Joan J. Sancho

BLIND EVALUATION OF THE EFFECT OF OCTREOTIDE (SMS 201-995), A SOMATOSTATIN ANALOGUE, ON SMALL-BOWEL FISTULA OUTPUT

In a blind crossover trial for 4 days, after at least 7 days on conventional treatment, 14 patients with postoperative small-bowel fistula were randomised to 2 days on a somatostatin analogue, octreotide (SMS 201-995), followed by 2 days on placebo (group 1) or vice versa (group 2), after which all patients were treated with octreotide until the fistula closed or reoperation was deemed necessary. In group 2 mean fistula output was reduced from 698 ml per 24 h pretreatment to 246 mg per 24 h after 2 days on octreotide; output increased from 228 ml per 24 h to 497 ml per 24 h when treatment with octreotide was interrupted by placebo. In 11 patients fistulae closed spontaneously in an average of 4.5 days after continous treatment with octreotide.

Bone mineral density in menopausal women with primary hyperparathyroidism before and after parathyroidectomy.

The relationship between osteoporosis and primary hyperparathyroidism (pHPT) has not been definitely established because both diseases occur predominantly in postmenopausal women, and because PTH has a paradoxical effect on bone. We have investigated the prevalence of reduced bone mineral density (BMD) in women with pHPT, its relationship with metabolic parameters, and its course after parathyroidectomy. A prospective observational study was carried out on perimenopausal and postmenopausal women consecutively diagnosed and operated on for pHPT. Demographic data were recorded, as well as, PTH, Ca, calciuria/24h, P, vitamin D, adenoma weight. The BMD was measured at three sites: femoral neck (FN), proximal femur (PF), and lumbar spine (LS). Fifty-two patients were included with a mean age of 61 ± 12 years. The prevalence of reduced BMD (≤ 1SD, T-score) was 80%–100% depending on site. Parathyroid hormone was higher in patients with osteoporosis (319 ± 181 pg/ml) than in those with osteopenia (230 ± 83 pg/ml) or normal BMD (148 ± 81 pg/ml; p < 0,04). Twenty-eight patients were investigated 1 year after parathyroidectomy. The BMD improved significantly at all sites, particularly in patients with osteoporosis. Age correlated inversely with BMD increases at the femoral sites (r= –0,47; p = 0,02) but not at the LS. 25-OHD3 plasma levels correlated inversely with BMD increases at PF (r= –0,76; p < 0,0001). In pHPT, there is a high prevalence of BMD abnormalities. No metabolic variables had a definite influence on BMD values but a tendency was observed for lower BMD in severe pHPT. One year after parathyroidectomy, there were significant BMD increases that were more marked at femoral sites, in younger patients, in patients with preoperative osteoporosis, and in those with lower plasma levels of 25-OHD3.

Vitamin d status in patients operated for primary hyperparathyroidism: comparison of patients from southern and northern europe.

Aim. The interaction between vitamin D deficiency and primary hyperparathyroidism (PHPT) is not fully understood. The aim of this study was to investigate whether patients with PHPT from Spain and Sweden differed in vitamin D status and PHPT disease activity before and after surgery. Methods. We compared two cohorts of postmenopausal women from Spain (n = 126) and Sweden (n = 128) that had first-time surgery for sporadic, uniglandular PHPT. Biochemical variables reflecting bone metabolism and disease activity, including levels of 25-hydroxy vitamin D3 (25(OH)D) and bone mineral density, BMD, were measured pre- and one year postoperatively. Results. Median preoperative 25(OH)D levels were lower, and adenoma weight, PTH, and urinary calcium levels were higher in the Spanish cohort. The Spanish patients had higher preoperative levels of PTH (13.5 versus 11.0 pmol/L, P < 0.001), urinary calcium (7.3 versus 4.1 mmol/L, P < 0.001), and heavier adenomas (620 versus 500 g, P < 0.001). The mean increase in BMD was higher in patients from Spain and in patients with vitamin D deficiency one year after surgery. Conclusion. Postmenopasual women with PHPT from Spain had a more advanced disease and lower vitamin 25(OH)D levels. Improvement in bone density one year after surgery was higher in patients with preoperative vitamin D deficiency.

Tratamiento quirúrgico de la úlcera péptica perforada: comparación entre los abordajes laparoscópico y abierto

OBJECTIVE To analyse the outcomes of laparoscopic versus open repair for perforated peptic ulcers (PPU). METHODS All patients undergoing PPU repair between January 2002 and March 2012 were included in the study. Demographic characteristics, operation time, complications, and length of hospital stay were evaluated. RESULTS Two hundred and twelve patients (median age, 49 years) were included, 60 in the laparoscopic group and 52 in the open group. Patients operated laparoscopically were significantly younger and had a higher consumption of tobacco, alcohol and cannabis. Median acute symptoms time was shorter in the laparoscopic group (6h) compared to the open group (12h; P=.025) Symptoms time was shorter in the laparoscopic group. Median operating time was significantly longer in the laparoscopic group (104.5min vs. 76min, P=.025). The percentage of conversion to open repair was 25%. There was no difference in morbidity between 2 groups, but there were 3 deaths in the open group. Median hospital stay was significantly shorter in patients treated laparoscopically when compared with the open group (6 days vs. 8 days; P=.041). CONCLUSION Laparoscopic and open repair are equally safe in the management of PPU. A shorter hospital stay can be achieved in the laparoscopic group.

Controlling for chance agreement in the validation of medical expert systems with no gold standard: PNEUMON-IA and RENOIR revisited

In the validation of medical expert systems, agreement among different human specialists on a random sample of cases may be taken as a substitute to a missing gold standard. Distance measures between pairs of experts, extensively described in previous studies, do not take into account the influence of chance-expected agreement. A weighted kappa index, with three different weighting schemes, is proposed as an alternative to be applied in the general situation of N cases assessed by E experts about K possible diagnoses, each of them qualified with one of G ordinal categories. A hierarchical cluster analysis, applied to the kappa matrices generated, allows for the classification of the expert system among clinical specialists, providing a relative assessment of its diagnostic ability. The above methodology is applied to the validation of two medical expert systems, PNEUMON-IA and RENOIR.

A New Approach to Computerized Medical Knowledge Assessment

The development of “smart” test programs to assess the knowledge acquisition during the learning process and to identify areas in which to concentrate the effort, is a potential area of development in Computer Assisted Medical Instruction. We developed a “smart” interactive system, SuperTest, to train students to pass the test to have access to Residency Training Programs. We used object oriented techniques all over the project, from design up to the implementation phase, and developed it under a graphical interface. The program developed is able to assess the student initial knowledge in each area and produces a study plan balancing knowledge extension needs in each area with student proficiency. The plan is surveyed by small, one-area, tests, and continuously adapted to student progress. Eventually, a real test emulation is offered. The students acceptance has been encouraging. Similar techniques could be applied to a variety of tests.

Intelligent Tutorial System in Medicine through an Interactive Testing Program: HyperMIR

In Spain, as in many countries, the only pathway to reach postgraduate specialization in medicine is through a National MIR Exam (a multiple choice test). This exam exerts a great impact both in the teachers and students attitudes during the undergraduate period, promoting a test-oriented rather than a patient-oriented learning.