Long-Term Results of Cryoablation with a New Cryoprobe to Eliminate Chronic Atrial Fibrillation Associated with Mitral Valve Disease

The purpose of this study was to examine the performance of a new cryoprobe in the treatment of chronic atrial fibrillation (AF) associated with mitral valve disease. The study included 66 patients undergoing mitral valve replacement. The mean AF duration was 9.0 ± 9.0 years and mean left atrial (LA) was diameter 57 ± 10 mm. Cryoablation (−60°C) was applied to four pulmonary vein (PV) orifices over 2–3 minute. The spherical tip (2-cm in diameter) of the cryoprobe is capable of ablating the left atrium near the PV, as well as the PV ostium with a single cryoablation. After cryoablation, mitral valve surgery or a combined surgical procedure were performed in 66 patients. There were no intraoperative complications. Sinus rhythm was restored in 60 patients (91%) immediately after the operation. Recurrent AF was treated with antiarrhythmic drugs and/or direct current cardioversion in 43 patients (72%). At discharge, 48 patients (72%) were in sinus rhythm. During a mean follow-up period of 31 ± 16 months, 40 patients (61%) were in sinus rhythm with (29) or without antiarrhythmic drugs (11). In patients in sinus rhythm at the end of the follow-up period, the duration of preoperative AF duration was significantly shorter (P < 0.05) and the preoperative LA diameter and cardiothoracic ratio were significantly smaller than in patients who were in AF (both for P < 0.005). Using this new cryoprobe, sinus rhythm was restored and maintained in 61% of patients with chronic AF and mitral valve disease with a 12–15 minute cryoablation procedure.     

Steroid Therapy in IgA Nephropathy: A Prospective Pilot Study in Moderate Proteinuric Cases

Forty-three patients with IgA nephropathy whose proteinuriapersisted between 1.0 and 2.0 g/day were assessed in an uncontrolledpilot study of steroid treatment. Fourteen patients receivean initial dose of 40 mg/day of prednisolone, followed by gradualreduction of the dose over an average period of about 19 months.After discontinuation of corticosteroids, they were treatedwith non-steroid anti-inflammatory drugs and/or anti-thrombocytedrugs to the end of the study. Another 29 patients receivednon-steroid anti-inflammatory drugs and/or anti-thrombocytedrugs throughout the study. Fourteen patients treated with steroidsexperienced considerable reduction in proteinuria and maintainedrenal function over 81 months. In 29 patients treated with non-steroidanti-inflammatory drugs and/or anti-thrombocyte drugs alone,proteinuria did not decrease and renal function deterioratedsignificantly during 60 months. At the end of the study, differencesin degree of proteinuria and in levels of renal function betweenthe steroid and non-steroid groups were statistically significant.In addition, these differences became more distinct in patientswith initial creatinine clearance values 70 ml/min or more inboth groups. These results suggest that treatment with steroidsin IgA nephropathy may be beneficial, especially in the earlystage of the disease.     

Barriers to,and facilitators of post‐operative pain management in Iranian nursing: a qualitative research study

Background: Unrelieved post‐operative pain continues to be a major clinical challenge, despite advances in management. Although nurses have embraced a crucial role in pain management, its extent is often limited in Iranian nursing practice. Aim: To determine Iranian nurses' perceptions of the barriers and facilitators influencing their management of post‐operative pain. Methods: This study was qualitative with 26 participant nurses. Data were obtained through semi‐structured serial interviews and analysed using the content analysis method. Findings: Several themes emerged to describe the factors that hindered or facilitated post‐operative pain management. These were grouped into two main themes: (1) barriers to pain management after surgery with subgroups such as powerlessness, policies and rules of organization, physicians leading practice, time constraints, limited communication, interruption of activities relating to pain, and (2) factors that facilitated post‐operative pain management that included the nurse–patient relationship, nurses' responsibility, the physician as a colleague, and nurses' knowledge and skills. Conclusion: Postoperative pain management in Iran is contextually complex, and may be controversial. Participants believed that in this context accurate pain management is difficult for nurses due to the barriers mentioned. Therefore, nurses make decisions and act as a patient comforter for pain after surgery because of the barriers to effective pain management.     

Drug abuse, AIDS, and the coming crisis in long-term care

As the 21st century approaches and the proportion of the US population over 65 years of age increases, it is expected that the demand for long-term care will expand dramatically. This expectation has been widely discussed. Less widely discussed is a potential for increase in the demand for long-term care resulting, not from the geriatric conditions with which the industry is already familiar, but from chronic and debilitating substance abuse-related diseases. In the United States, the incidence of severe cardiovascular and hepatological deterioration in younger patients has begun to increase, partly due to the increased scope of drug use and the increased variety of drugs used by individuals under the age of 35. HIV disease progression resembles these degenerative conditions in some important ways, and HIV infection is now often accompanied by substance abuse disorders. Thus, the care of HIV-infected patients can serve as a model for the impact on the long-term care industry that this new type of patient is likely to make. Using HIV as a particularly dramatic example, this paper discusses those changes in detail, and concludes with recommendations for successfully adapting to them.     

Mental disorders and suicide prevention

Abstract In the research phase of the National Suicide Prevention Project, all suicides ( n = 1397) in Finland between March 1987 and April 1988 were examined retrospectively using the psychological autopsy method. Careful retrospective diagnostic evaluation of the victims according to DSM-III-R criteria was done by weighing and integrating all available information. A series of studies addressing the mental disorders among suicide victims, the treatment received before death and the life events is now reviewed.
Among a random sample of suicide victims from the nationwide suicide population, at least one psychiatric diagnosis was made for 93% of the victims. The most prevalent disorders were depressive syndromes (66%) and alcohol dependence/abuse (43%). The prevalence of major depression was higher among women than among men. Major depression as the principal diagnosis was more common among the elderly suicides. Among adolescent victims, depressive syndromes were also the most prevalent disorders. Adjustment disorders were common (25%) among male adolescent suicides. The majority of suicide victims of all ages suffered from comorbid mental disorders.
Among suicide victims who had had contact with a health carer before death, inadequacy of treatment for mental disorders seems to have been common. Of the major depressive victims only 3% were found to have received adequate psychopharmacological treatment, and only 7% received weekly psychotherapy by a trained therapist.
The analysis of the massive database collected in the research phase of the National Suicide Prevention Project in Finland is still ongoing, and the implications of the findings for suicide prevention will be refined during the research process. The necessity to improve recognition and treatment for comorbid depressive disorders in all age groups seems evident already.     

Managing MICA Clients in a Modified Therapeutic Community with Enhanced Staffing

To determine how effective a modified therapeutic community (TC) with enhanced mental health staffing would be in treating mentally ill chemical abusing (MICA) clients in a “mainstream” program, Project Return Foundation, Inc. (PRF) conducted a treatment outcome evaluation study involving 438 residents. Client admissions were screened by mental health specialists for Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) diagnoses and then placed into one of three diagnostic groups: non-MICA; general MICA (not requiring psychotropic medication); and, severe MICA (requiring psychotropic medication). Clients were administered the Tennessee Self-Concept Scale (TSCS; Roid & Fitts, 1991) after admission and at 6-month intervals thereafter. Results indicated that: (a) the three diagnostic groups were significantly different at initial TSCS testing, with the non-MICA group evidencing the least lowest measures of self-esteem and lesser degrees of psychopathology; the severe MICA group had the lowest psychological scores; (b) all three diagnostic groups showed significant improvement in their TSCS scores after 6 to 7 months of treatment; (c) covariance analyses observed that the three diagnostic groups did not significantly differ at 6 month testing when the initial TSCS testing was taken into account; and, (d) significant gender differences on several TSCS scales were noted, in that women scored lower than men in self-esteem and higher than men in psychopathology. Research limitations and clinical observations are considered.