Recurrent Chylous Pleural Effusions in a Patient Treated With Dasatinib.

Dasatinib is a second-generation BCR-ABL tyrosine kinase inhibitor (TKI) that is approved for the treatment of chronic myeloid leukemia (CML), a myeloproliferative disorder seen commonly in adults over the age of 50. Dasatinib is superior in tolerance and efficacy to first-generation TKIs such as imatinib, given its ability to target mutation products that are resistant to first-generation TKIs. One of the common side effects of dasatinib includes pleural effusion which can be seen in up to 25% of patients on treatment. These effusions are predominantly exudative; however, they tend to resolve upon discontinuation of the drug. While infrequent, chylous effusions have been reported with the use of dasatinib; they tend to resolve following discontinuation of the drug. We present a case of a patient who was treated with dasatinib and developed a chylous effusion which was refractory to the discontinuation of the medication. Our patient was switched to imatinib and since his first episode, he has had multiple reaccumulation requiring thoracentesis, all of which have revealed chylous pleural fluid as per fluid analysis. We present this case to highlight a rare adverse effect of dasatinib which, via an unknown mechanism, can potentially lead to irreversible damage to the lymphatic duct resulting in recurrent chylous effusions.

Detection of postoperative sleep-disordered breathing using a portable monitoring device.

PURPOSE: Adverse surgical outcomes may occur more frequently in patients with sleep-disordered breathing (SDB). Despite this concern, there have been no prospective studies using objective measures of postoperative SDB to determine the scope of the problem. We designed a prospective study to determine the feasibility of identifying SDB in elective postoperative patients by the use of a type IV portable monitor (PM). METHODS: Patients >18 years old who presented for elective surgery with at least one postoperative hospital night on a non-monitored unit were enrolled and wore a type IV device that measured nasal flow, heart rate, and oxygen saturation on their first postoperative night. Respiratory disturbance index (RDI) and oxygen desaturation index (ODI) were generated for each patient. RESULTS: Data sufficient for interpretation were collected on 100/116 patients enrolled. SDB (RDI ≥5) was observed in 51% of the study group, and 17% had a RDI >15. An elevated ODI ≥5 was seen in 42%, while 17% had an ODI ≥15. Device malfunction occurred in 16% of the study participants. CONCLUSION: A type IV PM can be employed in the postoperative setting to detect and gauge the severity of SDB.

N-terminal pro-brain natriuretic peptide for detection of cardiovascular stress in patients with obstructive sleep apnea syndrome.

Patients with obstructive sleep apnea syndrome (OSAS) have an elevated incidence of cardiovascular events that may be related to an increased ventricular load and hypoxemia caused by apneas and hypopneas. N-terminal pro-brain natriuretic peptide (NTproBNP) appears to be an excellent marker of myocardial stretch and could serve as an indicator of subclinical cardiac stress, thereby identifying a patient population at risk for cardiac effects from OSAS. Adult patients presenting with suspected OSAS and scheduled for nocturnal polysomnography were recruited. Patients with heart or renal failure or severe lung disease were excluded. NTproBNP was measured the evening before and the morning after sleep. Blood pressure (BP) was monitored intermittently throughout the night. Fifteen male and 15 female subjects with a mean +/- SD body mass index of 38.2 +/- 9.8 were studied. Mean Apnea-Hypopnea Index (AHI) was 38.4 +/- 26, with 17 subjects having severe OSAS (AHI > 30). No subject had a significant rise in BP. NTproBNP values overnight decreased in 19 patients and rose in 11 (mean change 3.8 +/- 33 pg mL(-1)), but only one patient had an abnormal morning value. Three patients had an abnormal NTproBNP value prior to sleep, but their levels decreased with sleep. No correlations were detected between the evening baseline or postsleep NTproBNP levels and OSAS. Monitoring pre- and postsleep NTproBNP levels revealed no association with the occurrence or degree of OSAS, making it unlikely that NTproBNP could serve as a marker of cardiac stress in OSAS patients with stable BP and without overt heart failure.

Courts and health policy: judicial policy making and publicly funded health care in Canada.

The 1982 Canadian Charter of Rights and Freedoms provided political actors with the opportunity to make rights-based challenges to public policy decisions. Two challenges launched by providers and consumers of health care illuminate the impact of judicial review on health care policy and the institutional capacity of courts to formulate policy in this field. The significant impact of rights-based claims on cross-jurisdictional policy differences in a federal regime is noted.

Expressive freedom and tobacco advertising: a Canadian perspective.

In 1989, Canada enacted the Tobacco Products Control Act (TPCA), which prohibited tobacco advertising, required health warnings on tobacco packaging, and restricted promotional activities. Canada's tobacco companies challenged the TPCA's constitutionality, arguing that it infringed on freedom of expression. Although it seemed likely that the Canadian Supreme Court would uphold the legislation, in 1995 the court declared the impugned provisions to be unconstitutional. The decision is testimony to the constraining force of liberalism on tobacco regulation, but it is also evidence of the power of political will. While the Canadian government could have used the decision to justify withdrawing from further confrontations with powerful commercial interests, it chose instead to enact new tobacco control legislation in 1997.