Surgical treatment of cholesteatoma: a comparison of closed and open techniques in a follow-up of 164 ears

Reimer A., Andreasson L. & Harris S. (1987) Clin. Otolaryngol. 12 , 447–454 Surgical treatment of cholesteatoma: a comparison of closed and open techniques in a follow-up of 164 ears In the Malmö community (230 000 inhabitants) 188 ears with cholesteatoma were operated on during 1975–1981. This number corresponds to an incidence of 12 cholesteatomas per 100000 inhabitants a year. A detailed follow-up was possible in 164 ears. The primary operation was performed with an intact canal wall technique (CAT) in 148 ears and a radical operation in 40 ears. A planned second look was performed in 138 of the CAT ears and residual cholesteatoma was found in 41 or 30%, mainly in the epitympanic space. An initially good healing and hearing result was obtained in 71 % but in the course of time several ears developed new retractions and a new mastoid cholesteatoma. The number of ears with perfect hearing tended to decrease with time, but about one-third of CAT ears remained intact with good hearing. The CAT technique is preferable in ears with a large mastoid air cell system and when the cholesteatoma is easily accessible by the approach. A planned second look should be performed including ossiculoplasty and obliteration of the antrum. In the remaining cases a radical operation including middle ear reconstruction and obliteration of the mastoid cavity is preferred.     

Novel Use of a Vascular Plug to Anchor an Azygous Vein ICD Lead

Vascular Plug for ICD Lead.   We describe the case of a young patient with severe hypertrophic cardiomyopathy and marginal defibrillation thresholds (DFTs) at implant of a standard transvenous implantable cardioverter-defibrillator (ICD) system. The patient subsequently experienced multiple failed ICD shocks during a prolonged episode of spontaneous ventricular tachycardia/fibrillation. Placement of a second single-coil shocking lead in the azygous vein resulted in acceptable DFTs, but the new lead migrated superiorly within hours of the procedure. To stabilize the lead position, a vascular plug was placed in the distal azygous vein, and the shocking lead screw was actively fixated to the meshwork of the device. Subsequent testing confirmed both adequate defibrillation and stable lead position. (J Cardiovasc Electrophysiol, Vol. 21, pp. 99–102, January 2010)     

Student midwives' learning experience on the wards

• ? This paper is based on an investigation into the learning experiences of student midwives in the clinical setting in one maternity unit in the Republic of Ireland.
• ? A questionnaire approach was adopted for the data collection and 42 student midwives participated in the study.
• ? A number of factors were identified which appear to influence students' experiences of ‘learning on the job’. The quality of their clinical teaching and their observations of the way in which trained staff practise midwifery may influence their decision to continue practising midwifery following registration.
• ? These findings clearly point to the importance for midwives to reassert their true role as ‘independent practitioners’ of normal maternity care.

     

Larvicidal properties of macrophages induced by cloned murine schistosomal egg antigen-specific CD4 positive T-helper lymphocytes

The role of T-helper (TH) lymphocytes in activating peritoneal macrophages (PM) to kill larvae of the helminth Schistosoma mansoni (schistosomula) was investigated with the use of egg antigen-specific CD4 positive TH clones of both the TH1 and TH2 types. Results showed that stimulated TH1 clones, in exceedingly small numbers, or supernatants thereof, conferred on PM the ability to kill schistosomula. The molecule responsible for PM activation was found to be interferon-gamma (IFN-gamma). IFN-gamma-induced PM larvicidal activity was dependent on live cells, energy, as well as protein synthesis, and appeared to be mediated by toxic nitrogen metabolites. In contrast, egg antigen-specific TH2 clones, or their supernants, failed to induce PM larval killing, as they did not secrete IFN-gamma, or any equivalent macrophage activating factor. We postulate a mechanism by which egg antigen-specific TH1 clones may be capable of playing a critical role in the resistance to schistosomal reinfection through IFN-gamma-mediated activation of macrophage helminthotoxicity.     

Mast cell degranulation and parenchymal cell injury in the rat mesentery.

OBJECTIVE: The objective of this study was to explore the degree of parenchymal cell injury after mast cell degranulation by application of compound 48/80 (CMP 48/80) in the absence of adherent leukocytes in the rat mesentery. METHODS: Rats were rendered leukopenic by injection of an antibody against leukocytes, and the mesentery was superfused with CMP 48/80 during intravital microscopy. The extent of cell injury was determined using a fluorescent cell-viability indicator, propidium iodide (PI). In an additional group, mast cell degranulation with CMP 48/80 was prevented by using the mast cell stabilizer Ketotifen. RESULTS: After a reduction in the number of circulating leukocytes, mast cell degranulation produced a mild increase in parenchymal cell injury. The injury levels significantly increased when individual regions of the mesentery were compared. Stabilization of the mast cells with Ketotifen reduced the injury to below baseline values. CONCLUSIONS: In the absence of leukocyte adhesion to the endothelium, mast cell degranulation contributes to parenchymal cell injury in the mesentery.     

A Case-Control Study of Peripartum Cardiomyopathy Using the Rochester Epidemiology Project

BackgroundThe incidence of peripartum cardiomyopathy (PPCM) is known through referral center databases that may be affected by referral, misclassification, and other biases. We sought to determine the community-based incidence and natural history of PPCM using the Rochester Epidemiology Project.Methods and ResultsIncident cases of PPCM occurring between January 1, 1970, and December 31, 2014, were identified in Olmsted County, Minnesota. A total of 15 PPCM cases were confirmed yielding an incidence of 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Clinical information, disease characteristics, and outcomes were extracted from medical records in a 27-county region of the Rochester Epidemiology Project including Olmsted County and matched in a 1:2 ratio with pregnant women without PPCM. A total of 48 women were identified with PPCM in the expanded 27-county region. There was 1 death and no transplants over a median of 7.3 years of follow-up. Six of the 23 women with subsequent pregnancies developed recurrent PPCM, all of whom recovered. Migraine and anxiety were identified as novel possible risk factors for PPCM.ConclusionsThe population-based incidence of PPCM was 20.3 cases per 100,000 live births in Olmsted County, Minnesota. Cardiovascular outcomes were generally excellent in this community cohort.     

Postshock Potential Gradients and Dispersion of Repolarization in Cells Stimulated with Monophasic and Biphasic Waveforms

Effects of Monophasic and Biphasic Stimuli. Introduction: Even though the clinical advantage of biphasic defibrillation waveforms is well documented, the mechanisms that underlie this greater efficacy remain incompletely understood. It is established, though, that the response of relatively refractory cells to the shock is important in determining defibrillation success or failure. We used two computer models of an isolated ventricular cell to test the hypothesis that biphasic stimuli cause a more uniform response than the equivalent monophasic shocks, decreasing the likelihood that fibrillation will be reinduced. Methods and Results: Models of reciprocally polarized and uniformly polarized cells were used. Rapid pacing and elevated [K]_o were simulated, and either 10-nisec rectangular monophasic or 5-msec/5-msec symmetric biphasic stimuli were delivered in the relative refractory period. The effects of stimulus intensity and coupling interval on response duration and postshock transmembrane potential (V_m) were quantified for each waveform. With reciprocal polarization, biphasic stimuli caused a more uniform response than monophasic stimuli, resulting in fewer large gradients of V_m (only for shock strengths ≤ 1.25× threshold vs ≤ 2.125× threshold) and a smaller dispersion of repolarization (1611 msec² vs 1835 msec²). The reverse was observed with uniform polarization: monophasic pulses caused a more uniform response than did biphasic stimuli. Conclusion: These results show that the response of relatively refractory cardiac cells to biphasic stimuli is less dependent on the coupling interval and stimulus strength than the response to monophasic stimuli under conditions of reciprocal polarization. Because this may lead to fewer and smaller spatial gradients in V_m, these data support the hypothesis that biphasic defibrillation waveforms will be less likely to reinduce fibrillation. Further, published experimental results correlate to a greater degree with conditions of reciprocal polarization than of uniform polarization, providing indirect evidence that interactions between depolarized and hyper polarized regions play a role in determining the effects of defibrillation shocks on cardiac tissue.     

The use of esmolol to attenuate the haemodynamic response when extubating patients following cardiac surgery -- a double-blind controlled study

We have assessed the cardiovascular changes associated withemergence from anaesthesia, reversal of neuromuscular blockadeand extubation in a group of 14 patients immediately after coronaryartery bypass graft surgery had been completed. Patients wererandomly allocated to receive either esmolol 500µg. kg^–1over 1 min followed by 100 µg . kg^–1. min^–1or placebo starting prior to reversal. Significant hypertensionand tachycardia occurred in the placebo group, whilst thesechanges were prevented by the administration of esmolol.     

Compliance,concordance and the revolving door of care: caring for elderly people with mental health problems

□ The project involved community pharmacists receiving specialised training, becoming integrated into the community mental health teams and providing pharmaceutical care when making joint domiciliary visits with the key workers. □ Community pharmacists, psychiatrists and key workers all wanted the project to develop into a service and had similar views about the general benefits of the study. However, they had contrasting expectations of the project, based on their own perspectives on compliance, concordance and models of care □ The key workers valued the provision of monitored dosage systems for patients with confusion or memory problems. But the pharmacists felt that they were being expected to organise compliance aids; they recognised that it was their role to assess complaince and that other measures could be taken before organising an MDS □ The psychiatrists stated that involuntary non‐compliance with medication, arising from confusion, memory and physical problems, was a major issue and the project had made improvements in this area; they wanted to keep patients in the community and particularly valued reductions in morbidity, relapses and the “revolving door of care”     

The use of Roy's adaptation model applied to a patient with breast cancer

Roy's adaptation model provides a framework for holistic oncology nursing practice. In this article an overview of Roy's model is provided, and the model is applied to a patient with breast cancer for an assessment of behaviour and the stimuli influencing behaviour, and for the planning and evaluation of nursing care. Also, a comprehensive list of nursing diagnoses is categorized according to Roy's four adaptive modes.