Usefulness of the N-Terminal Fraction of Brain Natriuretic Peptide for Deciding When to Refer Patients With Sleep Apnea-Hypopnea Syndrome to the Cardiologist

Introduction and objectiveWhen sleep apnea-hypopnea syndrome (SAHS) and cardiovascular disease occur concurrently, prognosis is affected. Echocardiography can detect structural cardiac abnormalities but using this technique in all patients would place a heavy burden on resources. The objective of this study was to investigate whether the N-terminal fraction of brain natriuretic peptide (NT-proBNP) can be used as a marker for silent heart disease.Patients and methodsNT-proBNP concentration was measured in the 114 consecutive patients with SAHS who underwent echocardiography before starting treatment. Left and right ventricular systolic and diastolic function, as well as structural abnormalities, were studied. Correlations between NT-proBNP concentration and the abnormalities detected were investigated. A receiver operating characteristics (ROC) curve was plotted for NT-proBNP concentration and cardiac abnormalities.ResultsData for 98 patients were finally analyzed. NT-proBNP concentration was significantly correlated with ventricular septal thickness (r=0.63), posterior wall thickness (r=0.45), and left ventricular enddiastolic diameter (r=0.51) (P<.0001 for all correlations). The area under the ROC curve was significant (0.870; 95% confidence interval, 0.801-0.939; P<.0001). Assuming that specificity would be more useful for clinical practice, we calculated that NT-proBNP concentrations below 100 and 200 pg/mL could rule out structural abnormalities with a reliability of 90% and 100%, respectively.ConclusionsNT-proBNP concentration was strongly correlated with echocardiographic abnormalities and so could be a useful tool for identifying patients who should be referred to the cardiologist.     

Use of Indwelling Pleural Catheter in the Outpatient Management of Recurrent Malignant Pleural Effusion

IntroductionTo analyse the effectiveness and safety of the indwelling pleural catheter in the management of recurrent malignant pleural effusion.Patients and methodsA prospective multicentre study was performed in 63 consecutive outpatients from four Spanish hospitals. A total of 43 men and 20 women were included, with a median age of 67 years. In seven of the cases treatment with pleurodesis had failed; in five other cases their lung was trapped; in another five cases after repeat therapeutic thoracocentesis, and the rest of them as a preference choice to pleurodesis. All patients had an indwelling pleural catheter inserted (PleurX^®, Denver Biomedical).ResultsMost of patients (94.5%) reported an improvement in their respiratory symptoms (cough and dyspnoea) and their ability to function independently. Average length of the catheterisation was 45 days (6-222). Average amount of drained pleural effusion was 75 ml, with a frequency of drainage of between 3 and 4 times per week and once fortnightly. Spontaneous pleurodesis was achieved following 34.9% of procedures. No complications occurred during the insertion of the catheter. The post-catheterisation complications were empyema (3 cases), chest pain (2 cases), and tumour metastasis (3 cases).ConclusionsThe use of an indwelling pleural catheter is an effective palliative treatment in the outpatient management for patients suffering malignant pleural effusion. It is also a simple treatment that can be easily applied, does not require hospitalisation and can be easily managed by the patient at home, with a low rate of complications.     

An alternative to the neoliberal model in health: the case of Venezuela.

The authors present a synthesis of the proposals put forth by the health sector of Venezuela during the framing of the new Venezuelan Constitution. They summarize the background to the National Constituent Assembly and the legal framework typical of the health sector at that time, identify the methodological aspects that substantiated the health topics included in the new Constitution, and analyze the articles that shape the current constitutional health framework in Venezuela, summarizing their most important features and comparing them with neoliberal health proposals.     

Metformina también como primera elección en pacientes con peso normal. ¿Se ha incrementado su uso?

ObjectiveTo assess whether the release of the new consensus algorithms in August 2006, along with the consensus recommendation of also using metformin as first choice in patients with normal weight, has led to an increase in the use of this drug in the period immediately after.DesignRetrospective longitudinal Study.SitesSantiago de Compostela Health District (A Coruña).ParticipantsUsers of the Galician health service in the Santiago de Compostela Health District.MethodsThe evolution of the monthly number of DHD (Daily Defined Doses/1000 inhabitants/day) of metformin from early 2003 until 12 months after the issuing of new algorithms was analysed graphically and using a multiple regression model.ResultsThe graphical representation of the DHD of metformin over time shows a linear growth for the period, but there is an increasing trend after the publication of the new consensus algorithm. The multiple regression showed that the increase is statistically significant.ConclusionsFollowing the publication of the new consensus algorithm an increasing trend in the use of metformin is observed in the short term.     

Patient comprehension and recall of laparoscopic surgery and outcomes in a non-English speaking population.

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine patient recall and comprehension after laparoscopic appendectomy in an underserved population. Laparoscopic surgery can lead to diagnostic uncertainty secondary to poor recall and variable port placement. METHODS: After institutional review board approval, we identified a cohort of patients who underwent laparoscopic appendectomy from 2000 to 2004 at a single institution. We then attempted to contact the patients to conduct a 10-question telephone survey, which determined whether the patient spoke English or Spanish as a primary language, ethnicity, educational level, and questions about recall of perioperative events and diagnoses. If we could not reach the patient, we tried to call back on 2 different occasions. RESULTS: Between 2000 and 2004, 186 patients underwent laparoscopic appendectomy. Of these, 65% were Hispanic. We found that only 17% of these patients returned for a postoperative visit. Only 19.3% could be contacted by phone. Forty-seven percent of the patients contacted by phone spoke Spanish exclusively. Overall 92% of patients contacted knew what operation they had, and gave their correct diagnosis. CONCLUSIONS: The low percentage of patients available to follow-up makes this study statistically insignificant. However, we believe that fact in itself is important. In Southwestern states, we see a large migrant population. This highlights the need to communicate effectively with the patients at the time of surgery, which we speculate we did based on the percentage of patients that knew their diagnosis.     

Robotic-assisted heller myotomy versus laparoscopic heller myotomy for the treatment of esophageal achalasia: multicenter study

Laparoscopic Heller myotomy (LHM) has become the standard treatment option for achalasia. The incidence of esophageal perforation reported is about 5%–10%. Robotically assisted Heller myotomy (RAHM) is emerging as a safe alternative to LHM. Data comparing the two approaches are scant. The aim of this study was to compare RAHM with LHM in terms of efficacy and safety for treatment of achalasia. A total of 121 patients underwent surgical treatment of achalasia at three institutions. A retrospective review of prospectively collected perioperative data was performed. Patients were divided into two groups: group A (RAHM), 59 patients, and group B (LHM), 62 patients. All the operations were completed using minimally invasive techniques. There were 63 women and 58 men, with a mean age of 45 ±19 years (14–82 years). Fifty-one percent of patients in group A and 95% of patients in group B reported weight loss. Duration of symptoms was equal for both groups. Dysphagia was the main complaint in both groups (P = NS). There was no difference in preoperative endoscopic treatment in both groups (44% versus 27%, P = NS). Operative time was significantly shorter for LHM in the first half of the experience (141 ± 49 versus 122 ± 44 minutes, P < .05). However, in the last 30 cases there was no difference in operative time between the groups (P = NS). Intraoperative complications (esophageal perforation) were more frequent in group B (16% versus 0%). The incidence of postoperative heartburn did not differ by group. There were no deaths. At 18 and 22 months, 92% and 90% of patients had relief of their dysphagia. This study suggests that RAHM is safer than LHM, because it decreases the incidence of esophageal perforation to 0%, even in patients who had previous treatment. At short-term follow-up, relief of dysphagia was equally achieved in both groups. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation). This study was supported in part by a grant provided by Intuitive Surgical, Inc. and Ethicon Endo-Surgery, Inc.     

Adult rat seminiferous tubules secrete a fraction greater than 30 kDa to regulate spermatogenesis

The present study was designed to examine the effects of a >30kDa fraction of medium conditioned for 2 days by adult rat seminiferoustubules on inhibin secretion by cultured tubules, and on spermatogenesisand fertility of male rats. Inhibin secretion was assayed byadding the >30 kDa fraction to 5 cm segments of adult ratseminiferous tubules and measuring inhibin by radioimmunoassayat 2 day intervals. Fertility was assayed by injecting malerats daily for up to 45 days with the >30 kDa fraction andthen mating them with a proestrus female, or by injecting for15 days and mating them with two female rats. The assay usedto evaluate the in-vivo effect of the >30 kDa fraction onthe testis involved an assessment of frequencies of seminiferoustubule stages scored by transillumination on intact tubules.The addition of the >30 kDa fraction to the adult rat seminiferoustubules cultured for 2 days resulted in an inhibition of inhibinsecretion into the medium. This effect was reversed when thefraction was removed and changed with fresh medium and culturedfor a further 4 days. The >30 kDa fraction administered i.p.to adult male rats resulted in a low fertilization rate comparedto control rats (67%) (P < 0.05). The assessment of frequenciesof seminiferous tubule stages scored by transillumination showedan increased frequency of stage VI and decreased frequency ofstages VII and VIII after treatment. The results of the presentstudy provide additional evidence that local regulation of Sertolicell function is mediated by a >30 kDa component or componentssecreted by adult seminiferous tubules which could arrest spermatogenesis.