, p < .0001). gE-specific polyfunctional CD4+ T cell frequencies (n = 38) also increased from baseline (median 85 per 10⁶ CD4+ T cells; IQR: 46–180) to the first (median 128 per 10⁶ CD4+ T cells; IQR: 82–353; p = .023) and after the second dose (median 361 per 10⁶ CD4+ T cells; IQR: 146–848; p < .0001). Tenderness (83.0%; 95%CI: 69.2–92.4%) and redness (31.9%; 95%CI: 19.1–47.1%) at injection site were common. One rejection episode within 3 weeks of vaccination was observed. This is the first study demonstrating that RZV was safe and elicited significant humoral and cell-mediated immunity in lung transplant recipients. RZV is a new option for the prevention of shingles in this population.     

Susceptibility and resistance to environmental carcinogens in the development of carcinoma of the lung

Eight selected cases are presented to show different effects of the environment on the lung. Some appear to lack resistance to environmental carcinogens. The variations in response and an assessment of the carcinogens involved are discussed. Further study of these poorly understood etiologic factors is needed.     

The inappropriate use of acute hospital beds in an inner London District Health Authority

The requirement for District Health Authorities to assess the health care needs of their population implies that they must consider how well acute hospital care meets these identified needs. This study, which was conducted in an inner London health district, identified that 123 (14.6%) patients were perceived by medical and/or nursing staff to be inappropriately located in an acute bed. This group was dominated by patients aged 65 years or above, those in general and geriatric medicine, those with a length of stay of 30 days or more, and those with high levels of physical and mental dependency. The main reasons for patients being labelled as 'inappropriate' were the need for non-acute health services (eg rehabilitation, terminal care etc), a need for nursing home places or because of social or housing problems. Five months after identification, the notes of 100 of the 123 inappropriate patients were traced. Retrospective classification of these notes using the more 'objective' Oxford Bed Study Instrument showed that 97 patients were still defined as inappropriate. Details of the length of inappropriate stay were available for 74 patients who accrued 7,519 inappropriate bed days at a cost of 836,547 pounds. These patients are an illustration of the potential failings of current health and social care systems and highlight the need for imaginative care solutions which bridge this divide.     

Computerized photo-plethysmography of the finger

A microcomputer system for studying photo-plethysmography of the finger (PPF) was designed and applied to 50 non-premedicated healthy boys (one to ten years old) undergoing general anaesthesia (halothane in 70% N₂O, with mechanical ventilation) for outpatient inguinal hernia repair. The purpose of this study was to assess the accuracy of computerized estimations of the photo-plethysmographic (arterial waves) amplitude and to evaluate whether or not PPF allows discrimination between two different surgical stimuli (skin incision, and manipulation of the spermatic cord). When anaesthesia was stable for at least five minutes (end-tidal halothane=1.25–1.5%;PetCO₂=32–38 mmHg; SpO₂≥98%; rectal temperature=36.3–37°C; ambient operating room temperature=20–21°C), and immediately before the skin incision, computerized estimations of the photo-plethysmographic (arterial waves) amplitudes (PPA) were recorded and saved for later comparison with direct (manual) measurements of the plethysmographic tracing, using an arbitrary scale of 0–255 units. Also, the values of PPA, systolic blood pressure, and pulse rate recorded immediately before the skin incision were later compared with the maximum changes in these same values recorded 30–90 sec after skin incision, and 30–90 sec after manipulation (traction + dissection) of the spermatic cord. Six boys (three to ten years old) stayed quiet enough, during induction of anaesthesia by mask, to allow regression analysis of PPA, systolic blood pressure, and pulse rate (Y) on end-tidal halothane/70% N₂O (X). Computerized estimations tended to give a higher reading, by between 0.2 to 0.8 units, than direct measurements. Spearman and Kendall correlations showed that computerized and direct measurements were associated (P<0.0001), the Kolmogorov-Smirnov’s test revealed that the two distributions were identical (P=1), the mean difference between computerized and direct estimations of the PPA was 0.52±1.08 units, and the limits of agreement (?1.6 and 2.6 units) were small enough to be confident that computerized (automatic) estimations of PPA can be used for clinical purposes. Skin incision caused a smaller decrease of PPA (24%) than manipulation of the spermatic cord (37%). Changes in PPA were more pronounced than changes in systolic blood pressure or pulse rate (P<0.05). Linear regressions and Fisher’s exact test (two-tailed) showed that, during induction of anaesthesia with halothane in 70% N₂O by mask (n=6), changes in end-tidal halothane concentration were related more to changes in PPA than to changes in systolic blood pressure and/or in pulse rate (P<0.05). In conclusion, computerized PPF allows discrimination between two different surgical stimuli, provides quantification of the sympathetic response to preoperative anxiety, and may be useful for studying pre-anaesthetic sedation.     

Trends in presentation of congenital heart disease in a population-based study in Malta

Differing pathological haemodynamics in cardiac malformations lead to varying modes and timings of presentation. This study identifies historical trends in presentation of congenital heart disease in a population-based study. All patients diagnosed as having congenital heart disease in Malta between 1960–1994 were included (n = 868). Analysis was carried out on trends in referral sources, modes of presentation and birth prevalence. The number of patients diagnosed with congenital heart disease increased over the period under study. For both patients not requiring intervention (n = 283) and those requiring intervention (n=585), the proportion diagnosed prior to hospital discharge increased (p 0.005). There was a decreasing trend for general practitioners to refer cases (p < 0.0001), and an increasing trend for paediatricians to refer such patients (p 0.0003). The commonest presentation to the general practitioner was an incidental finding (92%), while paediatricians referred more patients for cyanosis or heart failure (p 0.005). For lesions not requiring intervention, the commonest lesion referred was ventricular septal defect from all sources. For lesions requiring intervention, the commonest lesion detected prior to hospital discharge was tetralogy of Fallot. Atrial septal defects were the commonest lesions detected after discharge by both paediatricians and general practitioners. An increase in the proportion of hospital diagnoses is attributed to increasing rate of hospital delivery, and greater training and experience in doctors performing neonatal examinations prior to discharge. Patients diagnosed after discharge are increasingly diagnosed by paediatricians due to an increasing pool of paediatricians and better parent awareness and education.     

Kawasaki disease in Malta

Kawasaki disease is an acute febrile illness of childhood of unknown origin which may cause coronary arteritis and death. The Maltese incidence of 3.2/100,000 population <5 years of age is similar to that reported in non-Asiatic communities. None of the patients had coronary arteritis or other complications. A significant decline in delay to diagnosis was found, attributed to increased awareness of the disease.