Stapled hemorrhoidectomy: Initial experience of a Latin American group

The purpose of the present study was to determine the value of circular emorrhoidectomy (procedure for prolapse and hemorrhoids [PPH]) on the basis of data collected prospectively during the initial experience of a group of Latin American surgeons. Between 2000 and 2001, PPH was performed using a circular stapler in 177 patients who had third- and fourth-degree hemorrhoidal disease. The average age of the patients was 47.7 years (range 26 to 85 years). Anal bleeding was the most common preoperative complaint (93.2%) followed by anal pain (60.2 %), anal itching (43%), and constipation (41 %). Hemorrhoids were classified as third degree in 132 patients (74%) and fourth degree in 45 patients (25.4%). Skin tags were detected in 86 patients (48.8%) and rectocele in 14 patients (7.9%). Data collected included patient demographics, type of anesthesia, and specific details of the surgery such as duration of the operation, distance from the staple line to the dentate line, need for complementary hemostasis, and any unexpected occurrences. Postoperative data collected included the degree of pain, which was evaluated on the basis of the type and dosage of analgesics required, laxative consumption, and the presence of bleeding, fever, urinary retention, or hematomas. Each patient completed a written questionnaire addressing these events. Patients returned for follow-up visits on days 7, 15, 30, and 90. Responses to pain, bleeding, fever, anal continence, recurrence of hemorrhoids, and level of satisfaction were compiled. The duration of the procedure ranged from 6 minutes to 2 hours (average 2 3 minutes), and most operations lasted no more than 20 minutes, with the exception of one that lasted 2 hours because of intraoperative bleeding. Intraoperative problems were minor. An additional one or a few sutures were required in 58.7% of patients to achieve perfect hemostasis. In 128 patients (72.3%) the hospital stay was less than 24 hours. Same-day surgery was chosen for 37 patients (20.9%). Pain was controlled with analgesia only using one to six doses of oral dipirona in 126 patients. Five patients were readmitted to the hospital: four for control of bleeding and one for conventional hemorrhoidectomy due to an acute episode of external hemorrhoidal thrombosis. At day 30, patients rated the efficacy of the procedure in alleviating preoperative symptoms as follows: 77.5% excellent; 16% good; 5.3% average, and 1.2% poor. At 3 months postoperatively no patient had had a recurrence of hemorrhoidal prolapse, and there were no instances of stenosis or anal incontinence. Surgeons also rated the efficacy of the procedure as excellent in 75%, good in 19.8%, average in 4.7%, and poor in 0.6%. With proper selection of patients and adequate stapling technique, stapled hemorrhoidectomy may be considered safe; it is easily learned, has a satisfactory degree of pain, and is well accepted by both patients and surgeons. Supported in part by Johnson & Johnson.     

Role of ethnicity in predicting antipsychotic medication adherence

BACKGROUND: Clinicians treating schizophrenia face increasingly diverse ethnic populations. Ethnic groups may have different approaches to the management of schizophrenia, which could impact antipsychotic medication adherence. OBJECTIVE: To examine the association between adherence and ethnicity or the specific medication used after controlling for other factors. METHODS: Texas Medicaid claims were retrieved for persons aged 21-65 years, diagnosed with schizophrenia or schizoaffective disorder, after initiating treatment with olanzapine (n = 1875), risperidone (n = 982), or haloperidol (n = 726) between January 1997 and August 1998. The association between ethnicity (African American, Mexican American, white) or medication and days' use of the medication in the year following initiation was assessed using multivariate linear regression. Covariates included other patient demographics, region, comorbid mental health conditions, and prior medication and healthcare resource use. RESULTS: African American and Mexican American patients were significantly less adherent than white patients (19 d less, p < 0.001 for African Americans; 18 d less, p = 0.003 for Mexican Americans). For patients of all ethnicities, olanzapine was associated with 23 more adherent days than risperidone and 55 more adherent days than haloperidol (p < 0.001 for each comparison). CONCLUSIONS: When other factors were controlled for, ethnicity was a significant predictor of medication adherence following initiation on an antipsychotic medication, and patients of all ethnicities were most adherent when taking olanzapine, less adherent when taking risperidone, and least adherent when taking haloperidol.     

Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations

Natriuretic peptide [NP; B‐type NP (BNP), N‐terminal proBNP (NT‐proBNP), and midregional proANP (MR‐proANP)] concentrations are quantitative plasma biomarkers for the presence and severity of haemodynamic cardiac stress and heart failure (HF). End‐diastolic wall stress, intracardiac filling pressures, and intracardiac volumes seem to be the dominant triggers. This paper details the most important indications for NPs and highlights 11 key principles underlying their clinical use shown below.

1. NPs should always be used in conjunction with all other clinical information.
2. NPs are reasonable surrogates for intracardiac volumes and filling pressures.
3. NPs should be measured in all patients presenting with symptoms suggestive of HF such as dyspnoea and/or fatigue, as their use facilitates the early diagnosis and risk stratification of HF.
4. NPs have very high diagnostic accuracy in discriminating HF from other causes of dyspnoea: the higher the NP, the higher the likelihood that dyspnoea is caused by HF.
5. Optimal NP cut‐off concentrations for the diagnosis of acute HF (very high filling pressures) in patients presenting to the emergency department with acute dyspnoea are higher compared with those used in the diagnosis of chronic HF in patients with dyspnoea on exertion (mild increase in filling pressures at rest).
6. Obese patients have lower NP concentrations, mandating the use of lower cut‐off concentrations (about 50% lower).
7. In stable HF patients, but also in patients with other cardiac disorders such as myocardial infarction, valvular heart disease, atrial fibrillation or pulmonary embolism, NP concentrations have high prognostic accuracy for death and HF hospitalization.
8. Screening with NPs for the early detection of relevant cardiac disease including left ventricular systolic dysfunction in patients with cardiovascular risk factors may help to identify patients at increased risk, therefore allowing targeted preventive measures to prevent HF.
9. BNP, NT‐proBNP and MR‐proANP have comparable diagnostic and prognostic accuracy.
10. In patients with shock, NPs cannot be used to identify cause (e.g. cardiogenic vs. septic shock), but remain prognostic.
11. NPs cannot identify the underlying cause of HF and, therefore, if elevated, must always be used in conjunction with cardiac imaging.