Impact of continuous positive airway pressure treatment on right ventricle performance in patients with obstructive sleep apnoea, assessed by three-dimensional echocardiography

BackgroundObstructive sleep apnoea (OSA) is a predictor of right ventricle (RV) impairment. However, there is scant information on the effect of OSA treatment on RV performance. We sought to evaluate the impact of OSA treatment with a continuous positive airway pressure (CPAP) device on RV volume and function, as well as on variables related to pulmonary vascular haemodynamics.MethodsFifty-six OSA patients and 50 controls were studied. All individuals underwent three-dimensional echocardiogram (3DE) to estimate RV volumes, function, pulmonary vascular resistance, and tricuspid regurgitation velocity. A total of 30 patients with apnoea-hypopnoea index greater than 20 were randomly selected to receive placebo (n = 15) or effective CPAP (n = 15) for 24 weeks. They underwent 3DE examination on three different occasions: at baseline, after 12 weeks, and after 24 weeks of CPAP or placebo.ResultsHigher pulmonary vascular resistance (2.1 Wood’s ± 0.5 vs. 1.8 Wood’s ± 0.4), larger end-diastolic RV volume index (52.2 mL/m² ± 7.3 vs. 49.9 mL/m² ± 6.0), larger end-systolic RV volume index (18.7 mL/m² ± 4.3 vs. 15.4 mL/m² ± 3.6), and lower RV ejection fraction (64.3% ± 6.8 vs. 68.4% ± 5.9) were observed in the OSA group compared to non-OSA controls (P < 0.05, all). In the effective CPAP group we observed the following changes from the baseline to the 24-week echo evaluation: (A) reduction in pulmonary vascular resistance (2.2 Wood’s ± 0.3 to 1.8 Wood’s ± 0.3); (B) reduction in the RV end-systolic volume index (20.3 mL/m² ± 4.5 to 16 mL/m² ± 2.1); and (C) increase in RV ejection fraction (63.0% ± 7.2 to 70.8% ± 0.9) (P < 0.05 for all).ConclusionTwenty-four-week treatment with CPAP improved RV performance but did not change RV structural variables.     

Cost per capita in outpatients by gender

The objective of this study is to identify the annual cost per capita by gender in first level of attention. It is a cost study in Family Physician Units in Mexico. The information corresponded to the year of 2004 and the study divided in the use profile and cost attention. USE PROFILE OF SERVICES: it was studied 1,585 clinical registries of patients, use profile defined by average and attention reasons by department, gender and age group. COST ATTENTION: considered in American dollars it included fixed unit cost (departmentalization adjusted by productivity), variable unit cost (micro cost technical), department unite cost by type attention, and department unit cost by age and gender. The life expectancy was of 73 years for men and 78 for women. Three scenes were identified. The annual cost per capita is superior among woman [US$73.24 (IC 95% $11.38 - $197.49)] than in man [$ 53.11 (IC 95% 2.51 - 207.71)]. The conclusion found that in the first level of attention the cost per capita is greater in woman than in man.     

Challenges of providing confidential care to adolescents in urban primary care: clinician perspectives

PURPOSE Clinician time alone with an adolescent has a major impact on disclosure of risk behavior. This study sought to describe primary care clinicians’ patterns of delivering time alone, decision making about introducing time alone to adolescents and their parents, and experiences delivering confidential services.METHODS We undertook qualitative interviews with 18 primary care clinicians in urban health centers staffed by specialists in pediatrics, family medicine, and adolescent medicine.RESULTS The annual preventive care visit is the primary context for provision of time alone with adolescents; clinicians consider the parent-child dynamic and the nature of the chief complaint for including time alone during visits for other than preventive care. Time constraints are a major barrier to offering time alone more frequently. Clinicians perceive that parental discomfort with time alone is rare. Many clinicians wrestle with internal conflict about providing confidential services to adolescents with serious health threats and regard their role as facilitating adolescent-parent communication. Health systems factors can interfere with delivery of confidential services, such as inconsistent procedures for determining whether unaccompanied youth would be seen.CONCLUSION Despite competing time demands, clinicians report commitment to offering time alone during preventive care visits and infrequently offer it at other times. Experienced clinicians can gain skills in the art of managing complex relationships between adolescents and their parents. Office systems should be developed that enhance the consistency of delivery of confidential services.     

West syndrome: early remission is not assurance of normal final outcome

Background West syndrome (WS), an age‐specific epilepsy of infancy and early childhood, considered of poor prognosis, may have remission. With the objective of describing the clinical features, treatment and outcome of the children with WS followed in a Latin American country, we devised a retrospective study. Methods Infants with recurrent spasms, and typical or atypical hypsarrhythmia on electroencephalography (EEG) were included, and their medical report reviewed with particular interest on therapy (anti‐epileptic drug, steroids) and outcome. Short‐term (remission of spasms up to 6 months after the beginning) and long‐term outcome (development and seizure status over the age of 2 years) were focused. Results Of the 37 selected infants, most (29/37, 78.3%) were classified as symptomatic, and neonatal history of hypoxia (10/29) was the most frequent etiology. The majority had a typical hypsarrhythmia EEG pattern. Most used a combination of anti‐epileptic drugs and steroids. A favourable short‐term outcome occurred in 20 infants, but only three had normal development and were seizure free after the age of 2 years. Conclusion Early seizure remission is not assurance of normal final outcome in WS.     

Progression of Blood Pressure and Cardiovascular Outcomes in Hypertensive Patients in a Reference Center

Background

Hypertension is a public health problem, considering its high prevalence, low control rate and cardiovascular complications.

Objective

Evaluate the control of blood pressure (BP) and cardiovascular outcomes in patients enrolled at the Reference Center for Hypertension and Diabetes, located in a medium-sized city in the Midwest Region of Brazil.

Methods

Population-based study comparing patients enrolled in the service at the time of their admission and after an average follow-up of five years. Participants were aged ≥18 years and were regularly monitored at the Center up to 6 months before data collection. We assessed demographic variables, BP, body mass index, risk factors, and cardiovascular outcomes.

Results

We studied 1,298 individuals, predominantly women (60.9%), and with mean age of 56.7±13.1 years. Over time, there was a significant increase in physical inactivity, alcohol consumption, diabetes, dyslipidemia, and excessive weight. As for cardiovascular outcomes, we observed an increase in stroke and myocardial revascularization, and a lower frequency of chronic renal failure. During follow-up, there was significant improvement in the rate of BP control (from 29.6% to 39.6%; p = 0.001) and 72 deaths, 91.7% of which were due to cardiovascular diseases.

Conclusion

Despite considerable improvements in the rate of BP control during follow-up, risk factors worsened and cardiovascular outcomes increased.