Retinal and choroidal thickness measurements in obstructive sleep apnea: impacts of continuous positive airway pressure treatment.

PURPOSE: To examine retinal and choroidal thicknesses in individuals with obstructive sleep apnea (OSA) and determine the impacts of continuous positive airway pressure (CPAP) treatment. METHODS: Prospective follow-up study conducted at a university hospital. 40 patients with OSA, 28 treated with CPAP, and 12 untreated, were enrolled immediately after diagnosis and graded according to the apnea hypopnea index (AHI) determined in an overnight polysomnography. Inclusion criteria were a new diagnosis of OSA and CPAP indicated. Participants underwent a full ophthalmologic examination including optical coherence tomography (OCT) at the peripapillary, macular, and choroidal levels and the same examination 3 months later. Outcome measures were peripapillary retinal nerve fiber layer (RNFL), total retinal (TRT), retinal ganglion cell layer (RGCL), inner plexiform layer (IPL), photoreceptor layer (PL), and choroidal thicknesses. RESULTS: At 3 months, RGCL thickness was reduced at the inner nasal macula segment in the no-CPAP group (P = 0.016). In + CPAP, increases were produced in RNFL thickness (5/6 segments) and TRT (7/ 9 segments), while choroidal thinning was observed temporally (P = 0.003). At baseline, positive correlation was detected between choroidal thickness and AHI (r = 0.352, P = 0.005) and between IPL thickness (7/9 segments) and AHI (r = 0.414, P < 0.001). CONCLUSIONS: Initial retinal and choroidal thickening was followed by RGCL thinning over 3 months. In patients receiving CPAP, we observed no thinning of any retinal layer and normalization of choroidal thickness.

Prematurity With Extrauterine Growth Restriction Increases the Risk of Higher Levels of Glucose, Low-Grade of Inflammation and Hypertension in Prepubertal Children.

Introduction: An adipose tissue programming mechanism could be implicated in the extrauterine growth restriction (EUGR) of very preterm infants with morbidity in the cardiometabolic status later in life, as has been reported in intrauterine growth restriction. The aim of this study was to assess whether children with a history of prematurity and EUGR, but also with an adequate growth, showed alterations in the metabolic and inflammatory status. Methods: This was a case-control study. A total of 88 prepubertal children with prematurity antecedents were selected: 38 with EUGR and 50 with an adequate growth pattern (PREM group). They were compared with 123 healthy children born at term. Anthropometry, metabolic parameters, blood pressure (BP), C-reactive protein, hepatocyte growth factor (HGF), interleukin-6 (IL-6), IL-8, monocyte chemotactic protein type 1 (MCP-1), neural growth factor, tumour necrosis factor-alpha (TNF-α) and plasminogen activator inhibitor type-1 were analysed at the prepubertal age. Results: EUGR children exhibited higher BP levels and a higher prevalence of hypertension (46%) compared with both PREM (10%) and control (2.5%) groups. Moreover, there was a positive relationship between BP levels and values for glucose, insulin and HOMA-IR only in children with a EUGR history. The EUGR group showed higher concentrations of most of the cytokines analysed, markedly higher TNF-α, HGF and MCP-1 levels compared with the other two groups. Conclusion: EUGR status leads to cardiometabolic changes and a low-grade inflammatory status in children with a history of prematurity, and that could be related with cardiovascular risk later in life.

Biomarcadores cardiacos en el síndrome de bajo gasto cardiaco en el posoperatorio de cirugía de cardiopatías congénitas en niños / Cardiac biomarkers of low cardiac output syndrome in the postoperative period after congenital heart disease surgery in children

Introducción y objetivos: Determinar el valor del péptido natriurético auricular, el péptido natriurético cerebral, la copeptina, la región medial de la proadrenomedulina (MR-proADM) y la troponina I cardiaca (cTn-I) como indicadores de síndrome de bajo gasto cardiaco posoperatorio en niños con cardiopatía congénita intervenidos en circulación extracorpórea (CEC).Métodos: Estudio piloto prospectivo observacional, realizado durante 2 años, que incluyó a 117 niños (edad, 10 días-180 meses) intervenidos de cardiopatías congénitas en CEC, clasificados según presentaran o no síndrome de bajo gasto cardiaco. Los biomarcadores se determinaron tras 2, 12, 24 y 48 h del posoperatorio. Se utilizó un modelo de regresión logística multivariable para evaluar los factores asociados al bajo gasto cardiaco. Resultados: Tenían síndrome de bajo gasto cardiaco 33 pacientes (29%). Tras el ajuste por las demás variables, los valores plasmáticos de cTn-I > 14 ng/ml a las 2 h de CEC (odds ratio = 4,05; intervalo de confianza del 95%, 1,29-12,64; p = 0,016) y de MR-proADM > 1,5 nmol/l a las 24 h (odds ratio = 15,54; intervalo de confianza del 95%, 4,41-54,71; p < 0,001) fueron los únicos predictores independientes de bajo gasto cardiaco.Conclusiones: Los resultados indican que las concentraciones de cTn-I elevadas 2 h después de la CEC son, por sí solas, un predictor independiente de síndrome de bajo gasto cardiaco. Este valor predictivo se incrementa cuando se asocia con cifras de MR-proADM elevadas 24 h tras CEC. Estos 2 biomarcadores cardiacos podrían ayudar en la toma de decisiones terapéuticas en cuidados intensivos pediátricos, incluidas modificaciones en el tipo de soporte circulatorio (AU)

Introduction and objectives: To assess the predictive value of atrial natriuretic peptide, β-type natriuretic peptide, copeptin, mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin I (cTn-I) as indicators of low cardiac output syndrome in children with congenital heart disease undergoing cardiopulmonary bypass (CPB). Methods: After corrective surgery for congenital heart disease under CPB, 117 children (aged 10 days to 180 months) were enrolled in a prospective observational pilot study during a 2-year period. The patients were classified according to whether they developed low cardiac output syndrome. Biomarker levels were measured at 2, 12, 24, and 48 hours post-CPB. The clinical data and outcome variables were analyzed by a multiple logistic regression model. Results: Thirty-three (29%) patients developed low cardiac output syndrome (group 1) and the remaining 84 (71%) patients were included in group 2. cTn-I levels > 14 ng/mL at 2 hours after CPB (OR, 4.05; 95%CI, 1.29-12.64; P = .016) and MR-proADM levels > 1.5 nmol/L at 24 hours following CPB (OR, 15.54; 95%CI, 4.41-54.71; P < .001) were independent predictors of low cardiac output syndrome. Conclusions: Our results suggest that cTn-I at 2 hours post-CPB is, by itself, an evident independent early predictor of low cardiac output syndrome. This predictive capacity is, moreover, reinforced when cTn-I is combined with MR-proADM levels at 24 hours following CPB. These 2 cardiac biomarkers would aid in therapeutic decision-making in clinical practice and would also enable clinicians to modify the type of support to be used in the pediatric intensive care unit (AU)

Cardiac Biomarkers of Low Cardiac Output Syndrome in the Postoperative Period After Congenital Heart Disease Surgery in Children.

INTRODUCTION AND OBJECTIVES: To assess the predictive value of atrial natriuretic peptide, ß-type natriuretic peptide, copeptin, mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin I (cTn-I) as indicators of low cardiac output syndrome in children with congenital heart disease undergoing cardiopulmonary bypass (CPB). METHODS: After corrective surgery for congenital heart disease under CPB, 117 children (aged 10 days to 180 months) were enrolled in a prospective observational pilot study during a 2-year period. The patients were classified according to whether they developed low cardiac output syndrome. Biomarker levels were measured at 2, 12, 24, and 48 hours post-CPB. The clinical data and outcome variables were analyzed by a multiple logistic regression model. RESULTS: Thirty-three (29%) patients developed low cardiac output syndrome (group 1) and the remaining 84 (71%) patients were included in group 2. cTn-I levels >14 ng/mL at 2hours after CPB (OR, 4.05; 95%CI, 1.29-12.64; P=.016) and MR-proADM levels>1.5 nmol/L at 24hours following CPB (OR, 15.54; 95%CI, 4.41-54.71; P<.001) were independent predictors of low cardiac output syndrome. CONCLUSIONS: Our results suggest that cTn-I at 2hours post-CPB is, by itself, an evident independent early predictor of low cardiac output syndrome. This predictive capacity is, moreover, reinforced when cTn-I is combined with MR-proADM levels at 24hours following CPB. These 2 cardiac biomarkers would aid in therapeutic decision-making in clinical practice and would also enable clinicians to modify the type of support to be used in the pediatric intensive care unit.

Confidentiality breaches in clinical practice: what happens in hospitals?

BACKGROUND: Respect for confidentiality is important to safeguard the well-being of patients and ensure the confidence of society in the doctor-patient relationship. The aim of our study is to examine real situations in which there has been a breach of confidentiality, by means of direct observation in clinical practice. METHODS: By means of direct observation, our study examines real situations in which there has been a breach of confidentiality in a tertiary hospital. To observe and collect data on these situations, we recruited students enrolled in the Medical Degree Program at the University of Cordoba. The observers recorded their entries on standardized templates during clinical internships in different departments: Internal Medicine; Gynecology and Obstetrics; Pediatrics; Emergency Medicine; General and Digestive Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics and Traumatology; Digestive; Dermatology; Rheumatology; Mental Health; Nephrology; Pneumology; Neurology; and Ophthalmology. RESULTS: Following 7138 days and 33157 h of observation, we found an estimated Frequency Index of one breach per 62.5 h. As regards the typology of the observed breaches, the most frequent (54,6 %) were related to the consultation and/or disclosure of clinical and/or personal data to medical personnel not involved in the patient's clinical care, as well as people external to the hospital. As regards their severity, severe breaches were the most frequent, accounting for 46.7 % of all incidents. Most of the reported incidents were observed in public areas (37.9 %), such as corridors, elevators, the cafeteria, stairs, and locker rooms. CONCLUSIONS: In addition to aspects related to hospital organization or infrastructure, we have shown that all healthcare personnel are involved in confidentiality breaches, especially physicians. While most are committed unintentionally, a non-negligible number are severe, repeated breaches (9.5 %), thus suggesting a certain carelessness, perhaps through ignorance about certain behaviors that can jeopardize patient confidentiality.

Lung recruitment manoeuvres do not cause haemodynamic instability or oxidative stress but improve oxygenation and lung mechanics in a newborn animal model: an observational study.

BACKGROUND: Lung recruitment manoeuvres in neonates during anaesthesia are not performed routinely due to concerns about causing barotrauma, haemodynamic instability and oxidative stress. OBJECTIVE: To assess the influence of recruitment manoeuvres and positive end-expiratory pressure (PEEP) on haemodynamics, oxidative stress, oxygenation and lung mechanics. DESIGN: A prospective experimental study. SETTING: Experimental Unit, La Paz University Hospital, Madrid, Spain. ANIMALS: Eight newborn piglets (<48 h) with healthy lungs under general anaesthesia. INTERVENTIONS: The recruitment manoeuvres in pressure-controlled ventilation (PCV) were performed along with a constant driving pressure of 15 cmH2O. After the recruitment manoeuvres, PEEP was reduced in a stepwise fashion to find the maximal dynamic compliance step (maxCDyn-PEEP). Blood oxidative stress biomarkers (lipid peroxidation products, protein carbonyls, total glutathione, oxidised glutathione, reduced glutathione and activity of glutathione peroxidase) were analysed. MAIN OUTCOME MEASURES: Haemodynamic parameters, arterial partial pressure of oxygen (paO2), tidal volume (Vt), dynamic compliance (Cdyn) and oxidative stress biomarkers were measured. RESULTS: The recruitment manoeuvres did not induce barotrauma. Haemodynamic instability was not detected either in the maximum pressure step (overdistension step 5) or during the entire process. No substantial differences were observed in blood oxidative stress parameters analysed as compared with their baseline values (with 0 PEEP) or the values obtained 180 min after the onset of the recruitment manoeuvres (optimal PEEP). Significant maximal values were achieved in step 14 with an increase in paO2 (32.43 ±â€Š8.48 vs. 40.39 ±â€Š15.66 kPa; P = 0.037), Vt (47.75 ±â€Š13.59 vs. 73.87 ±â€Š13.56 ml; P = 0.006) and Cdyn (2.50 ±â€Š0.64 vs. 4.75 ±â€Š0.88 ml cmH2O; P < 0.001). Maximal dynamic compliance step (maxCdyn-PEEP) was 2 cmH2O. CONCLUSION: Recruitment manoeuvres in PCV with a constant driving pressure are a well tolerated open-lung strategy in a healthy-lung neonatal animal model under general anaesthesia. The recruitment manoeuvres improve oxygenation parameters and lung mechanics and do not cause barotrauma, haemodynamic instability or oxidative stress.

Neoadjuvant intraperitoneal chemotherapy with paclitaxel for the radical surgical treatment of peritoneal carcinomatosis in ovarian cancer: a prospective pilot study.

PURPOSE: The admitted benefits of intraperitoneal chemotherapy during postoperative administration for the treatment of peritoneal carcinomatosis from ovarian origin are limited by their associated morbidity and restricted diffusion by the presence of multiple intra-abdominal adherences. The purpose of the study was to evaluate the security, effectiveness, and cytoreduction optimization of intraperitoneal paclitaxel administration previously to radical surgery/peritonectomy/HIPEC (hyperthermic intraoperative intraperitoneal chemotherapy) either in monotherapy or combined with intravenous carboplatin. METHODS: Prospective pilot study of 10 patients with ovarian peritoneal carcinomatosis in stage IIIc-FIGO without previous treatment. After staging of the diseases by laparoscopy, five patients received paclitaxel by weekly intraperitoneal administration (60 mg/m(2), 10 cycles), and other five patients additionally received intravenous carboplatin every 21 days (AUC 6, 4 cycles). Subsequently radical surgery/peritonectomy with HIPEC was performed. RESULTS: The presence of moderate abdominal pain was the most common (70%) side effect associated with neoadjuvant paclitaxel intraperitoneal administration. The intravenous carboplatin administration was not associated with significant increase in adverse effects. It boosted intraperitoneal paclitaxel-associated antitumoral activity with a high average decrease in Index Cancer Peritoneal (21.2 vs. 14.4, P = 0.066) and CA 125(1,053 vs. 346, P = 0.043). All the patients who received combined neoadjuvant chemotherapy obtained R0 cytoreduction. Five-year overall survival was 62%. CONCLUSIONS: The intraperitoneal paclitaxel weekly administration combined with intravenous carboplatin administration prior to radical surgery/peritonectomy with HIPEC is a safe and effective option in the treatment of ovarian peritoneal carcinomatosis. This study shows the possibility to investigate other forms of intraperitoneal chemotherapy and their combinations thoroughly.

BNP as marker of heart dysfunction in patients with liver cirrhosis.

BACKGROUNDS: Patients with liver cirrhosis suffer various degrees of cardiac dysfunction which may be crucial in determining the outcome of surgery. The aim of this study was to determine the role of natriuretic peptides on the assessment of cardiac dysfunction in patients with liver cirrhosis. METHODS: Prospective longitudinal study of 30 patients with hepatic cirrhosis. Severity of disease was assessed according to the Child-Turcotte-Pugh and Model for End Stage Liver Disease (MELD) scores. Cardiac function was assessed using endocrine markers [atrial natriuretic peptide-brain natriuretic peptide (BNP)] and isotopic ventriculography at baseline and after stimulation with dobutamine. RESULTS: The ejection fraction was higher in patients with Child A+B and MELD less than 18 than in patients with advanced liver disease. A significant correlation between BNP plasma levels and MELD values was observed. Dobutamine induced a marked improvement in myocardial performance associated to a decrease in BNP levels. Multivariate analysis showed that BNP has prognostic value as a marker of cardiac ejection fraction. Patients whose baseline BNP concentrations were more than 70 pg/ml had an ejection fraction of around 45%. CONCLUSION: This study has shown that increased baseline BNP concentrations may be regarded together with high Child and MELD scores, as the critical cardiac dysfunction threshold in cirrhotic patients.

The role of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal carcinomatosis in recurrent ovarian cancer.

BACKGROUND AND OBJECTIVES: Peritoneal carcinomatosis in women frequently has an ovarian origin. Hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) along with radical surgery/peritonectomy could present a new therapeutic approach with curative intention. The purpose of this research is to evaluate the role of the administration of HIPEC. METHODS: A series of patients (N=26) diagnosed with peritoneal carcinomatosis for recurrent epithelial ovarian cancer (stage III) from January 1997 to December 2004 submitted to radical surgery/peritonectomy with optimal cytoreduction (R0-R1) were included in this study, 14 treated with HIPEC and 12 without HIPEC. RESULTS: The variables age, histologic type, peritonectomy procedures, peritoneal cancer index (PCI) and lymph node affectation were similar in both groups. The 5-year global survival was 58% and 17% (p=0.046), and 67% and 29% in patients with maximal cytoreduction (R0) (p=0.264), in the HIPEC- and non-HIPEC-treated patients, respectively. In patients with optimal cytoreduction and partial peritonectomy, 5-year global survival was also superior in the HIPEC group (75% vs. 11%, p=0.011). Average time free of disease was superior in the HIPEC group (48+/-42 vs. 24+/-21 months), with less reinterventions due to a new reappearance during the first three evolutionary years (2/14 vs. 4/12). Postoperative morbidity did not show substantial differences in both groups and there was no surgical mortality. CONCLUSIONS: HIPEC is a complement to radical surgery/ peritonectomy, which has been shown to be a surgical procedure with high tolerability, low morbimortality, enhanced survival and prolonged disease-free interval in patients with peritoneal carcinomatosis for recurrent ovarian cancer.

Beneficial properties of melatonin in an experimental model of pancreatic cancer.

Pancreatic cancer is a major health problem because of the aggressiveness of the disease and the lack of effective systemic therapies. Melatonin has antioxidant activity and prevents experimental genotoxicity. However, the effect of melatonin in pancreatic cancer has not been tested. Pancreatic carcinogenesis was induced by N-nitrosobis (2-oxopropyl)amine (BOP) in Syrian hamsters. Melatonin was administered during the BOP-induction phase (12 wk) and/or following the postinduction phase (12 wk). Different parameters of oxidative stress including lipid peroxides (LPO) and antioxidants (superoxide dismutase, catalase, reduced glutathione and glutathione peroxidase) were determined in pancreatic tissue. Also, the presence of atypical hyperplasia (AH), well and moderately differentiated adenomacarcinoma (ADC-WD and ADC-MD, respectively) were studied. The administration of BOP induced an intense oxidative stress and ADC induction in the pancreas. The administration of melatonin during the induction or postinduction phase reduced LPO and improved the antioxidant status, as well as drastically reducing the presence of ADC but some AH remained. In conclusion, treatment with melatonin reduced oxidative damage and cancer nodules induced by BOP in the pancreas.