Clinical Use of Permanent Pacemaker for Conversion of Intraatrial Reentry Tachycardia in Children

The use of the implanted atrial-based pacemaker to overdrive postsurgical intraatrial reentry tachycardia (IART) was evaluated in a large group of pediatric patients over a 14-year study period. The authors sought to determine the feasibility of this noninvasive technique in the management of this specialized population and to determine factors associated with successful conversion. They examined 128 manual overdrive attempts performed on 22 consecutive patients. There were 10 patients with post-Fontan repair, 7 with post-Mustard/Senning procedure, and 5 with miscellaneous lesion types. The number of IART episodes for overdrive pacing per patient ranged from 1 to 15. The first overdrive pacing attempt was successful in 63% (14/22) of the patients. The mean IART cycle length was 278 +/- 59 ms. The mean pacing rate for effective conversion of IART was 66 +/- 10% faster than the IART rate. By controlling for repeated measures for individual patients, three factors were found to be independently associated with a successful outcome: (1) lesion type other than Fontan surgery (P = 0.007), (2) lack of acceleration of IART with the overdrive attempt (P < 0.001), and (3) patient use of amiodarone with attempt (P = 0.005). There were three procedural complications: two inadvertent overdrive pacing episodes, and one episode of acceleration of IART cycle length and conduction resulting in need for cardioversion. Manual pacemaker overdrive conversion of IART is a useful adjunct in the management of postsurgical IART in the pediatric population and should be considered as an initial treatment option.     

COLON CANCER AND POLYPS IN ACROMEGALY: INCREASED RISK ASSOCIATED WITH FAMILY HISTORY OF COLON CANCER

A cohort of 52 subjects diagnosed with acromegaly in southeastern Michigan and northern Ohio between 1935 and 1985 were followed to determine the incidence of colon cancer and polyps. Medical records were reviewed, subjects or their next-of-kin were interviewed, and screening examinations of the colon were offered to the living patients who were located. Data on demographics, personal histories of cancer and colon polyps, family history of colon cancer, and cure from acromegaly were obtained for both living and deceased subjects. The risk for colon cancer compared to the general population was estimated using standardized incidence ratios (SIRs). The expected number of cases was determined utilizing age, sex and race-specific rates provided by the cancer registry in southeastern Michigan. Among the 52 subjects, one could not be located and nine were deceased, none from colon cancer, with one known to have a history of colon polyps. Of 13 (31%) who declined the screening physical, one had a history of polyps and none reported a history of colon cancer. Two of 29 screened patients were found to have right-sided adenocarcinoma of the colon. Of the entire cohort, eight people (including one deceased) had a current or previous diagnosis of polyps, with five known to be histologically adenomatous. The SIR for colon cancer was 4.7 (95% confidence interval 0.6-17.1). Seven subjects, including the two with detected adenocarcinoma and four of the six living subjects with polyps only, reported a family history of colon cancer. The SIR for the subset of subjects with a family history of colon cancer was 29.1 (95% confidence interval of 3.5-104.6).(ABSTRACT TRUNCATED AT 250 WORDS)     

Impact of Programmed Sensitivity Safety Factor on Atrial Sensing in Children

The relationship between the pacemaker sensitivity safety factor (PSSF) and atrial under- or oversensing as documented by 24-hour Holter monitoring was examined. Our study comprised 78 transvenous fixed atrial leads implanted between 1983–1995 in 71 children. Overall, 210 Holter reports identified 143 (68%) Holters with normal atrial sensing function, 31 (15%) with undersensing, 32 (15%) with oversensing, and 4 (2%) with both problems. From 161 Holter reports in which the PSSF was available, the incidence of undersensing at a PSSF of 2.0 (range 1.5–2.4) was 25% (14/57). There was a dramatic decline in undersensing when the PSSF was 3 (3%) compared to a FSSF < 3 (21 %) (P < 0.001). A PSSF cut-off point of 2.0 best predicted occurrence of undersensing with a sensitivity of 79% and a specificity of 67%. Other variable were also examined by multiple logistic regression analysis, but only PSSF remained highly associated with undersensing (odds ratio [OR] = 0.6, P = 0.03). In contrast, PSSF did not have a significant role in predicting oversensing, but presence of sick sinus syndrome (OR = 10.5) or unipolar lead (OR = 5.6) were significantly associated with oversensing (P = 0.0001). The majority of undersensing problems can be avoided by routinely allowing for at least a threefold or more programmed sensitivity margin. Other factors may increase the risk of oversensing, regardless of the PSSF.     

What kind of nurses do patients want?

• ? This article discusses whether certain aspects of ‘New Nursing’ which involve changes in nurse-patient relationships and the emphasis of the nurse's role fit with patients' preferences for their care.
• ? It reports on a study investigating these issues, and concludes that patients in general want a warm and friendly style of nursing, but a substantial minority do not agree with the use of patients' first names.
• ? Patients' evaluations of the most important nursing activities focus on listening to patients' worries, teaching them about their conditions, and relieving pain.

     

The quality and management of written information presented to women undergoing hysterectomy

• ? A study of a random sample of hospitals in England that provide information leaflets for women undergoing hysterectomy indicates a large variation in quality.
• ? In general, the findings reveal that written information for patients is given a relatively low priority.
• ? Production and dissemination of information for hysterectomy patients is somewhat ad hoc.
• ? It is not clear that any evaluation of the leaflets has been conducted to prove the efficacy of the available literature.
• ? While the majority of leaflets include information deemed essential by past hysterectomy patients, the presentation of the recovery process often implies no control for the patient, and conceives normality with a narrow perspective about what healthy behaviour means for women. The provision of a specific timetable for resumption of housework duties in 65% of the leaflets is a case in point.
• ? On the basis of the results of the survey, recommendations are made concerning the improvement of the standard of patient information leaflets.

     

Anesthesia for videoscopic left cardiac sympathetic denervation in children with congenital long QT syndrome and catecholaminergic polymorphic ventricular tachycardia – a case series

Objective: To describe our experience in the anesthetic management of pediatric patients who have undergone left cardiac sympathetic denervation (LCSD) for congenital long QT syndrome (LQTS) and catecholaminergic polymorphic ventricular tachycardia (CPVT). Background: Long QT syndrome and CPVT predispose patients to ventricular arrhythmias and sudden death. One treatment option for these patients is LCSD. When these patients present for LCSD or other surgical procedures, anesthetic management is challenging, as many medications may exacerbate QT prolongation. Methods: Retrospective review of the electronic medical records of 22 pediatric patients who underwent LCSD between November 2005 and December 2008. Results: Six patients (27%) received midazolam as a premedication. Eleven patients (50%) underwent inhalation induction with sevoflurane. Eighty‐six percentage received either sevoflurane or isoflurane for maintenance of anesthesia, while the remaining 14% received a propofol infusion. Nine patients (41%) received esmolol infusions intraoperatively, while one patient (4.5%) received a labetalol infusion. Three patients (14%) received lidocaine infusions. No significant cardiac or other events occurred in any of these patients in the perioperative period. Conclusions: Important anesthetic considerations in this population include avoidance of sympathetic stimulation, correction of any abnormal electrolytes, and the immediate availability of a defibrillator and magnesium sulfate to treat arrhythmias. Anxious patients may benefit from premedication to reduce sympathetic tone. We have safely used both volatile agents and propofol for induction and maintenance of anesthesia. In our experience, intraoperative infusions of β‐blockers and lidocaine seem to be helpful in reducing arrhythmogenic potential, especially in patients with profound QT prolongation.     

Drug and Alcohol Education from a Distance: a good reason for collaboration

Education by distance learning is a rapidly growing industry. The main attraction for learners is the flexibility to study when and where they like. There are other significant advantages too; by taking the course to the student, equity of access to education is improved and educational choices are widened. Yet education at a distance does have important limitations; it can impose considerable demands and constraints on the educational process that are all too rarely addressed in the literature. This paper examines the challenges faced by institutions offering distance-based courses. Specifically, the authors share their separate experiences of producing distance learning programmesfor drug and alcohol workers. There are special complexities inherent in the design, delivery and operation of drugs courses by distance learning and these are examined. Parochial perspectives on drugs issues assume less relevance as the target group for distance learning courses widens notably to include learners in other geographical areas and in other countries. The authors begin to explore the case for seeking national, and even international, consensus on what drug and alcohol education programmes should comprise. Collaboration between the educational institutions could be an effective way of identifying quality standards in drugs education in general and could assist course organizers in avoiding unnecessary replication of effort. Further flexibility for students could also be introduced in the form of a national credit accumulation and transfer scheme. Faced with an even greater choice of educational products, learners should benefit too from collaboration and the assurance that the courses they purchase have been designed and tested to meet their educational needs.     

The ion exchange properties of human post-mortem caecal and colonic mucus: The effect of sodium butyrate

This study examined Na+/H+ ion exchange of caecal and colonic mucus. Two distinct Na+/H+ ion exchange populations of caecal mucus were identified, one group being a cation exchanger and the other an anion exchanger, suggesting that caecal mucus has ampholyte properties responsive to changing physical and chemical properties of luminal contents. Mucus from the colon was consistently an anionic exchanger--this may aid water and electrolyte absorption in the colon. When mucus was incubated with sodium butyrate, the Na+/H+ ion exchange properties of the mucus were decreased.     

Technique and Results of Percutaneous Mitral Valvuloplasty with the Multi-Track System

The Multi-Track System is a simplified double-balloon technique for percutaneous mitral valvuloplasty. Here we describe the technique and report the results obtained using it. The Multi-Track catheter has a short distal tip for connection to the guidewire. This leaves the rest of guidewire free to receive other catheters. Various catheters can be introduced over the same guidewire. The balloons are introduced one after the other allowing a smaller size of vascular access and transseptal passage. Furthermore, simultaneous pressure measurements in the left atrium and left ventricle are possible through a simple venous access, allowing avoidance of arterial puncture. We used this technique worldwide between June 1994 and February 2000 for the treatment of 153 patients with mitral stenosis worldwide. In 12 cases, the procedure was done using the exclusive venous approach. The mean mitral valve area increased from 0.75 ± 0.22 to 2 ± 0.33 cm²and the mean left atrial pressure dropped from 27 ± 8 to 11 ± 4 mmHg. Four patients had a significant increase in mitral regurgitation, requiring surgical treatment in two patients. There was no mortality. The Multi-Track system is a valid user-friendly and cost-effective alternative for the treatment of mitral stenosis. It is a rapid and effective procedure associated with low risks.