Resultados tardíos del tratamiento percutáneo de la reestenosis intrastent con el uso de stents con drogas: un estudio colaborativo / Percutaneous treatment of intra stent restenosis using drug eluting stents: late results in a multicenter study

Introducción. La proliferación neointimal es la causa de la reestenosis coronaria intra stent (RIS). Recientemente, el implante de stents liberadores de drogas (DES) ha emergido como una alternativa efectiva de tratamiento endovascular. Material y método. Seleccionamos pacientes con RIS de stents no recubiertos tratados con DES en forma consecutiva en 3 centros chilenos. Luego del alta los pacientes fueron seguidos por al menos 12 meses. Resultados. De 21 pacientes (19 por ciento mujeres) entre 47 y 91 años tratados por al menos una lesión coronaria con RIS, 33,3 por ciento eran diabéticos y 14,3 por ciento tenían cirugía coronaria previa. Se presentaron de preferencia con síndromes coronarios agudos y la mayoría tenía enfermedad de 1 vaso (71,4 por ciento). Se trató sólo 1 lesión con RIS, implantándose en 15 pacientes DES recubierto con Sirolimus y en 6 con Paclitaxel. El largo promedio de stent implantado fue de27,7 mm (13-51 mm). Se obtuvo éxito en todos los casos y no hubo complicaciones isquémicas intrahospitalarias. Durante el seguimiento, sólo 2 pacientes presentaron reestenosis intrastent y uno de ellos, un anciano, falleció en forma súbita en el seguimiento. El 90 por ciento se mantuvo libre de eventos isquémicos en el seguimiento. Conclusión. El implante de DES aparece como una alternativa efectiva en el tratamiento de la RIS.

Background. Neointimal proliferation causes coronary intrastent restenosis (ISR). Recently, drug eluting stents(DES) have emerged as an effective therapeutic approach to treat ISRMethods. Consecutive patients from 3 centers with in stent restenosis after bare metal stent implantation were treated with DES. Patients were followed for 12 months after discharge.Results. Of 21 patients (19 percent females), 47 to 91 years old, with one or more intrastent restenosis, diabetes was present in 33 percent and previous coronary artery surgery in 14 percent. Most patients presented with acute coronary syndromes and 71 percent had single vessel disease. Only one lesion in each patient was treated with DES implantation, 15 with paclitaxel and 6 with sirolimus stents. Mean stent length was 27.7 mm (13-51). The procedure was successful in all patients and no ischemic complications were observed prior to discharge. During follow up 2 patients developed new intra stent restenosis and one of them died suddenly. 90 percent of patients were free from ischemic events at the end of follow up. Conclusion. DES appears to be an effective therapy to treat intra stent restenosis.

[Cannabis and psychosis]. / Cannabis et psychose.

Cannabis is abused by a progressively larger and younger proportion of our population. For the clinician, this can raise the question of what the relationship between cannabis and psychosis is. For the patient who is already psychotic, this relationship is most certainly adverse; cannabis worsens the symptoms and prognosis of a psychosis. What may be of even greater concern is the growing evidence that cannabis may cause psychosis in healthy individuals. Many studies now show a robust and consistent association between cannabis consumption and the ulterior development of psychosis. Furthermore, our better understanding of cannabis biology allows the proposal of a plausible hypothetical model, based notably on possible interactions between cannabis and dopaminergic neurotransmission.

Seguimiento clínico al año de angioplastias coronarias exitosas en pacientes no seleccionados / One year follow up of successful coronary angioplasty in non selected patients

Background:Re-stenosis after percutaneous Coronary Angioplasty (PTCA) is related to clinical and angiographic features. Aim: To describe the clinical and angiographic characteristic of our patients with coronary cardiopathy subjected to PTCA and the predictor factors for re-stenosis. Material and methods: We gathered the clinical and angiographic characteristics of all patients who underwent a successful PTCA of a native coronary artery. All patients had a clinical assessment one year after the procedure. Patients were classified in Group 1, if they did not have angina or coronary events after the angioplasty or Group 2, if they had angina or a coronary event after the procedure. Only Group 2 patients were subjected to a coronary angiogram. Results: We collected 383 PTCA procedures. Follow up information was obtained in 92.2 percent. Three hundred forty two patients (89.3 percent) were assessed one year the procedure. Nine patients (2.3 percent) died of a cardiovascular cause. Ninety patients (26.3 percent) were classified in Group 2. In 65 patients, angiographic re-stenosis was demonstrated (19 percent). Re-stenosis occurred in 36 and 13 percent of patients with an without Diabetes Mellitus, respectively (p <0.01). The other clinical predictor variables were a history of myocardial infarction (p =0.007), obesity (p =0.041) and hypercholesterolemia (p =0.050). None of the angiographic characteristics predicted restenosis. Stents were protective factors against restenosis (15.6 percent in stented lesions vs 25.4 percent in nonstented; p =0.01). Conclusions: Re-stenosis after angioplasty occured in 19 percent of our patients with angina or coronary events. The clinical variables associated with a higher risk of re-stenosis were diabetes (the main risk factor), previous myocardial infarction, obesity and hypercholesterolemia. Angiographic variables were not associated with re-stenosis. The use of stents decreases the incidence of re-stenosis in all groups).

[One year follow up of successful coronary angioplasty in non selected patients]. / Seguimiento clínico al año de angioplastias coronarias exitosas en pacientes no seleccionados.

BACKGROUND: Re-stenosis after percutaneous coronary angioplasty (PTCA) is related to clinical and angiographic features. AIM: To describe the clinical and angiographic characteristic of our patients with coronary cardiopathy subjected to PTCA and the predictor factors for re-stenosis. MATERIAL AND METHODS: We gathered the clinical and angiographic characteristics of all patients who underwent a successful PTCA of a native coronary artery. All patients had a clinical assessment one year after the procedure. Patients were classified in Group 1, if they did not have angina or coronary events after the angioplasty or Group 2, if they had angina or a coronary event after the procedure. Only Group 2 patients were subjected to a coronary angiogram. RESULTS: We collected 383 PTCA procedures. Follow up information was obtained in 92.2%. Three hundred forty two patients (89.3%) were assessed one year the procedure. Nine patients (2.3%) died of a cardiovascular cause. Ninety patients (26.3%) were classified in Group 2. In 65 patients, angiographic re-stenosis was demonstrated (19%). Re-stenosis occurred in 36 and 13% of patients with an without Diabetes Mellitus, respectively (p <0.01). The other clinical predictor variables were a history of myocardial infarction (p =0.007), obesity (p =0.041) and hypercholesterolemia (p =0.050). None of the angiographic characteristics predicted restenosis. Stents were protective factors against restenosis (15.6% in stented lesions vs 25.4% in nonstented; p =0.01). CONCLUSIONS: Re-stenosis after angioplasty occurred in 19% of our patients with angina or coronary events. The clinical variables associated with a higher risk of re-stenosis were diabetes (the main risk factor), previous myocardial infarction, obesity and hypercholesterolemia. Angiographic variables were not associated with re-stenosis. The use of stents decreases the incidence of re-stenosis in all groups).

Evaluation of a pediatric hospitalist service: impact on length of stay and hospital charges.

OBJECTIVES: Inpatient medical services supervised by pediatric hospitalist physicians are a new development in academic medical centers in the United States. In a large pediatric teaching hospital, we compared length of stay, readmission rates, and hospital charges for children admitted to medical services with and without a hospitalist system of care. DESIGN: This retrospective observational study compared a baseline year of a traditional ward service (TS) with a subsequent year of a new hospitalist system of care called the Generalist Inpatient Service (GIS). Data were obtained from the hospital's clinical, demographic, and financial databases and from selected record review. All hospitalizations were at least 24 hours long and did not involve a stay in an intensive care unit. RESULTS: The average length of stay was longer for the 627 TS hospitalizations than for the 813 GIS hospitalizations (2.7 +/- 2.0 vs 2.4 +/- 1.7 days). Total hospital charges were significantly lower on the GIS ($3002 +/- $2160 vs $2720 +/- $1933) because of lower room and respiratory therapy charges. Three readmissions to the TS and 8 to the GIS occurred within 24 hours of hospital discharge and were, therefore, considered potentially preventable by a longer initial hospital stay. CONCLUSIONS: In a large pediatric teaching hospital, a system of inpatient care provided by hospitalists can reduce length of stay. This model has the potential to control hospital charges in a period of increasing health care costs.

Imaging of congenital anomalies of the temporal bone.

This article briefly presents the embryology of the ear and discusses the external auditory canal and middle ear, including first branchial cleft anomalies, external auditory canal atresia and stenoses, congenital cholesteatoma, and congenital teratoma. Topics related to the labyrinths include aplasia, the common-chamber anomaly, the pseudo-Mondini and Mondini malformations, semicircular canal dysplasia, and the large vestibular aqueduct. Vascular malformations and variations also are presented, including the absent and aberrant internal carotid artery, the persistent stapedial artery, and high jugular bulb; cerebrospinal fluid and perilymph fistulas are the subjects of the final section.

[Temporary medicosocial admission: alternative to hospitalization of elderly persons?]. / Hébergement médico-social temporaire: alternative à l'hospitalisation de personnes âgées?

The orientation of elderly patients, temporarily disabled, to acute care beds is inappropriate because of its adverse effects on functional status and its costs. The creation of short-stay units (SSU) in nursing homes provides an alternative to acute care hospitalization. The aim of this retrospective study, involving the first 64 patients oriented to the SSU from the emergency center, was to evaluate this new health care network. The analysis was focused on the rate of appropriate orientation (site of living at four month; subsequent medical events), as well as the functional quality of this health care network. Information were collected from medical records of the 64 patients oriented to SSU and 64 sex- and age-matched patients admitted during the same period, and the opinion of the network's partners. The mean age of patients and controls was 82 years. Four months after admission to the SSU, the orientation was considered appropriate in 58% of the cases (living at home without subsequent hospitalization), doubtful in 8%, and inappropriate in 33%; 27% of patients and 13% of controls were living definitely in nursing homes (p < 0.1). No medical or social characteristics was correlated to inappropriate orientations. In conclusion, the creation of SSU may be considered as an improvement in the care of elderly patients. The main problem of this orientation was the high percentage of patients living permanently in a nursing home four months later. Accurate assessment's tools capable to predict the subsequent decrease of the functional status should be used in the daily practice in order to improve the orientation of elderly patients.

Higher triglycerides, lower high-density lipoprotein cholesterol, and higher systolic blood pressure in lipoprotein lipase-deficient heterozygotes. A preliminary report.

BACKGROUND: Heterozygous lipoprotein lipase (LPL) deficiency has been associated with familial hypertriglyceridemia and familial combined hyperlipidemia. Studies of heterozygotes with LPL gene defects at amino acid residues 188 and 207 showed higher triglycerides (TG) and lower HDL cholesterol (HDL-C), with no elevation in LDL cholesterol (LDL-C). Other LPL defects may reveal alternate clinical phenotypes. METHODS AND RESULTS: We evaluated three families with defects at amino acid residues 64, 194, and 188. Thirty-eight heterozygotes (8 with defect 64, 14 with defect 194, and 16 with defect 188) and 95 family members without defects were studied. Plasma lipid, lipoprotein, and apolipoprotein (apo) values were measured, as well as blood pressure. Pooled carriers demonstrated higher systolic blood pressure (SBP) (127 versus 116 mm Hg, P < .0001) and TG (160 versus 125 mg/dL, P = .004) and lower HDL-C (44 versus 52 mg/dL, P = .001) than did noncarriers. A comparison of the 188 carriers and noncarriers revealed the most striking phenotypic characteristics, with lower HDL-C (36 versus 51 mg/dL, P < .0001) and HDL-C/(apo A-I + apo A-II) (0.21 versus 0.24, P = .002) and higher TG (206 versus 123 mg/dL, P = .0003), SBP (132 versus 116 mm Hg, P = .0004), and apo B/LDL-C (1.12 versus 0.93, P < .0001). CONCLUSIONS: These data confirm past observations that LPL deficient heterozygotes trend toward lower HDL-C and higher TG levels while potentially expressing higher SBP. These data also implicate the specific LPL gene defect as a contributing factor to the variable expression of HDL-C, TG, and SBP.

Incentive spirometry to prevent acute pulmonary complications in sickle cell diseases.

BACKGROUND: This study was designed to determine the incidence of thoracic bone infarction in patients with sickle cell diseases who were hospitalized with acute chest or back pain above the diaphragm and to test the hypothesis that incentive spirometry can decrease the incidence of atelectasis and pulmonary infiltrates. METHODS: We conducted a prospective, randomized trial in 29 patients between 8 and 21 years of age with sickle cell diseases who had 38 episodes of acute chest or back pain above the diaphragm and were hospitalized. Each episode of pain was considered to be an independent event. At each hospitalization, patients with normal or unchanged chest radiographs on admission were randomly assigned to treatment with spirometry or to a control nonspirometry group. Each patient in the spirometry group took 10 maximal inspirations using an incentive spirometer every two hours between 8 a.m. and 10 p.m. and while awake during the night until the chest pain subsided. A second radiograph was obtained three or more days after admission, or sooner if clinically necessary, to determine the incidence of pulmonary complications. Bone scanning was performed no sooner than two days after hospital admission to determine the incidence of thoracic bone infarction. RESULTS: The incidence of thoracic bone infarction was 39.5 percent (15 of 38 hospitalizations). Pulmonary complications (atelectasis or infiltrates) developed during only 1 of 19 hospitalizations of patients assigned to the spirometry group, as compared with 8 of 19 hospitalizations of patients in the nonspirometry group (P = 0.019). Among patients with thoracic bone infarction, no pulmonary complications developed in those assigned to the spirometry group during a total of seven hospitalizations, whereas they developed during five of eight hospitalizations in the nonspirometry group (P = 0.025). CONCLUSIONS: Thoracic bone infarction is common in patients with sickle cell diseases who are hospitalized with acute chest pain. Incentive spirometry can prevent the pulmonary complications (atelectasis and infiltrates) associated with the acute chest syndrome in patients with sickle cell diseases who are hospitalized with chest or back pain above the diaphragm.

Primary hyperlipidemia in a pediatric population: classification and effect of dietary treatment.

Patients seen at a pediatric lipid clinic over a 27-month period were reviewed retrospectively to evaluate types of primary lipid disorders and effect of dietary treatment at the first follow-up visit. One hundred eighty-two patients were classified into one of four categories: (1) elevated low-density lipoprotein cholesterol (LDL-C) with LDL-C > 95th percentile (32%); (2) isolated triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) abnormalities, with TG > 95th percentile and/or HDL-C < 5th percentile (30%); (3) borderline LDL-C, TG, or HDL-C (29%); (4) normal (9%). The American Heart Association Step-One Diet was prescribed for all patients older than 2 years, and they received extensive nutritional and risk-management counseling. Of these patients, 59 (32%) returned for at least one follow-up visit and mean changes in lipid values between initial and first follow-up visits were evaluated. Levels of LDL-C decreased by 24 mg/dL in 22 patients with elevated LDL-C levels. Triglyceride levels decreased by a mean of 22 mg/dL and HDL-C increased by a mean of 4 mg/dL in 21 patients with isolated TG/HDL-C abnormalities. Levels of LDL-C tended to rise in this group, but not to a significant degree. A new finding of this report is that screening for total cholesterol results in the identification of many children with TG or HDL-C abnormalities alone and that the Step-One Diet appears to be effective in improving both TG and HDL-C levels in these patients.

Trp64----nonsense mutation in the lipoprotein lipase gene.

A lipoprotein lipase (LpL) gene defect has been identified, a G----A transition at nucleotide position 446 of exon 3, resulting in a premature termination codon (Trp----stop) at amino acid residue 64. This defect was identified in a Type I hyperlipoproteinemic subject with an amino acid residue 194 defect in the other allele. Plasma lipoprotein values as well as LpL mass and activity in postheparin plasma were determined in the subjects with the residue 64 defect and in other LpL-deficient heterozygotes. LpL mass levels in both the Type I and the other subject with a 64 LpL defect were markedly reduced. This may be explained by rapid degradation of LpL protein or decreased secretion from the 64 defective allele. Alternatively, the marked reduction or absence of mass associated with the 64 defect may be due to synthesis of a severely truncated protein which escapes immunologic detection.

The evaluation of ear canal, middle ear, temporal bone, and cerebellopontine angle masses in infants, children, and adolescents.

Ear canal, middle ear, temporal bone, and CPA angle masses (except for cholesteatomas) are rare in the pediatric population. The physician needs to have a high degree of suspicion for such lesions if a child presents with ear pain unrelated to infection or otorrhea that fails to improve after treatment. A precise diagnosis needs to be made in these children and also in those with hearing loss, vertigo, and facial paralysis. The most useful imaging procedures for ear, temporal bone, and CPA masses are CT and MR imaging. With a suspected vascular lesion, a definitive diagnosis usually can be made by an imaging procedure or angiography. In all cases of mass lesions, except for some aneurysms and infections, a tissue diagnosis must be secured.

How I teach medical students as an attending physician.

The General Professional Education of the Physician (GPEP) Report (1984) recommended a major re-examination of the clinical clerkship, so that medical students could master the basic skills of medicine before graduation. These include clinical observation, interviewing, physical examination, and problem-solving skills. This essay discusses the teaching approach of one attending physician during the third year ward clerkship in pediatrics. It describes how many of the goals of clinical medical education can be accomplished during the clerkship in a practical, realistic way. It is the only description about what happens during the teaching sessions of a clinical clerkship on a day by day basis in the medical literature. This approach may serve as a model for clinical teachers of medicine in the organization and planning of the clerkship experience.