Management of recurrent ventricular tachyarrhythmias associated with Q-T prolongation

Eleven patients with acquired prolongation of the Q-Tc interval and recurrent ventricular tachyarrhythmias were studied. Five patients required 5 to 44 direct current shocks to correct prolonged ventricular tachyarrhythmias, and five were given at least two antiarrhythmic agents in an attempt to control the arrhythmias. In 4 of the 11 patients, when thioridazine, diuretic drugs and antiarrhythmic agents were withdrawn and hypokalemia or hypocalcemia corrected, ventricular tachyarrhythmias did not recur. The Q-Tc interval normalized in 2 to 3 days. Ventricular tachyarrhythmias were recurrent in the remaining seven patients, despite withdrawal of the drugs that caused the Q-Tc prolongation, attempted correction of hypokalemia when present and the administration of antiarrhythmic agents to four of the seven. All antiarrhythmic agents were then withdrawn in this group.

Immediately on the establishment of overdrive ventricular or atrioventricular sequential pacing in these patients, ventricular tachyarrhythmias were abolished. No breakthrough ventricular tachyarrhythmias occurred during temporary pacing. Temporary pacing was required for an average of 10 days and the Q-Tc interval normalized an average of 5 days from the onset of pacing. Three patients required a permanent pacemaker, one because of chronic complete heart block, one because of the sick sinus syndrome, and one because of frequent ventricular ectopic complexes complicating ischemic heart disease. All 11 patients survived their period of hospitalization.     

Effect of histamine H1-and H2-receptor blockade on canine gastric acid secretion

In dogs with gastric fistulae and Heidenhain pouches, inhibition of histamine-stimulated gastric acid secretion by the histamine H₂-receptor antagonist metiamide is not increased by the addition of a histamine H₁-receptor antagonist (mepyramine maleate). Under the conditions of this study there is no evidence for the presence of histamine H₁-receptor sites on the gastric parietal cell.Financial assistance was provided by the South African Medical Research Council.     

Multidisciplinary diabetes team care: the experiences of young adults with Type 1 diabetes

Background

This research examined whether young adults with Type 1 diabetes engage with the multidisciplinary consultation process and if not, then why.

Methods

We designed a web‐based self‐reported survey, available online from February to May 2011, for Australian adults 18–35 years with Type 1 diabetes. Respondents were asked about which clinicians they consulted to assist with self‐management. To expand on the results of the survey, we interviewed 33 respondents.

Results

Survey: Respondents (n = 150) consulted with the following clinicians: endocrinologist and diabetes educators: 23.3%; endocrinologist only: 18.0%; endocrinologist, diabetes educators and dieticians: 14.6%; endocrinologist, diabetes educators, dietician and general practitioners (GP): 11.3%; endocrinologist and GP: 10.6%; GP only: 4.6%; all clinicians recommended to assist with self‐management: 1.3%; 2.7% did not consult any clinician. Interview: Participants (n = 33) reported eight key disincentives to consultation with multidisciplinary clinicians. These were time constraints; provision of conflicting advice; inaccessibility of health services; variation in service standards; cost constraints; failure of clinicians to refer to other clinicians; lack of opportunity to build a therapeutic relationship; and failure of clinicians to engage in shared decision making.

Conclusion

Our results indicate that high attrition rates of young adults with Type 1 diabetes from recommended diabetes health services is linked to the failure of those services to meet the needs and preferences of their patients. The identified needs and preferences included joint consultation with multi‐disciplinary team clinicians; flexible access to advice by email or telephone consultation; and shared decision making. Patient engagement in health‐service re‐design has implications for improved health‐service delivery and enhanced treatment outcomes.     

Esophageal tamponade in the management of acute variceal hemorrhage

Over a seven-year period, 138 patients with portal hypertension presented on 223 occasions with endoscopically proven acute variceal hemorrhage. Hemorrhage ceased spontaneously on 92 occasions (41%). On 126 occasions (57%) passage of the four-lumen modification of the Sengstaken-Blakemore tube was required, and hemorrhage was successfully controlled in 98%. Intubation was refused on five occasions (2%). Hemorrhage recurred during these 223 admissions on 47 occasions (21%); on 11 occasions a second rebleed occurred and on two occasions, a third. Tamponade was required during all of these rebleeds and arrest of hemorrhage was achieved in 87%. Hemorrhage in patients with poorer modified Child's grade was less likely to cease with intubation. The overall rate of control in the 186 episodes of hemorrhage requiring tamponade was 94%. There were 28 complications attributed to the use of tamponade in 186 episodes of hemorrhage (15%). On 12 occasions these complications proved fatal (6.4%). In four further patients failure of tamponade to control hemorrhage was fatal.     

Discriminant analysis of data in ulcer and nonulcer populations

The purpose of this study was to assess whether consideration of age and body weight measurements improved discrimination between normal subjects and duodenal ulcer subjects using the maximal acid output test. Seventy-seven male volunteers were the normal group, and 155 patients with surgically proven duodenal ulcers were the ulcer group. We found that the ratio of maximal acid output to actual weight gave the best discrimination between the two groups. Using this ratio, there were 45 hypersecretors in the ulcer group, and only 1 false-positive among the normal subjects. A graphic method is described which employs the ratio of acid to weight and can correctly classify two-thirds of the ulcer group. The disadvantage of this method, however, is that one-third of the control group in our series were misclassified as hypersecretors; therefore, the clinician must consider history and barium meal findings as well as this evaluation of the subject.Deceased.     

Methotrexate: bioavailability and pharmacokinetics

Six adult patients with squamous cell carcinoma of the head and neck were treated with single low doses of methotrexate (MTX) (30 mg/m2) iv, im, and orally in the form of commercial tablets. A randomized crossover design was employed. Plasma concentrations were measured by a modified EMIT assay over a period of 24 hours following each dose. The mean (+/- SD) parameters following iv MTX were as follows: total-body clearance, 124 (36) ml/minute; Vss, 0.56 (0.18) L/kg; V lambda, 0.69 (0.24) L/kg; and beta-half-life, 3.20 hours. The absolute systemic bioavailability of the oral tablets was 36% (+/- 10%). After im administration, the systemic bioavailability was 93% (+/- 14%). Dose-dependent gastrointestinal absorption is suggested as the mechanism for the low availability of the oral tablets. Administration of MTX by the oral route will require further study to determine the optimal method of dosing.     

Percutaneous treatment of a popliteal bifurcation—The value of coronary devices and strategies

In this case report, we describe the use of coronary techniques and devices in the treatment of a complex popliteal artery bifurcation. In particular, we demonstrate that the Venture? wire control catheter is a useful tool not only in coronary lesions but also in wiring angulated peripheral lesions. © 2008 Wiley‐Liss, Inc.