Cardiac tamponade early after thrombolysis for acute myocardial infarction: a rare but not reported hemorrhagic complication

Among 392 consecutive patients admitted for acute myocardial infarction and treated with thrombolytic drugs, 4 patients (1%) developed an early hemorrhagic pericardial effusion (without ventricular wall rupture) evolving within 24 h to cardiogenic shock consequent to cardiac tamponade. They all suffered from a large anterior myocardial infarction treated within 4 h after onset of symptoms with intravenous anisoylated plasminogen streptokinase activator complex (one case), recombinant tissue-type plasminogen activator (rt-PA) (two cases) or streptokinase (one case), anticoagulation with heparin (all cases) and aspirin (three cases). As soon as pericardial effusion was established by echocardiography, emergency percutaneous pericardiocentesis was performed at the bedside 20 +/- 6 h after thrombolytic therapy was started. This corrected immediately the clinical and hemodynamic status of each patient and a catheter was left in the pericardial space for 34 +/- 18 h. Thus, in the presence of unexplained clinical and hemodynamic deterioration occurring during the first 24 h after thrombolytic treatment of a large myocardial infarction, cardiac tamponade should be suspected. Immediate percutaneous pericardiocentesis followed by continuous drainage is a simple and definitive treatment for this complication.     

Juvenile polyps at the site of a ureterosigmoidostomy

Five cases of juvenile polyps at the level of a ureterosigmoidostomy are described. One of the juvenile polyps contained an area of adenomatous tissue. The mechanisms that might cause these polyps are discussed. The presence of adenomatous tissue in one of the patients may be a step of the polyp cancer sequence at the level of ureteral implantation in the colon. The authors make a plea for a call-up and close follow-up of all patients who have a ureterosigmoidostomy.     

Towards quantitative diagnosis of ossicular fixation: Measurement of stapes fixations using magnetically driven ossicles in human temporal bones

Conclusion: Information on the degree of stapes fixation can be found by measuring the ratio of stapes to umbo and stapes to incus velocity. Objectives: To evaluate a method of quantifying ossicular fixation in an ear with elevated tympanic membrane. Method: Measurements were made on four fresh-frozen human temporal bones. After elevating the tympanic membrane, a small magnet was attached to the manubrium and an electromagnetic excitation coil was used to vibrate the ossicles. The vibration response of the umbo, the tip of the incus long process, and the posterior crus of the stapes were measured before and after partially fixing the footplate with luting cement. Results: The velocities at the different measurement points were unequally affected by the fixation. The difference in the velocity ratio between different points provides an indication of the degree of footplate fixation.     

Potential role of remote monitoring for scheduled and unscheduled evaluations of patients with an implantable defibrillator

Aims: Follow-up of implantable cardioverter defibrillator (ICD) patients,with regular in-office visits every 3–6 months, puts asignificant burden on specialized electrophysiology clinics.New technology allows for remote monitoring of device function.We wanted to investigate its potential reliability and to whichextent its use can reduce in-office visits. Methods and results: We retrospectively analysed data from 1739 prospectively codedICD visits in a random set of 169 patients (followed between2 month and 10.4 year in an academic centre). We defined (i)whether the visit was planned or not, (ii) what were the reasonsfor unplanned visits, (iii) whether any relevant finding wasmade, (iv) whether a remote monitoring system with the abilityor not to detect pacing threshold would have been able to capturethe problem, and (v) what actions were taken. The standard follow-upscheme consisted of in-office visits 1 month after implantationand then every 6 months, unless approaching battery depletion.From the 1739 visits, 1530 were performed according to clinicalschedule (88%) and in 1197 of those (78.2%), no relevant findingwas made. In 0.52% (n = 8) early post-implant pacing thresholdincreases would not have been detected by remote monitoringwithout the ability to determine thresholds (although two patientsshowed a high impedance). Moreover, in 6% of the planned visits,reprogramming would require a consecutive in-office visit (4%)or hospitalization (2%). Only 175 visits (9.6% of all) wereconducted prior to the planned follow-up date due to patientsymptoms [another 42 (2.4%) were due to planned surgery or safetywarnings]. The proportion of relevant findings during unscheduledvisits was significantly higher than during scheduled visits(80.6 vs. 21.8%; P < 0.0001) and a higher proportion of thosewas arrhythmia- and/or device-related (85.1 vs. 55.3%, P <0.0001). Reprogramming was required more often (33.1 vs. 4%;P < 0.0001) and hospitalization rate was higher (18.3 vs.2%; P < 0.0001), so that 51.4% of unscheduled visits wouldrequire in-office evaluation. Overall, remote follow-up wouldcorrectly exclude device function abnormalities or arrhythmicproblems in 1402 (82.2%), identify an arrhythmic problem in262 (15.3%), correctly identify a device-related problem in35 (2.1%), but potentially miss an isolated pacing problem in6 (0.46%). Clinical evaluation would diagnose a relevant clinicalproblem in the absence of any device interrogation abnormalityin 170 patients (10%). Conclusion: ICD remote monitoring can potentially diagnose >99.5% ofarrhythmia- or device-related problems if combined with clinicalfollow-up by the local general practitioner and/or referringcardiologist. It may provide a way to significantly reduce in-officefollow-up visits that are a burden for both hospitals and patients.     

Severe impairment in lung function induced by high peak airway pressure during mechanical ventilation. An experimental study

We explored the pulmonary effects of continuous mechanical ventilation (MV) at a peak inspiratory pressure of 50 cm H2O in healthy, paralyzed, and anesthetized adult sheep during a period of 48 h. The 9 control sheep (Group A) were ventilated with 40% oxygen at a tidal volume of about 10 ml/kg and a peak inspiratory pressure of 15 to 20 cm H2O. All these animals remained stable throughout the 48 h of MV with no change in lung function. The 7 sheep in Group B were ventilated with 40% oxygen using a pressure-controlled ventilator at 50 cm H2O peak inspiratory pressure, at a VT of 50 to 70 ml/kg. All sheep in Group B developed severe respiratory failure and died or were killed within 2 to 35 h, and showed parenchymal consolidation at autopsy. The 9 sheep in Group C were ventilated as in Group B, except that 3.8% CO2 was added to the inspired gases: the Group C animals deteriorated more slowly, with little change in PaO2 but with a severely reduced FRC, VT, total static lung compliance, and grossly abnormal lungs at autopsy. We conclude that in this model, mechanical ventilation at peak airway pressure of 50 cm H2O will lead to progressive impairment in pulmonary mechanics, lung function, acute respiratory failure, and alveolar cellular dysfunction, as demonstrated by highly abnormal minimal surface tension values of saline lung lavage fluid in both study groups.