Electrocardiographic and Clinical Predictors of Torsades de Pointes Induced by Almokalant Infusion in Patients with Chronic Atrial Fibrillation or Flutter: A Prospective Study

The aim of this study was to identify predictors of torsades de pointes (TdP) in patients with atrial fibrillation (AF) or flutter exposed to the Class III antiarrhythmic drug almokalant. TdP can be caused by drugs that prolong myocardial repolarization. One hundred patients received almokalant infusion during AF (infusion 1) and 62 of the patients during sinus rhythm (SR) on the following day (infusion 2). Thirty-two patients converted to SR. Six patients developed TdP. During AF, T wave alternans was more common prior to infusion (baseline) in patients developing TdP (50% vs 4%, P < 0.01). After 30 minutes of infusion 1, the TdP patients exhibited a longer QT interval (493 ± 114 vs 443 ± 54 ms [mean ± SD], P < 0.01), a larger precordial QT dispersion (50 ± 74 vs 27 ± 26 ms, P < 0.05), and a lower T wave amplitude (0.12 ± 0.22 vs 0.24 ± 0.16 mV. P < 0.01). After 30 minutes of infusion 2, they exhibited a longer QT interval (672 ± 26 vs 489 ± 74 ms, P < 0.001), a larger QT dispersion in precordial (82 ± 7 vs 54 ± 52 ms, P < 0.01) and extremity leads (163 ± 0 vs 40 ± 34 ms, P < 0.001), and T wave alternans was more common (100% vs 0%, P < 0.001). Risk factors for development of TdP were at baseline: female gender, ventricular extrasystoles, and treatment with diuretics; and, after 30 minutes of infusion: sequential bilateral bundle branch block, ventricular extrasystoles in bigeminy, and a biphasic T wave. Patients developing TdP exhibited early during almokalant infusion a pronounced QT prolongation, increased QT dispersion, and marked morphological T wave changes.     

New regimen for interpleural block in children

A new regimen for postoperative analgesia after thoracic surgery is proposed. Eight children received an interpleural infusion using bupivacaine 0.1% in a regimen from 0.5 ml·kg^?1·h^?1 up to 1 ml·kg^?1·h^?1, for 48 h according to the pain scores. The plasma levels after 24 h and 48 h were measured as well as the pleural level and in two patients the free fraction of plasma bupivacaine and the plasma PPX (a metabolite of bupivacaine) and one patient the orosomucoid (main plasma protein involved in bupivacaine protein binding) were also measured pre and postoperatively. The results shows the safety of such a regimen, for two days of postoperative analgesia.     

Changes of nursing organization in a surgical department: effects on work satisfaction and quality of care

• ? The aim of the study was to evaluate the effects of an organizational change programme in a surgical department in Sweden (the introduction of modular nursing) on the nursing staffs perception of job satisfaction and quality of care, and to identify factors which promote or hinder this organizational change.
• ? Planning and implementation of the change programme took about 1 year and comprised structural changes and staff training.
• ? Assessments of job satisfaction and quality of care were made immediately before, and 1 year after, implementation of the change programme. Data were collected from the staff of two wards.
• ? Virtually no statistically significant changes were found when looking at the department as a whole. However, considerable differences were noted between the two wards, particularly in the following areas: relationships with colleagues, identification and commitment, and perceived quality of care.
• ? The quality of the interpersonal relationships, and the leadership of the wards' head nurses, appeared to be crucial determinants of the outcome.

     

LESIONS OF THE MID-SHAFT OF THE HUMERUS PRESENTING AS SHOULDER CAPSULITIS

We describe three patients who presented with pain and restrictionof movement at the shoulder suggestive of capsulitis, but provedto have lesions of the mid-shaft of the humerus. It is importantto be aware of the possibility of this cause of a ‘frozenshoulder’, since radiographs of the shoulder are usuallycropped at the mid-humerus and lesions at this level may easilybe missed. A radiograph of the entire humerus, or an isotopebone scan, may be more useful than repeated shoulder radiographsin patients whose shoulder symptoms do not respond to standardtreatment KEY WORDS: Shoulder joint, Humerus, Radiographs, Pain Department of Rheumatology, The Whittington Hospita HighgateHill, London N19 5NF     

PCR-positivity in harvested bone marrow predicts relapse after transplantation with autologous purged bone marrow in children in second remission of precursor B-cell acute leukaemia

Purging of autologous bone marrow (BM) grafts of children in second remission after a relapse of precursor B acute lymphoblastic leukaemia (ALL) in the BM has been carried out in our laboratory since 1987, initially by complement mediated cell lysis. This protocol was extended by performing an immunorosette depletion before lysis with complement. The aim of the present study was to assess by polymerase chain reaction the presence of residual leukaemic cells in the BM grafts before and after purging. The results were then correlated to clinical outcome. In 24/28 patients a PCR product was obtained by amplification of IgH and/or TcR junctional regions. BM before purging was available for analysis in 13 patients. We found that leukaemic cells could be detected in 8/13 (62%) of these grafts before purging . All these eight patients experienced a relapse, regardless of whether the purging procedure had been successful (defined as achievement of PCR-negativity) or not. In contrast, none of the five patients with PCR-negative grafts before purging relapsed ( P  = 0.0008). One patient died due to transplant-related toxicity. Of the remaining 23 patients, nine patients received a PCR-positive BM graft after purging. All these nine patients experienced a relapse as compared to 6/14 whose BM was PCR-negative after purging ( P  = 0.0072). Two of eight PCR-positive BM grafts could be purged to PCR-negativity. Thus, improvements both in treatment of leukaemia and in purging efficacy are still needed.     

LATE ONSET HUNTINGTON'S DISEASE AS A CAUSE OF DEMENTIA: WHERE SHOULD THE CLINICIAN'S INDEX OF SUSPICION LIE?

Our experience with two genetically confirmed cases of late onset Huntington's disease (HD) in a longitudinal dementia research study suggested that clinical misdiagnosis can easily occur. We therefore undertook genetic testing for HD in a further 84 elderly subjects, 81 of whom had come to postmortem; 75 subjects had dementia and nine were normal controls. A quarter of the demented group had demonstrated extrapyramidal symptoms in life but in none had HD formed part of the differential diagnosis. Although no genetically confirmed cases were found in this second group, the original cases serve as a reminder that late onset HD is a cause of dementia. Genetic confirmation should be sought when the condition forms part of the final differential diagnosis. Further studies conducted in the routine clinical setting are now required since it is in this environment that late onset HD is likely to be misdiagnosed in favour of other forms of dementia.     

The state of the science of emotional intelligence related to nursing leadership: an integrative review

akerjordet k. & severinsson e. (2010) Journal of Nursing Management 18, 363–382
The state of the science of emotional intelligence related to nursing leadership: an integrative review Aim To explore the state of the science of emotional intelligence (EI) related to nursing leadership and its critiques. Background The phenomenon of EI has emerged as a potential new construct of importance for nursing leadership that enhances educational, organizational, staff and patient outcomes. Nevertheless, important questions and critical reflections related to exaggerated claims, conceptualizations and measurements exist. Method A literature search was conducted using international databases covering the period January 1999 to December 2009. A manual search of relevant journals and significant references increased the data. Results Critical reflection seems to be associated with the unsubstantiated predictive validity of EI in the area of nursing leadership. In addition, important moral issues are called into question. Conclusions It is important to possess in-depth knowledge of EI and its scientific critique when integrating the concept into nursing research, education and practical settings. More attention to the nature of emotion in EI is necessary. Implications for nursing leadership The dynamics of EI should be explored in the context of both the surrounding environment and individual differences, as the latter can be adaptive in some settings but harmful in others.     

Clinical incidence of lymphoedema in breast cancer patients in Jönköping County, Sweden

The clinical incidence of lymphoedema of the arm in breast cancer patients was studied before and after general mammography screening in the country of jönköping, Sweden. There was a significant decrease of incidence of lymphoedema from 15% in 1983 to 8% in 1988. Clinical and pathological therapy data have been analysed in relation to lymphoedema. Significant factors contributing to lymphoedema were the number of lymph nodes examined and the number of pathologically positive lymph nodes. A higher proportion of patients receiving post-operative radiotherapy to the axilla developed lymphoedema, compared with those with surgery alone.
A comparison between the two groups is impossible due to the fact that post-operative radiotherapy was prescribed only to patients with pathologically positive lymph nodes.