Negative flecainide test in Brugada syndrome patients with previous positive response.

Class I antiarrhythmic drug infusion has been established as the standard test to unmask Brugada syndrome. This report presents two patients with Brugada syndrome with positive flecainide response which was not reproducible in a subsequent test.     

Epidemiology, clinical characteristics, outcome, morbidity and mortality in acromegaly based on the Spanish Acromegaly Registry (Registro Espanol de Acromegalia, REA)

OBJECTIVE: To undertake a multicentre epidemiological study reflecting acromegaly in Spain. DESIGN: Voluntary reporting of data on patients with acromegaly to an online database, by the managing physician. METHODS: Data on demographics, diagnosis, estimated date of initial symptoms and diagnosis, pituitary imaging, visual fields, GH and IGF-I concentrations (requested locally), medical, radiotherapy and neurosurgical treatments, morbidity and mortality were collected. RESULTS: Data were included for 1219 patients (60.8% women) with a mean age at diagnosis of 45 years (s.d. 14 years). Reporting was maximal in 1997 (2.1 cases per million inhabitants (c.p.m.) per year); prevalence was globally 36 c.p.m., but varied between 15.7 and 75.8 c.p.m. in different regions. Of 1196 pituitary tumours, most were macroadenomas (73%); 81% of these patients underwent surgery, 45% received radiotherapy and 65% were given medical treatment (somatostatin analogues in 68.3% and dopamine agonists in 31.4%). Cures (GH values (basal or after an oral glucose tolerance test) <2 ng/ml, normal IGF-I, or both) were observed in 40.3% after surgery and 28.2% after radiotherapy. Hypertension (39.1%), diabetes mellitus (37.6%), hypopituitarism (25.7%), goitre (22.4%), carpal tunnel syndrome (18.7%) and sleep apnoea (13.2%) were reported as most frequent morbidities; 6.8% of the patients had cancer (breast in 3.1% of the women and colon in 1.2% of the cohort). Fifty-six patients died at a mean age of 60 years (s.d. 14 years), most commonly of a cardiovascular cause (39.4%); mortality was greater in patients given radiotherapy (hazard ratio 2.29; 95% confidence interval 1.03 to 5.08; P=0.026), and in those in whom GH and IGF-I concentrations were never normal (P<0.001). CONCLUSIONS: This acromegaly registry offers a realistic overview of the epidemiological characteristics, treatment outcome and morbidity of acromegaly in Spain. As active disease and treatment with radiotherapy are associated with an increase in mortality, efforts to control the disease early are desirable.     

Rectovaginal septum endometriosis: a disease with specific diagnosis and treatment

BACKGROUND: The involvement of the rectovaginal septum, of rectum and sigmoid by endometriosis leads to intense symptoms as dysmenorrhea, pelvic pain, deep dyspareunia, tenesmus and hematochezia in young and middle aged women during periods. The diagnosis can be made by tipycal history and vaginal examination, rectal examination, barium enema, proctoscopy and so on. The indications of operation include severe clinic symptoms and failed conservative therapy. The treatment of choice for this type of endometriosis is the surgical resection of affected tissue, in order to relieve patient symptoms, and avoid disease progression. The correct assessment as to the presence and extension of the endometriosis-affected sites such as the rectum, uterosacral ligaments and rectovaginal septum is extremely important to provide better results with the surgical treatment of endometriosis. AIM: To describe the main aspects related to rectovaginal septum endometriosis and offer the general surgeon some information about this enigmatic disease. CONCLUSION: Rectovaginal septum endometriosis is a frequent disease, with specific diagnosis and treatment.     

Universal approach for full endoscopic decompression and percutaneous transpedicular fixation of the lumbar spine: A medial central approach (ACM)

Cohort study.This study aimed to determine the effectiveness of the universal approach of full endoscopy and percutaneous transpedicular fixation via a medial central approach (ACM) performed to surgically treat patients with lumbar degenerative surgical pathologies.Alternatives to interventionist treatments available to patients with lumbar degenerative surgical pathologies are related to recovery from minimally invasive surgery. Considering this, full endoscopic spinal decompression (full endoscopy) and percutaneous transpedicular fixation via an ACM represent advances in neurosurgical procedures, in particular, spinal surgery. Thus, the introduction of endoscopic and minimally invasive surgeries for the lumbar region has become 1 of the most important advances in modern surgery.A cohort of 79 patients undergoing full endoscopy and percutaneous transpedicular fixation was evaluated 6 times in 1 year. Pain intensity was measured using the visual analog scale (VAS), and lumbar functionality was measured using the Oswestry Disability Index (ODI). Six evaluations were performed: before surgery and on discharge after surgery as well as at 1, 3, 6, and 12 months after surgery.Before the ACM was applied, the VAS pain score was 8.52. At 11 hours post-surgery, the pain score reduced to 2.59 points (a difference of 5.73 points; P = 0.001). Of the 10 ODI domains evaluated, a difference was found between the period prior to surgery and 1 month later (P < 0.01).The universal approach to full endoscopy and lumbar percutaneous transpedicular fixation via an ACM is highly effective for patients with lumbar surgical degenerative pathologies.     

A strategy to improve treatment‐related mortality and abandonment of therapy for childhood ALL in a developing country reveals the impact of treatment delays

Background

Treatment‐related mortality and abandonment of therapy are major barriers to successful treatment of childhood acute lymphoblastic leukemia (ALL) in the developing world.

Procedure

A collaboration was undertaken between Instituto Nacional de Cancerologia (Bogota, Colombia), which serves a poor patient population in an upper‐middle income country, and Dana‐Farber/Boston Children's Cancer and Blood Disorders Center (Boston, USA). Several interventions aimed at reducing toxic deaths and abandonment were implemented, including a reduced‐intensity treatment regimen and a psychosocial effort targeting abandonment. We performed a cohort study to assess impact.

Results

The Study Population comprised 99 children with ALL diagnosed between 2007 and 2010, and the Historic Cohort comprised 181 children treated prior to the study interventions (1995–2004). Significant improvements were achieved in the rate of deaths in complete remission (13% to 3%; P = 0.005), abandonment (32% to 9%; P < 0.001), and event‐free survival with abandonment considered an event (47% to 65% at 2 years; P = 0.016). However, relapse rate did not improve. Medically unnecessary treatment delays were common, and landmark analysis revealed that initiating the PIII phase of therapy ≥4 weeks delayed predicted markedly inferior disease‐free survival (P = 0.016). Conversely, patients who received therapy without excessive delays had outcomes approaching those achieved in high‐income countries.

Conclusions

Implementation of a twinning program was followed by reductions in abandonment and toxic deaths, but relapse rate did not improve. Inappropriate treatment delays were common and strongly predicted treatment failure. These findings highlight the importance of adherence to treatment schedule for effective therapy of ALL. Pediatr Blood Cancer 2015;62:1395–1402. © 2015 Wiley Periodicals, Inc.     

Aortic valve replacement with pulmonary autograft (the Ross procedure) in adult and pediatric patients

Aortic valve replacement with pulmonary autograft was first performed by Donald Ross in 1967. Initially, the procedure was not widely accepted, by Cardiologists and Cardiac surgeons fundamentally due to its complexity and demanding surgical technique, and because innumerous series two cardiac valves were at risk. The results published in the last 10-15 years established the pulmonary autograft as one of the best methods of aortic valve replacement, especially in pediatric patients and young adults. In the present article, we reviewed present indications and contraindications, and our clinical experience with 26 patients (pediatrics and adults). Analysis of the first 22 the patients with a minimum of 6 months of follow-up (180-620 days) was performed. Follow-up is complete (100%). Mean age was 31.4 +/- 12.6 years. Five patients were pediatrics (<= 14 years). Three patients (11%) with previous percutaneous procedures and 4 patients (14%) with previous surgical procedures. There was no early or late mortality. In the last follow-up, 19 of 22 (86.36%) had no autograft insufficiency (>= grade 1), and in one patient it was moderate (grade 2). The 2 remaining patients developed severe autograft insufficiency (grade 4) and were reoperated on, with satisfactory postoperative outcome. Mean maximal gradient was 7.85 +/- 5 mmHg at 18 months (3-29). Patients with preoperative aortic stenosis showed a significant reduction in myocardial mass index (208.7 +/- 32 a 95.8 +/- 28.8 g/m2) at 18 months. In these patients, septal and posterior wall thickness decreased significantly, in the first month. Two pediatric patients have developed transpulmonar gradient > 50 mmHg. One of them underwent successful stent implantation. We have not observed significant homograft insufficiency in any of our patients. All our patients remain asymptomatic (functional class I) without medical treatment. We have not observed either thromboembolic or haemorrhagic episodes, nor endocarditis. No patient is receiving anticoagulants. Clinical and echocardiographic mid term results in pulmonary autograft and homograft in our series, are excellent after the Ross procedure.     

Health Effects of Unemployment Benefit Program Generosity

Objectives. We assessed the impact of unemployment benefit programs on the health of the unemployed.Methods. We linked US state law data on maximum allowable unemployment benefit levels between 1985 and 2008 to individual self-rated health for heads of households in the Panel Study of Income Dynamics and implemented state and year fixed-effect models.Results. Unemployment was associated with increased risk of reporting poor health among men in both linear probability (b = 0.0794; 95% confidence interval [CI] = 0.0623, 0.0965) and logistic models (odds ratio = 2.777; 95% CI = 2.294, 3.362), but this effect is lower when the generosity of state unemployment benefits is high (b for interaction between unemployment and benefits = −0.124; 95% CI = −0.197, −0.0523). A 63% increase in benefits completely offsets the impact of unemployment on self-reported health.Conclusions. Results suggest that unemployment benefits may significantly alleviate the adverse health effects of unemployment among men.An extensive body of research has linked job loss to poorer physical and mental health1 and higher risk of premature death.2 Recent literature has focused on establishing the causal nature of this association,2–8 but few studies have explored whether specific social programs modify the health effects of job loss. Understanding the impact of policies is useful for identifying intervention approaches to reduce the harms associated with unemployment, but they may also reveal some of the mechanisms explaining the association between job loss and health. Job loss is associated with a substantial loss in earnings.9 If earnings losses are the primary mechanism linking job loss to health, we would expect generous unemployment benefit programs to mitigate some of the negative consequences of job loss on health. On the other hand, unemployment benefits may be less effective if job loss influences health primarily through nonfinancial mechanisms, such as the loss of a time structure for the day, decreased self-esteem, chronic stress,10 or changes in health-related behavior.A few studies have investigated the association between unemployment benefit receipt and self-reported health measures.11–13 For example, Rodriguez11 analyzed self-reported health data from Britain, Germany, and the United States and found that unemployed workers in receipt of unemployment benefits do not have statistically higher likelihood of reporting poor health compared with the employed, while unemployed workers receiving no benefits are in worse health than these 2 groups. She concluded that benefit receipt moderates the association between unemployment and poor subjective health. Similarly, McLeod et al.14 found that unemployed US workers not receiving benefits are more likely to report poor health than employed workers, but the health of unemployed workers in receipt of benefits does not statistically differ from the health of employed workers. The association between receiving benefits and health was most pronounced among low-skilled unemployed workers, who appear to gain substantially from receipt of cash benefits.A key caveat in these studies is that they do not account for selection into benefit receipt, a bias that could lead to either over- or underestimation of effects. For example, if those who lose their jobs are healthier and more likely to be eligible for and receive unemployment benefits, the health benefits of unemployment benefits will be overestimated. During the recent recession, for example, non-Hispanic White race, higher educational level, and being married, characteristics associated with better health, also predicted receipt of benefits among long-term unemployed workers.15 On the other hand, job losers in poor health may anticipate longer-term spells of unemployment and therefore may be more likely to claim unemployment benefits than healthier individuals who expect to quickly find new employment. While 61% of workers in manufacturing and 66% of workers in construction were receiving benefits in the period 2008 to 2011, only 52% of professional and management workers and 49% of workers in the retail trade industry were receiving benefits in the same period.15 These findings suggest that selection is a serious source of potential bias in the relationship between unemployment benefit receipt and health, though the direction of bias is unclear.In the United States, the Federal–State Unemployment Insurance Program provides temporary wage replacement for eligible workers who become unemployed through no fault of their own. Although all states must follow general rules established at the federal level relating to coverage and eligibility, each state operates its own program. As a result, there is considerable variation in the generosity of unemployment benefit programs across states and over time. An approach to account for selection is to exploit these variations in the generosity of unemployment benefit programs to understand their effects on the health of workers. The assumption is that changes in unemployment benefit policy are uncorrelated with a worker’s health or other characteristics, as individuals have no control over the policy at the time they experience job loss. Variations in unemployment benefit generosity across states and over time, therefore, offer a unique natural experiment to estimate the impact of this policy on the health of unemployed workers.In a recent study, Cylus et al. exploited these variations to assess whether unemployment benefits moderate the relationship between aggregate unemployment rates and suicide,16 which are known to increase during recessions.17,18 Findings from this study suggest that more generous unemployment benefits are associated with a weaker effect of recessions on suicide. However, this study was based on aggregate data and did not estimate whether unemployment benefits reduced the negative impact of job loss among unemployed workers or whether benefits might in fact lead to improvements in mental health among both employed and unemployed workers, for example, by reducing the stress associated with the fear of job loss.19 Likewise, it is not clear whether results for suicide are applicable to self-rated health, a measure that combines elements of both physical and mental health, and a strong predictor of mortality.20In this study, we assessed the impact of unemployment benefit programs on the health of the unemployed. We hypothesized that income from unemployment benefits reduces psychological and physical morbidity among displaced workers such that individuals losing their job at a time of more generous unemployment benefit policies will suffer fewer health consequences than comparable individuals losing their jobs during years of lower benefit generosity. By focusing on unemployment benefit program generosity at the state level, we circumvent the bias generated by selection into benefits in the aforementioned studies.21,22 To identify this effect, we exploited variation in state unemployment benefit program generosity across US states and linked these to longitudinal individual-level data.