Ejection fraction (EF), the ratio between stroke volume (SV) and end-diastolic volume (EDV), is a valuable contractility indicator. Unlike SV, the Frank-Starling effect is automatically compensated in the calculation of EF. It was the aim of this study to evaluate the physiological behavior of impedance derived measurements of relative right ventricular (RV) volumes and EF, obtained with standard pacing leads. Seven patients were evaluated at the time of pacemaker implant or replacement. Since no absolute standard of comparison was available for RV volumes, the value of the measurements was assessed by observing their behavior under cardio-circulatory challenges. A 2.5-kHz carrier was fed to the ring and tip electrodes of standard bipolar pacing leads and the resulting voltage was digitized and stored. The peak-to-peak voltage (PPV) of the carrier at the time of QRS was used as EDV, and the largest PPV as end-systolic volume (ESV). Relative SV was the difference between EDV and ESV, and EF = SV/EDV x 100. Pacing was used to reduce EDV, and the effect of contractility was tested with isometric hand grip, recumbent leg exercise, or isoproterenol drip. Only minimal changes in EF were noted during incremental pacing; relative SV and EDV decreased as expected; and EF increased significantly during contractility challenges. A high correlation coefficient was observed between EDV and SV changes induced by incremental pacing at rest (r values from 0.62 to 0.98, P from < 0.01 to 0.001). The study revealed that impedance volumetry, utilizing conventional bipolar pacing leads, yields useful hemodynamic data related to EDV, ESV, and EF. Given the simplicity of the method, it is reasonable to conclude on the feasibility of using said impedance derived hemodynamic parameters in implantable rhythm control devices.

The future impact of the feminization of medicine in Argentina Summary. In recent years, the proportion of women studying medicine grew steadily in many countries. In Argentina, the feminization of the medical profession shows an overrepresentation of women in the younger group of physicians, and the 10-year projection indicates that women will comprise 60-70% of the medical workforce in all age strata. Adaptation to labor characteristics of women will require flexibility to accept part-time work and career interruptions caused by motherhood or other family obligations. A future consequence of women avoidance of most surgical specialties, is a relative shortage of doctors in these specialties. Anyway, it should be explored whether this supposed lack of interest in surgical specialties depends on the strong conditioning of the male model in these spaces. Despite being majority, woman is less represented in academia, resulting underrepresented in medical leadership in turn. Medical woman seems to be more humanistic, empathetic and honest than male. These contributions could be very significant, as long as women were able to achieve an egalitarian opinion leadership with men. There are potentially significant differences between the female and male occupational profiles, and this will certainly influence the organization and economy of future medical services, which are likely to be more complex, comparatively more expensive and better socialized.

To evaluate clinical and economic value of ipilimumab in the treatment of advanced melanoma compared with drugs available for the treatment of advanced cancer. MethOds: An analysis was performed comparing ipilimumab and other drugs for advanced cancer regarding overall survival (OS) and costs associated with improvement in survival. Parameters analyzed were: improvement in median/mean OS, improvement on survival rate at 1 year and the number needed to treat (NNT) to avoid one death. Monthly costs for improvement in mean OS were evaluated. Efficacy data were obtained from clinical trials. Medications costs were obtained from official price lists, such as Banco de Dados de Preços do Sistema de Saúde do Ministério da Saúde Brasileiro and Lista da Câmara de Regulação do Mercado de Medicamentos da Agência Nacional de Vigilância Sanitária (CMED). Results: Improvement in median OS ranged from +2.8 (sorafenib) to +4.8 (transtuzumab), and improvements in mean OS ranged from +1.6 (sorafenib) to +6.1 (ipilimumab). Only ipilimumab showed better mean OS compared with the median OS (6.1 vs. 3.7). This demonstrates the effect of ipilimumab in prolonging OS in long term, which is observed in a considerable proportion of patients treated with this drug. Major improvement in the survival rate in 1 year occurred with ipilimumab (20%). The NNT to prevent 1 death ranged from 7 (ipilimumab) to 61 (bevacizumab for lung cancer). Costs per month of mean OS improvement ranged from BRL 34,906 (sorafenib) to BRL 64,410 (bevacizumab for lung cancer). cOnclusiOns: This comparative analysis of drugs used for treatment of advanced cancer used key parameters for decision making in health sciences. The results suggest that ipilimumab delivers superior clinical and economic benefits when compared with other drugs available in Brazil for the treatment of advanced cancer.

Purpose 18F-DOPA Positron Emission Tomography/Computed Tomography (18F-DOPA PET/CT) is a sensitive functional imaging method (65-75%) for detecting disease localization in medullary thyroid cancer (MTC). We aimed: i) to assess the clinical usefulness of 18F-DOPA PET/CT in patients with MTC and elevated calcitonin (Ctn) and CEA levels and, ii) to evaluate changes in disease management secondary to the findings encountered with this methodology. Methods thirty-six patients with MTC and Ctn levels ≥150 pg/ml were prospectively included. Neck ultrasound, chest contrast-enhanced CT, liver magnetic resonance imaging/ abdominal 3-phase contrast-enhanced CT and bone scintigraphy were carried out up to 6 months before the 18F DOPA PET/CT. Results 77.7% were female and 27% had hereditary MTC. Median Ctn level was 1450 pg/ml [150-56620], median CEA level 413 ng/ml [2.9-7436]. Median Ctn DT was 37.5 months [5.7-240]; median CEA DT was 31.8 [4.9-180]. 18F-DOPA PET/CT was positive in 33 patients (91.6%); in 18 (56%) uptake was observed in lymph nodes in the neck or mediastinum, in 7 cases (22%) distant metastases were diagnosed, and in 8 additional patients (24%) both locoregional and distant sites of disease were found. Ctn and CEA levels were higher in patients with ≥ 3 foci of distant metastases. In 14 patients (38.8%), findings on 18F-DOPA PET/CT led to changes in management; surgery for locoregional lymph nodes was the most frequent procedure in 8 patients (22%). Conclusion 18F-DOPA PET/CT was useful for the detection of recurrent disease in MTC and provided helpful information for patient management.