Right-sided prepectoral implantation of an implantable cardioverter defibrillator in a right pneumonectomized patient

Right-sided prepectoral implantation of an ICD is performed in unusual circumstances only, like in patients with abnormal venous drainage and preexisting left-sided devices. This case report describes a 42-year-old man who had undergone previous right pneumonectomy and who required ICD implantation for symptomatic inducible nonsuppressable hemodynamically unstable ventricular tachycardia. To avoid the small but real possibility of inadvertent iatrogenic left-sided pneumothorax in a patient with previous right pneumonectomy, a dual chamber ICD with an active can was implanted in the right prepectoral position.     

Impact of clinical experience on quantification of clinical signs at physical examination

Abstract. Drager LF, Abe JM, Martins MA, Lotufo PA, Benseñor IJM (School of Medicine, University of São Paulo, São Paulo, Brazil). Impact of clinical experience on quantification of clinical signs at physical examination. J Intern Med 2003; 254: 257–263. Purpose. Although physical examination is a fundamental component of medical decision making, relatively few studies have evaluated how physicians quantify clinical signs and whether different methods of assessment have different effects on clinical practice. Objectives. To evaluate a possible impact of clinical experience when attending physicians, medical residents and medical students quantify qualitative signs of physical examination in a teaching hospital. Setting. Hospital das Clínicas, University of São Paulo, Brazil. Subjects. A total of 244 randomly selected physicians and medical students completed a reliable and consistent eight‐item questionnaire. Main outcome measures. To compare how they quantified clinical signs of cyanosis, anaemia, jaundice, oedema and dehydration, why they used the method(s) they described, and whether the method used could affect diagnosis, further testing or patient management. A chi‐square test was used to calculate differences between the groups. Results. Whilst the majority of those surveyed tended to use a four‐level evaluation for these clinical signs, attending staff physicians were more likely to employ two‐level evaluations than were residents or medical students. For all five signs, attending physicians’ use of dichotomous evaluations was significantly higher than that of residents or medical students: anaemia (P = 0.004), cyanosis (P < 0.001), oedema (P = 0.005), dehydration (P < 0.001) and jaundice (P = 0.002). Conclusion. Although medical students and residents are routinely taught to use a four‐level evaluation for these clinical signs, many of those surveyed tend to abandon this experience for a dichotomous approach. Given that the clinicians in this survey tended not to change their initial approach to a patient based on the intensity of this semi‐quantitative method, increased emphasis on teaching dichotomous approach evaluations in medical school should be encouraged.     

A holistic-existential approach to health promotion

Health promotion seems to be implicit in many nursing theories, but the theoretical and philosophical basis of health promotion in nursing is not always explicitly stated. The interpretation of health promotion is closely related to the interpretation of man, health, illness and nursing. There is a need to clarify, refine and redefine health promotion in nursing because the concept is partly nonspecific and has not been used to identify a distinctive nursing focus. The aim of this study was to formulate a stipulative definition of health promotive nursing with a holistic-existential approach. A philosophical frame of reference in combination with conceptual analysis and theoretical synthesis were used as the methodological approach. The philosophical framework served as a basis in selecting the nursing theories and influenced the analysis. Two nursing theories and one nursing model were selected due to their influence on Norwegian nursing and because of their philosophical basis. Through analysis and synthesis of the selected nursing theories, the concepts man, health, illness/disease and nursing were analysed. The paper proposes a stipulative definition of health promotion in nursing based on a holistic-existential approach, supported by five necessary conditions. The definition and conditions needs to be further investigated by both empirical studies and by comparing with other relevant nursing theories, in order to formulate theoretical statements. The proposed definition may be the first step in a process of developing a theoretical framework of health promotive nursing with a holistic-existential approach.     

Help in times of crying: nurses' approach to parents with colicky infants

BACKGROUND: Colic, a condition that is well known to parents and nurses working in child health centres, is characterized by excessive crying. However, the criteria for defining colic are vague, there is no agreed definition and no effective treatment exists. Even though there is no cure for colic, nurses in child health centres have to deal with the condition as parents bring their crying infants to them. AIM: To develop an understanding of how nurses deal with infant colic/excessive crying, how the parents perceive nurses' contribution, and whether nursing makes a difference to the situation or not. ETHICAL ISSUES AND APPROVAL: The project was reviewed and approved by the Research Ethics Committee in Norway where the study was carried out. METHODS: The design is explorative, and data were collected through qualitative in-depth interviews with nurses and parents of crying infants. The analysis follows the guidelines of Kvale, which imply a phenomenological/hermeneutical mode of understanding. FINDINGS: The primary aim of nursing is to assist parents in their efforts to cope with the challenges of infant colic. Nurses and parents differ to some extent in how they define the problems and the needs of the families. In addition, both parents and nurses question the nurses' knowledge and ability to help in this situation. A relationship with the parents based on trust is fundamental to enable the nurses to achieve their goals, but such a relationship is not always developed. CONCLUSIONS: Even though nursing interventions do not cure infant colic, the amount of crying may be reduced and life made easier for the families if the parents are offered help in coping with the situation. Consequently, this should be the primary aim of nursing when approaching families with a colicky infant.     

Successful resection of prostatic rhabdomyosarcoma by the posterior sagittal approach combined with preoperative chemotherapy

The authors used a posterior sagittal approach to successfully remove a huge prostatic rhabdomyosarcoma from a 3-year-old boy after he had received intensive chemotherapy. This procedure enables safe removal of the prostatic rhabdomyosarcoma under direct vision and with minimal damage to other pelvic organs.     

Laparoscopic ablation of peripelvic renal cysts

Recently, laparoscopic surgery has been reported for symptomatic renal cysts. A 60-year-old female was referred to Toyama Medical and Pharmaceutical University Hospital with a chief complaint of general fatigue and left back pain. CT demonstrated bilateral peripelvic renal cysts, and DIP demonstrated left hydronephrosis and a medical shift of the left renal pelvis. Laparoscopic ablation of bilateral peripelvic renal cysts was performed under general anesthesia and a round excision was made in the cyst wall via the peritoneum. After surgery, the left back pain disappeared and CT demonstrated resolution of peripelvic renal cysts. Laparoscopic ablation of peripelvic renal cyst is a highly effective and minimally morbid procedure.     

Morphometry of the anterior third ventricle region as a guide for the subfrontal (translaminaterminalis) approach

The anterior third ventricle region acquires clinical significance in benign and malignant tumors and cyst formations, of which craniopharyngiomas and gliomas are the most common. The subfrontal approach is one of the most preferred approaches for removing these tumors. In this study, the microsurgical anatomy of 81 Turkish, adult cadaveric hemispheres was examined to provide morphometric data of the region. These measurements from the anterior third ventricle region serve as a guide for neurosurgeons during surgical approach for removing anterior third ventricle tumors.     

Conservative (labyrinth-preserving) transpetrosal approach to the clivus and petroclival region – indications,complications, results and lessons learned

Objective. Tumours or vascular lesions of the clivus and juxtaclival region present a unique challenge to neurosurgeons and a variety of techniques, with a wide spectrum of complexity, have been advocated. This report presents the use of a conservative transpetrosal approach which combines partial removal of the postero-lateral petrous bone with preservation of the labyrinth, with particular focus on efficacy and the reduction of complications. Patients and methods. Over 9 years, 52 patients underwent a conservative combined supra-infratentorial, labyrinth-preserving transpetrosal approach. There were 32 women and 20 men; 33 had tumour lesions including 22 patients with a clival or petroclival meningioma. Among the 19 patients with a vascular lesion, 12 patients had a basilar artery trunk aneurysm, including one giant midbasilar aneurysm. 3 Patients had vertebro-basilar junction aneurysms, and 4 patients had a pontine cavernoma. Data on the clinical features, investigations and operative techniques were extracted from the patients case records. Outcome was assessed by serial examinations of the patients or by telephone interview with the treating physician, and in survivors graded as excellent, good or poor. Results. 52 patients, 23 patients (44%) had an excellent outcome, in 21 patients (41%) the outcome was good and in 7 patients (13%) the outcome was poor. One patient with a complex fusiform basilar trunk aneurysm, operated upon as an emergency, died in the postoperative period. Total resection was achieved, as demonstrated by follow-up MRI in 20 of 33 patients with a tumour, including 15 of 22 patients with clival or petro-clival meningiomas. All vascular lesions were treated effectively and in 14 patients with a basilar or vertebro-basilar junction aneurysm, clipping of the aneurysm was achieved. In one patient, a giant calcified vertebro-basilar junction aneurysm was resected. New cranial nerve deficits or an accentuation of a pre-existing deficit, occured in 8 patients with a tumour and 4 patients with a vascular lesion. Complications included: temporary conductive hearing deficit in 4 patients, a minor laceration of the sigmoid/transverse sinus in 4 and transient post-operative CSF leakage in 12 patients. Temporary lumbar drainage resulted in sealing of the CSF leak in 8 patients, but in 3 patients a permanent ventriculo-peritoneal shunt had to be implanted. Conclusion. When based on adequate experience in skull base surgery, the combined supra-infratentorial, conservative transpetrosal approach, with preservation of the labyrinth, allows direct and wide exposure of a large variety of tumour and vascular lesions located along the supra- and infratentorial juxta-clival area; little or almost no retraction of neurovascular structures is needed and with adherence to important principles, complications related to the approach can be minimised.Published online July 23, 2003     

Large sphenocavernous meningiomas: Is there still a role for the intradural approach via the pterional-transsylvian route?

Summary.  Background: Large-sized sphenocavernous meningiomas represent a surgical challenge. Although the role of skull base techniques with combined extra- and intradural steps has been recently emphasized, pure intradural resection tactics via the pterional route constitute the traditional microsurgical approach for resection of such tumours.  Method: We report the application of the pterional-transsylvian approach in 13 patients with sphenocavernous meningiomas. This series is unique because it includes only patients with tumours exceeding 5 cm in their greatest dimension.  Findings: A gross total resection was accomplished in 10 patients (77%). Eight patients had a good outcome, one had a persistent mild hemiparesis, and one died. No recurrences occurred in this group. Three patients (23%) had subtotal resections owing to invasion of the cavernous sinus in one instance and encasement of the middle cerebral artery in the others. Two had a good outcome and one died. In these patients minimal asymptomatic tumour progression was seen 3 and 6 years after surgery. The overall surgical outcome was good in 10 patients (77%), fair in one, and death in two.  Interpretation: In our experience, large sphenocavernous meningiomas may be operated on adopting pure intradural resection tactics via the pterional-transsylvian route with rates of gross total removal and surgical complications related to brain retraction or vascular manipulation comparable to those of extensive skull base approaches. The traditional intradural pterional transsylvian approach continues to have a place in the treatment of these lesions. Published online April 28, 2003 RID="*" ID="*"  This paper was supported in part by Grant “Piano B008 – P.R. 2” from M.U.R.S.T. and European Community.  Correspondence: Domenico d'Avella, M.D., Neurosurgical Clinic, Department of Neuroscience, Psychiatric and Anesthesiolgical Sciences, Policlinico Universitario, via Consolare Valeria 1, 98122 Messina, Italy.     

Iranian migrants' discourses of health and the implications for using standardized health measures with minority groups

This paper explores the concept of health implied in the SF-36 within a group of Iranians in Australia. Qualitative data were collected from a sample of 21 people—10 females and 11 males. For the first time, the NUD*IST program was used to organize and manage the data in Persian (also known as Farsi), the language spoken by Iranians. Health was defined in terms of holistic, spiritual, social, physical/emotional aspects, and absence-of-disorder dimensions. Among these, physical, absence of disorder, holistic, and spiritual aspects of health were mentioned more frequently than other themes. The findings of the study raise concerns about the extent to which the SF-36 captures the diversity of the concept of health as expressed by the sample of Iranian migrants.