Impact of intraoperative transesophageal echocardiography during noncardiac surgery

OBJECTIVE: The purpose of this study was to test if parameters measured by intraoperative transesophageal echocardiography (TEE) could be useful to evaluate the hemodynamic status of high-risk cardiovascular patients and if this information was sufficient to make changes in intraoperative management. DESIGN: Prospective clinical study. SETTING: Single-university hospital. PARTICIPANTS: Ninety-eight patients undergoing noncardiac surgery. INTERVENTIONS: Every patient was assessed with a baseline examination of 2-dimensional, color, pulsed, and continuous Doppler images. Intraoperative changes in any of the evaluated and measured parameters led to a specific change according to the protocol. MEASUREMENTS AND MAIN RESULTS: After continuous monitoring with TEE during surgery, all patients were assigned to 1 of the following groups: (1) TEE was of no use, (2) TEE-directed intraoperative management changes, (3) intraoperative TEE-directed changes in postoperative management, and (4) TEE successfully used as a substitute for pulmonary artery catheter monitoring. Two patients (2%) were assigned to group 1, 47 (48%) patients to group 2, 25 (25%) patients to group 3, and 24 (24%) patients to group 4. The most frequent modifications in intraoperative management were changes in drug therapy and fluid administration. Postoperative management changes were mostly made because of new diagnosis (14%) and new left ventricular wall motion abnormalities (9%). CONCLUSION: These results strongly suggest that objective measurements made by intraoperative TEE are effective in unveiling relevant clinical findings and useful information in high-risk patients undergoing noncardiac surgery.     

Renal replacement therapy in the Canary Islands: demographic and survival analysis

BACKGROUND: The continuous increase in the number of patients on renal replacement therapy (RRT) has heightened the importance of renal patient registries to respond to the demand for data on the state of health, quality and cost of care provided for these patients. Our aim was to analyze the epidemiological profile of this population in the Canary Islands. METHODS: All patients on RRT between January 1999 and December 2003 were considered in this analysis. The information was obtained from the database of the Canary Registry of Renal Patients. RESULTS: We observed a continuous increase in incidence throughout the study period (from 138 per million population (pmp) in 1999 to 160 pmp in 2003), being more evident in patients >65 yrs. Prevalence followed a similar course, increasing from 875 to 972 pmp, being especially evident in the 65-74 yr age group. An alarming finding was the high incidence (43.5%) and prevalence (37.5%) of diabetic nephropathy. While the proportion of hemodialysis (HD) or transplant patients increased, that of peritoneal dialysis (PD) remained low and stable (prevalence of 5% in 2003). Almost half the RRT patients had functioning grafts, with a notably high rate of 58 transplants pmp in 2003, and a prevalence of 425 pmp. Age (hazard ratio (HR) [95% confidence interval (95% CI)] 1.04 [1.03-1.05]; p < 0.001) and diabetic nephropathy (1.47 [1.19-1.82]; p < 0.001) were independently associated with mortality in dialysis patients. Those returning to dialysis after graft loss had a 69% greater risk of death than incident dialysis patients (1.69 [1.06-2.69]; p = 0.026). Cardiovascular events were the main cause of death in all dialysis modalities. Patient death was the main cause of graft loss. CONCLUSIONS: The most outstanding finding was the high incidence and prevalence of patients on RRT, mainly due to diabetic nephropathy. Renal transplant rates were among the highest reported in renal patient registries.     

Racial/ethnic disparities in the HIV and substance abuse epidemics: communities responding to the need

In 1998, community leaders prompted members of the Black and Hispanic Congressional Caucuses to urge President Clinton to declare HIV/AIDS a crisis in the African American and Latino communities; their advocacy resulted in the formation of the Minority AIDS Initiative. As part of this initiative, the Center for Substance Abuse Prevention (CSAP) of the Substance Abuse and Mental Health Services Agency funded the Substance Abuse and HIV Prevention Youth and Women of Color Initiative (CSAP Initiative). The CSAP Initiative is the first major federal effort to develop community-based integrated HIV and substance abuse prevention approaches targeting racial/ethnic populations that have been disproportionately impacted by HIV/AIDS. This article describes the current state of HIV prevention research involving racial/ethnic minority populations and the current status of the CSAP Initiative. The data collected through the CSAP Initiative, implemented by 47 community organizations, will help to fill the existing knowledge gap about how to best prevent HIV in these communities. This data collection effort is an unparalleled opportunity to learn about risk and protective factors, including contextual factors, that are critical to the prevention of HIV/AIDS in African American, Latino, and other racial/ethnic minority communities but that are often not investigated.