Pacing to restore right ventricular contraction after surgical disconnection for arrhythmia control in right ventricular cardiomyopathy

Ventricular tachycardia in ARVC (arrhythmogenic right ventricular cardiomyopathy) is typically managed by ICD implantation, with a limited role of catheter ablation. Surgical disconnection of the right ventricular (RV) has been used to control ventricular tachycardia (VT) in ARVC, but it often led to refractory RV failure due to loss of RV contraction after surgery. We report multisite pacing to recruit the disconnected RV to prevent ventricular failure.     

Pharmacology of Intraperitoneal Cefazolin in Patients Undergoing Peritoneal Dialysis

Cefazolin was added to dialysis fluid in nine patients with renal failure undergoing peritoneal dialysis with 2 liters/h per exchange. With 50 mg/liter (three patients), the first measurable mean serum concentration was 3.7 μg/ml (range, 2.4 to 4.9 μg/ml) after three exchanges and was 30.3 μg/ml (range, 13.3 to 44.3 μg/ml) after 24 exchanges. After 18 to 24 more exchanges without cefazolin, the mean serum concentration was 12.3 μg/ml (range, 3.8 to 24.6 μg/ml). The mean concentration in the dialysis outflow was 26.9 μg/ml (range, 2.5 to 58.5 μg/ml). With 150 mg/liter (six patients), the mean serum concentration was 5.2 μg/ml (range, 3.6 to 7.8 μg/ml) after the first exchange and 8.4 (range, 6.1 to 14.0 μg/ml), 15.0 (range, 8.2 to 23.5 μg/ml), and 71.9 (range, 26.2 to 142.1 μg/ml) μg/ml after the second, third, and twenty-fourth exchanges, respectively. After 17 to 24 more exchanges without cefazolin, the mean serum concentration was 38.2 μg/ml (range, 15.4 to 65.7 μg/ml). The mean concentration in the dialysis outflow was 71.4 μg/ml (range, 21.9 to 150.8 μg/ml). After 1 g of cefazolin was given intraperitoneally with no more dialysis, serum concentrations rose by a mean of 62.5 μg/ml (range, 18.9 to 107.8 μg/ml). The maximum rise occurred within 2 h with two-thirds of the rise occurring within 30 min. During the subsequent 22 h levels dropped to 65.4% of the peak.     

Achalasia cardia: A study of 113 patients managed with indigenous dilator.

BACKGROUND: Endoscopic dilatation of achalasia cardia is an effective nonsurgical management option. It requires costly pneumatic dilators which are used under fluoroscopic guidance. This study assesses the efficacy and safety of an indigenous pneumatic dilator used without fluoroscopic guidance. METHODS: Over a period of eleven years, 113 patients (69M, 44F) ofachalasia cardia underwent dilatation with indigenous pneumatic dilators without fluoroscopic guidance. The dilatation was performed under endoscopic vision. RESULTS: The procedure was successful in all patients. After six weeks following dilatation, there was significant improvement in the mean dysphagia score 3.63 + 0.61 to 0.53 + 0.93 (P<0.01). The response was still significant (0.78 + 1.03, P <0.05) at the end of one year. Excellent response with single dilatation was seen in 70.7% patients. After two dilatation sessions 92% of patients showed an excellent response. One patient had perforation. There was no mortality. CONCLUSION: Pneumatic dilatation under endoscopic vision without fluoroscopic assistance with the indigenous dilator is very effective and safe for short term treatment of achalasia carida.     

A dietary intervention for chronic diabetic neuropathy pain: a randomized controlled pilot study

Background:

Diabetic neuropathy is a common and often debilitating condition for which available treatments are limited. Because a low-fat plant-based diet has been shown to improve glycemic control in individuals with type 2 diabetes, we hypothesized that such a diet would reduce painful symptoms of diabetic neuropathy.

Methods:

In this 20-week pilot study, individuals with type 2 diabetes and painful diabetic neuropathy were randomly assigned to two groups. The intervention group was asked to follow a low-fat, plant-based diet, with weekly classes for support in following the prescribed diet, and to take a vitamin B12 supplement. The control group was asked to take the same vitamin B12 supplement, but received no other intervention. At baseline, midpoint and 20 weeks, clinical, laboratory and questionnaire data were collected. Questionnaires included an analog ‘worst pain'' scale, Michigan Neuropathy Screening Instrument, global impression scale, Short Form McGill Pain Questionnaire, Neuropathy Total Symptom Score, a weekly pain diary and Norfolk Quality of Life Questionnaire.

Results:

After 20 weeks, body weight change with the intervention was −6.4 kg (95% confidence interval (CI) −9.4 to −3.4, P<0.001) in an effect size analysis. Electrochemical skin conductance in the foot improved by an average of 12.4 microseimens (95% CI 1.2–23.6, P=0.03) with the intervention in an effect size analysis. The between-group difference in change in pain, as measured by the McGill pain questionnaire, was −8.2 points (95% CI −16.1 to −0.3, P=0.04). Michigan Neuropathy Screening Instrument questionnaire score change was −1.6 points (95% CI −3.0 to −0.2, P=0.03).

Conclusions:

Improvements were seen in some clinical and pain measures. This pilot study suggests the potential value of a plant-based diet intervention, including weekly support classes, for treating painful diabetic neuropathy.     

Subarachnoid hemorrhage: who dies,and why?

IntroductionSubarachnoid hemorrhage (SAH) is a devastating form of stroke. Causes and mechanisms of in-hospital death after SAH in the modern era of neurocritical care remain incompletely understood.MethodsWe studied 1200 consecutive SAH patients prospectively enrolled in the Columbia University SAH Outcomes Project between July 1996 and January 2009. Analysis was performed to identify predictors of in-hospital mortality.ResultsIn-hospital mortality was 18 % (216/1200): 3 % for Hunt-Hess grade 1 or 2, 9 % for grade 3, 24 % for grade 4, and 71 % for grade 5. The most common adjudicated primary causes of death or neurological devastation leading to withdrawal of support were direct effects of the primary hemorrhage (55 %), aneurysm rebleeding (17 %), and medical complications (15 %). Among those who died, brain death was declared in 42 %, 50 % were do-not-resuscitate at the time of cardiac death (86 % of whom had life support actively withdrawn), and 8 % died despite full support. Admission predictors of mortality were age, loss of consciousness at ictus, admission Glasgow Coma Scale score, large aneurysm size, Acute Physiology and Chronic Health Evaluation II (APACHE II) physiologic subscore, and Modified Fisher Scale score. Hospital complications that further increased the risk of dying in multivariable analysis included rebleeding, global cerebral edema, hypernatremia, clinical signs of brain stem herniation, hypotension of less than 90 mm Hg treated with pressors, pulmonary edema, myocardial ischemia, and hepatic failure. Delayed cerebral ischemia, defined as deterioration or infarction from vasospasm, did not predict mortality.ConclusionStrategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-1036-0) contains supplementary material, which is available to authorized users.     

A 24-year old man with persistent progressive breathlessness: early onset COPD.

We describe the case of a 24-year old male who had been a heavy smoker since the age of 9 and who presented with an 8-year history of respiratory symptoms. He was having treatment for asthma. Spirometric studies and high-resolution computed tomography (HRCT) scans confirmed COPD with centrilobular emphysema. His blood level of alpha-1-antitrypsin was within the normal range. Early onset emphysema in smokers with a normal alpha-1-antitrypsin has been previously described. However, this case is, as far as we know, one of the youngest cases ever reported.     

Antibiotic Use in Sore Throat: Are We Judicious?

Introduction Sore throat (acute tonsillitis/pharyngitis) is one of the most common clinical diagnosis encountered in ENT practice. It is a common practice to advice antibiotics in patients of sore throat not only in otolaryngology practice but also in pediatricians, GP’s and internists. This is now becoming a matter of concern for two reasons, for the side effects of antibiotics and bacterial drug resistance. Methods To analyse patients on their symptoms and rapid streptococcal test for group A Stretococcus and determine antibiotic use. A prospective study was done in 600 patients who were clinically diagnosed as acute tonsillitis or acute pharyngitis and results analysed. Discussion Results showed that 24 % patients needed antibiotics while the rest did well without antibiotics. Results Rapid streptococcal test is a useful test in determining whether the patient needs antibiotic and help is reducing irrational use of antibiotics.