The Vascular "Cold Patch" is Not a Prognostic Index for Headache

Our previous research has determined that the vascular "cold patch" is a valid diagnostic "marker" and is a persistent constituent of the thermal geography of the external carotid region. It has been suggested by Dalla Volta and Anzola (1988) that the cold patch may be a prognostic index of vascular headache physiology; that is, as headaches improve through the use of vasoactive prophylactic medication, the cold patch would decrease in size or disappear. The purpose of this study is an attempt to replicate these findings. Forty migraine patients were randomly selected, and a thermographic re-examination of the external carotid region (forehead) was conducted. The post-treatment thermogram was then compared to the initial pre-treatment thermogram. Thirty subjects demonstrated an improved condition (IC) and ten subjects a worsened condition (WC). The IC Group exhibited a 73.2% reduction in headache frequency following a mean treatment period of 6.3 months. The WC Group demonstrated a 48.1% increase in headache occurrence at a mean treatment interval of fifteen months. Results demonstrated little thermographic difference between the two conditions. Within the IC Group, 46.7% of subjects exhibited and increase in cold patch size with an improved condition, 40% of cold patches remained stable, 6.7% of cold patches reduced in size, and zero cold patches disappeared with successful treatment. Within the WC Group, 20% of cold patches decreased in size with a worsened condition, 40% increased in size, and 40% remained stable. Chi square analysis determined there was no significant difference in cold patch changes between patients whose headache condition improved or worsened (p less than .70).(ABSTRACT TRUNCATED AT 250 WORDS)     

Initial results with left ventricular pacemaker lead implantation using a preformed "peel-away" guiding sheath and "side-wire" left ventricular pacing lead

We report our preliminary experience with the use of preformed "peel-away" guiding sheaths and "side-wire" pacing leads for permanent biventricular pacemaker insertion in 13 patients with heart failure. Three of these patients were undergoing an upgrade of a preexistent VVIR pacing system after prior His ablation for medically refractory atrial fibrillation. Six of the patients had undergone attempted biventricular pacemaker insertion, but required left ventricular lead repositioning after total implantation failure or late displacement of the lead. The remaining patients were undergoing new system implantation. Target vessel cannulation was achieved in all patients. However, in one patient, diaphragmatic pacing throughout the target vessel length prevented successful implantation. All other implants were ultimately successful (92% success rate). We conclude that device implantation using a preformed sheath and side-wire pacing lead is feasible and may offer significant benefits over implantation with currently available technology.     

"Sagging heart syndrome": a cause of acute lead dislodgment in two patients

Acute passive fixation atrial lead dislodgment occurred due to an unexpected and marked postural descent of the heart after permanent pacemaker implantation in two patients. Sagging of the heart in these two individuals may have been related to a history of morbid obesity followed by weight loss of over 100 pounds. Lead replacement with active fixation leads was required in both cases. The term "sagging heart syndrome" is proposed to describe this clinical entity. In certain adult populations, such as in patients with a history of significant weight loss, the "sagging heart syndrome" may represent a previously unrecognized cause of acute lead dislodgment.     

"Towering genius disdains a beaten path" Abraham Lincoln

We see nursing leadership existing at all levels in nursing...all nurses leading. Nurse executives within academic health environments across Canada will be influencing health policy directions and dialogue within the profession nationally. They will be contributing to the development of a national agenda for nursing practice, education, research and leadership. These nurse executives will lead in a way that makes an invigorating impact on human service in health care environments and they will be dedicated to preparing the nursing leaders of tomorrow. The Academy of Canadian Executive Nurses will connect with the Office of Nursing Policy, Canadian Nurses Association, Canadian Association of University Schools of Nursing, Association of Canadian Academic Health Care Organizations and others to develop position papers regarding key issues such as patient safety, health human resource planning and leadership in the Canadian health care system. Our definition of professional nursing practice, fully integrated with education and research, will be advanced through these endeavours. The end result of a strong individual and collective voice will be improved patient outcomes supported by professional nursing practice in positive practice environments. This paper is intended to stimulate dialogue among nursing leaders in Canada, dislodge us from a long and traditional path, and place us firmly in a new millennium of leadership for the profession and practice of nursing, a style of leadership that is needed, wanted and supported by nurses and the clients we serve. It is the responsibility of those of us who lead in academic health science centres to be courageous for the students we support, the puactitioners we lead and the renewal of the profession. We are the testing ground for nursing research, and need to be the source of innovation for nursing practice. It is incumbent on us to leap forward to engage a new vision of the professional practice of nursing with a reconfigured work design and work environment compatible with the new economy, workplace and workforce.     

Infections with Nonthoracotomy Implantable Cardioverter Defibrillators: Can These Be Prevented?

Nonthoracotomy ICDs are believed to be the best therapeutic modality for treatment of life-threatening ventricular arrhythmias. Little is known about the risk of infection with initial implantation of these devices. We studied the incidence, clinical characteristics, and risk factors associated with infections in 1,831 patients with nonthoracotomy ICD from the Endotak-C nonthoracotomy lead registry of Cardiac Pacemakers, Inc. A transvenous lead was implanted in 950 patients (51.9%) and a combination transvenous plus subcutaneous patch was used in 881 patients (48.1%). Nine preselected data variables were studied, and all investigators identified as having patients with infections were personally contacted. Infections occurred in 22 (1.2%) of 1,831 patients receiving this nonthoracotomy ICD system. The mean time to infection was 5.7 ± 6.5 months (range 1–25 months). Staphylococci were isolated in 58% of patients with reported infection. The presence of a subcutaneous defibrillator patch system was associated with the development of infection. Six of 950 patients (0.63%) with a totally transvenous lead system developed infection versus 16 of 838 (1.9%) patients with a transvenous lead plus subcutaneous patch system configuration (P = 0.015, Chi-square test), with an unadjusted estimated odds ratio of 3.06 (CI 1.19–7.86). The risk of infection encountered with the nonthoracotomy ICD is low, estimated from our data to be 1.2%. Placement of a subcutaneous defibrillator patch appears to be an independent risk factor for development of infection.     

Removal of the Protruding Retention Wire Via a Femoral Approach While Leaving the Active-Fixation Atrial "J" Lead In Situ: A Technique for the Management of Class III Atrial "J" Leads

The Telectronics Accufix Atrial "J" pacing lead poses a mechanical risk to patients of retention wire fracture and protrusion. Standard lead extraction techniques include percutaneous approaches, which are associated with significant risk of morbidity and mortality, and open procedures, which necessitate thoracotomy. In nine patients referred with Class III retention wire fractures, attempts were made to snare the protruding retention wire from a femoral approach using snare devices and hioptomes. In six cases, the retention wire was successfully removed, leaving the lead body in place. In four patients with lead function that was able to be evaluated, the atrial lead remained functional after the procedure. There were no complications. Snare removal of the protruding retention wire via a femoral approach should be considered as an option in the management of patients with Class III Accufix leads.     

Several Unsuccessful Internal and External Defibrillations During Active Can ICD Implantation in a Patient with Pneumothorax

During implantable cardioverter defibrillator (ICD) implantation of an active can ICD several defihrillations with 20 J and 34 J as well as 360 J externally were ineffective. The implant criteria were finally met with a second defibrillation lead and reversed polarity. A left-sided pneumothorax due to subclavian vein puncture was detected soon after ICD implantation. It is assumed that especially in the active can alignment the developing pneumothorax made defibrillation current flow more difficult. In case of several unsuccessful defibrillations during active can ICD implantation in which the subclavian vein was punctured, the possibility of a pneumothorax should be considered.     

Effects of Respiration Phase on Ventricular Defibrillation Threshold in a Hot Can Electrode System

The impedance of defibrillation pathways is an important determinant of ventricular defibrillation efficacy. The hypothesis in this study was that the respiration phase (end-inspiration versus end-expiration) mayalter impedance and/or defibrillation efficacy in a "hot can" electrode system. Defibrillation threshold (DFT) parameters were evaluated at end-expiration and at end-inspiration phases in random order by a biphasic waveform in ten anesthetized pigs (body weight: 19.1 ±2.4 kg; heart weight: 97 ± 10g). Pigs were intubated with a cuffed endotracheal tube and ventilated through a Drager SAVrespirator with tidal volume of 400–500 mL. A transvenous defibrillation lead (6 cm long, 6.5 Fr) was inserted into the right ventricular apex. A titanium can electrode (92-cm² surface area) was placed in the left pectoral area. The right ventricular lead was the anode for the first phase and the cathode for the second phase. The DFT was determined by a "down-up down-up" protocol. Statistical analysis was performed with a Wilcoxon matched pair test. The median impedance at DFT for expiration and inspiration phases were 37.8 ±3.1 Ω and 39.3 ± 3.6 Ω, respectively (P = 0.02). The stored energy at DFT for expiration and inspiration phases were 5.7 ± 1.9 J and 6.0 ± 1.0 J, respectively (P = 0.594). Shocks delivered at end-inspiration exhibited a statistically significant increase in electrode impedance in a "hot can" electrode system. The finding that DFT energy was not significantly different at both respiration phases indicates that respiration phase does not significantly affect defibrillation energy requirements.     

"Trading bickering for teamwork"

Bickering is an unpleasant phenomena found wherever groups of people congregate. Bickering on a health care team such as that found in the nurse department can create a negative environment and poor morale. The nurse manager should take responsibility for action which can deter this type of behavior and should visibly lead the staff to more productive interactions.     

The "baseball cap orthosis": a simple solution for dropped head syndrome

Dropped head syndrome (DHS) is a well-recognized condition characterized by gradual sagging of the head. At the extreme, the condition may lead to a "chin on chest deformity" where the chin rests on the chest wall and the patient is unable to look straight ahead. Dropped head syndrome tends to develop in patients with severe weakness of the neck extensors. Various neuromuscular disorders and surgical procedures may compromise the stability of the cervical spine and lead to this disorder. The condition may severely compromise the patient's quality of life and result in significant disability. A simple device-the "baseball cap orthosis"-was developed to help patients maintain their head in the upright position. Two patients with DHS who were provided with the baseball cap orthosis are presented.     

From "clinical proteomics" to "clinical chemistry proteomics": considerations using quantitative mass-spectrometry as a model approach

Clinical Proteomics biomarker discovery programs lead to the selection of putative new biomarkers of human pathologies. Following an initial discovery phase, validation of these candidates in larger populations is a major task that recently started relying upon the use of mass spectrometry approaches, especially in cases where classical immune-detection methods were lacking. Thanks to highly sensitive spectrometers, adapted measurement methods like selective reaction monitoring (SRM) and various pre-fractionation methods, the quantitative detection of protein/peptide biomarkers in low concentrations is now feasible from complex biological fluids. This possibility leads to the use of similar methodologies in clinical biology laboratories, within a new proteomic field that we shall name "Clinical Chemistry Proteomics" (CCP). Such evolution of Clinical Proteomics adds important constraints with regards to the in vitro diagnostic (IVD) application. As measured values of analytes will be used to diagnose, follow-up and adapt patient treatment on a routine basis; medical utility, robustness, reference materials and clinical feasibility are among the new issues of CCP to consider.     

Myopericarditis diagnosed by a 64-slice coronary CT angiography "triple rule out" protocol

We report a case of myopericarditis in a 30-year-old male complaining of shortness of breath. In an emergency department (ED) setting, the symptoms of myopericarditis may overlap with many disease entities and can be a challenging diagnosis to make. However, with the use of a 64-section coronary CT angiography in a "triple rule out" (TRO) protocol, we were able to detect a large pericardial effusion surrounding the heart and moderate global hypokinesis in the setting of normal-sized heart chambers and normal coronary arteries. We were further able to exclude pulmonary embolism and thoracic dissection. This is the first reported case of diagnosing myopericarditis using a TRO protocol. It demonstrates the usefulness of TRO in making an emergent diagnosis of myopericarditis while excluding other life-threatening diseases that can lead to earlier appropriate ED disposition and care.     

The Effects of Pneumothorax on Defibrillation Thresholds during Pectoral Implantation of an Active Can Implantable Cardioverter Defibrillator

Pneumothorax has previously been reported to increase defibriliation thresholds and lead impedance in monophasic systems. This article demonstrates a case using an active can system in which the lead impedance between the right ventricular defibriliation coil and the device improved from 70 il with pneumothorax to 48 Ω after resolution. The defibriliation threshold also improved from > 30 fto ≤ 10 J after the pneumothorax had resolved. We conclude that acute pneumothorax can increase the transthoracic lead impedance and defibriliation thresholds: however, with resolution both parameters can return to acceptable levels with an active can system.     

"The Golden Rule": Only a starting point for quality care

The Golden Rule guides people to choose for others what they would choose for themselves. The Golden Rule is often described as 'putting yourself in someone else's shoes', or 'Do unto others as you would have them do unto you'(Baumrin 2004). The viewpoint held in the Golden Rule is noted in all the major world religions and cultures, suggesting that this may be an important moral truth (Cunningham 1998). The Golden Rule underlies acts of kindness, caring, and altruism that go above and beyond "business as usual" or "usual care" (Huang, 2005). As such, this heuristic or 'rule of thumb' has universal appeal and helps guide our behaviors toward the welfare of others. So why question the Golden Rule? Unless used mindfully, any heuristic can be overly-simplistic and lead to unintended, negative consequences.A heuristic is a rule of thumb that people use to simplify potentially overwhelming or complex events. These rules of thumb are largely unconscious, and occur irrespective of training and educational level (Gilovich, Griffin & Kahneman 2002). Rules of thumb, such as the Golden Rule, allow a person to reduce a complex situation to something manageable-e.g., 'when in doubt, do what I would want done'. Because it is a simplifying tool, however, the Golden Rule may lead to inappropriate actions because important factors may be overlooked.In this article we describe "The Golden Rule" as used by administrators, supervisors, charge nurses, and CNAs in case studies of four nursing homes. By describing use of this rule-of-thumb, we aim to challenge nurses in nursing homes to: 1) be mindful of their use of "The Golden Rule" and its impact on staff and residents; and 2) help staff members think through how and why "The Golden Rule" may impact their relationships with staff and residents.     

A Multicenter, Randomized Trial Comparing an Active Can Implantable Defibrillator with a Passive Can System

Replacing one defibrillation electrode lead by the defibrillator can may simplify implantation of the ICD. In this multicenter study, 304 patients were randomized to receive either the biphasic active can (AC) (model 7219C system, Medtronic, Inc.) or the passive can (PC) (model 7219D system). The AC and PC systems were compared with respect to their ability to meet the implant defibrillation criterion and to defibrillate VF, and to DFTs, implant time, patient adverse events, and survival rates. A higher percentage fulfilled the implant defibrillation criterion on the first configuration with the AC (86.3% vs 75.9% for PC; P = 0.023), and the first shock success for terminating induced VF was 94% for AC compared to 89% for PC (P = 0.026). DFTs were significantly lower (10.9 vs 12.7 J; P = 0.031), and implant time was significantly shorter for the AC patients (99.2 vs 112.0 min; P = 0.002). The two groups showed no significant differences in 3-month adverse event rates, 3-month survival, and hospital stay.     

Can there be a good death?

While some deaths are worse than others, there is no such thing as a ‘good death’ since the plausible desiderata of a ‘good death’ form an inconsistent set. Because death is of the greatest existential consequence to us, a ‘good’ death must be a self‐aware death in which we grasp the import of what is happening to us; however, such realization is incompatible with our achieving the tranquillity of mind which is another requirement for the ‘good’ death. Nevertheless, the welcome recognition in recent years by medical personnel, palliative care workers and hospice staff that dying is an existential predicament as well as a physiological condition has enabled more people to avoid a ‘soulless death in intensive care’, even if it pays insufficient regard to the personal virtues that we need if we are to mitigate the worst evils of dying.     

A New Endocardial "Over-the-Wire" or Stylet-Driven Left Ventricular Lead:

Transvenous left ventricular (LV) leads are primarily inserted "over-the-wire" (OTW). However, a stylet-driven (SD) approach may be a helpful alternative. A new polyurethane-coated, unipolar LV lead can be placed either by a stylet or a guide wire, which can be inserted into the lead body from both ends. The multicenter OVID study evaluates the clinical performance of this new steroid- and nonsteroid eluting lead. The primary endpoint is the LV lead implant success rate after identification of the coronary sinus (CS). Secondary endpoints include complication rate, short- and long-term lead characteristics, overall procedure and LV lead placement duration, total fluoroscopy time, and lead handling characteristics ratings. To date, 96 patients with heart failure (68 ± 9 years old, 76% men) are enrolled. The CS was identified in 95 patients and, in 85 (88.5%), the LV lead was successfully implanted. The final lead positioning was lateral in 41%, posterolateral in 35%, anterolateral in 18%, and great cardiac vein in 6% of patients. In 70%, the 85 successful implantations, both stylet-driven and guide-wire techniques were used, a stylet only was used in 22%, and a guide wire only in 8%. Mean overall duration of 85 successful procedures was 112 ± 40 minutes, total fluoroscopy time 28 ± 15 minutes, and the duration of LV lead placement was 35 ± 29 minutes. During a 3-month follow-up, the loss of LV capture occurred in three and phrenic nerve stimulation in six patients. The mean long-term pacing threshold is 0.8 V/0.5 ms and pacing impedance is 550 Ω. The OVID data suggest that these new leads are safe and effective. The choice of both OTW and SD techniques during lead implantation offers greater procedural flexibility.     

Straight screw-in atrial leads "J-post shaped" in right appendage versus J-shaped systems for permanent atrial pacing: a safety comparison

Background and Objectives: The reliability of active‐fixation atrial leads has been compared with that of passive‐fixation leads; comparisons have also been made between straight and J‐shaped screw‐in lead systems. However, few data are available on procedural and short‐term safety. This retrospective study compared the procedural safety of non‐pre‐shaped screw‐in leads with that of passive‐ and active‐fixation J‐shaped leads. Patients and Methods: From January 2004 to January 2010, 1,464 patients underwent new pacemaker/implantable cardioverter‐defibrillator implantation. Of these, 915 (study population) received a passive‐ or active‐fixation pre‐J‐shaped lead, or a straight screw‐in atrial lead; the remaining 549 patients, who received only a ventricular lead, were excluded. The three study groups were: Group S‐FIX (165 patients, 18%), receiving a straight screw‐in atrial lead (postshaped in the right appendage); Group J‐PASS (690 patients, 75.4%), receiving a passive‐fixation J‐shaped atrial lead; and Group J‐FIX (60 patients, 6.6%), receiving an active‐fixation screw‐in J‐shaped atrial lead. Procedural and short‐term complication rates were analyzed up to 3 months postimplantation. Results: One complication occurred in each group (S‐FIX 0.6% vs J‐PASS 0.1% vs J‐FIX 1.6%, P = 0.3, 0.1, and 0.4, respectively, for each comparison). The rate of atrial lead dislodgement was higher in Group J‐PASS than in S‐FIX but not J‐FIX (Group S‐FIX 0 vs Group J‐PASS 16 vs Group J‐FIX 1 dislodgements; P = 0.04 and 0.7, respectively). Conclusion: Straight screw‐in atrial leads, “J‐post shaped” in the right appendage, offer better stability than passive‐fixation J‐shaped leads and display a similarly acceptable safety profile compared with both the J‐shaped systems. (PACE 2011; 34:325–330)     

The "why" and "how" of JointICA: results from a visual detection task

Since several years, neuroscience research started to focus on multimodal approaches. One such multimodal approach is the combination of electroencephalography (EEG) and functional magnetic resonance imaging (fMRI). However, no standard integration procedure has been established so far. One promising data-driven approach consists of a joint decomposition of event-related potentials (ERPs) and fMRI maps derived from the response to a particular stimulus. Such an algorithm (joint independent component analysis or JointICA) has recently been proposed by Calhoun et al. (2006). This method provides sources with both a fine spatial and temporal resolution, and has shown to provide meaningful results. However, the algorithm's performance has not been fully characterized yet, and no procedure has been proposed to assess the quality of the decomposition. In this paper, we therefore try to answer why and how JointICA works. We show the performance of the algorithm on data obtained in a visual detection task, and compare the performance for EEG recorded simultaneously with fMRI data and for EEG recorded in a separate session (outside the scanner room). We perform several analyses in order to set the necessary conditions that lead to a sound decomposition, and to give additional insights for exploration in future studies. In that respect, we show how the algorithm behaves when different EEG electrodes are used and we test the robustness with respect to the number of subjects in the study. The performance of the algorithm in all the experiments is validated based on results from previous studies.