Retained pacemaker leads

Increasingly, functionless pacemaker leads are being abandoned in place because they cannot be safely removed. One hundred eighty-nine intact or partially removed pacemaker leads were abandoned in situ in 152 patients between Jan. 1, 1965, and Dec. 31, 1985. The leads, sometimes several leads in a single patient, were deemed uninfected at the time of abandonment in 137 patients and contaminated with Staphylococcus epidermidis in 15 patients. All of the contaminated leads have remained clinically uninfected during follow-up. One clean lead became infected early after implantation and the patient died after an open cardiac operation to remove that lead and an adjacent abandoned lead that was adherent to the subclavian vein. No other patient has had a late complication during follow-up to 256 months (mean 47.6). Properly managed abandonment of an uninfected lead can carry a very low complication rate.     

Patients with Fabry disease on dialysis in the United States.

BACKGROUND.: Fabry disease results from an X-linked deficiency of lysosomal alpha-galactosidase A and is a rare cause of end-stage renal disease. Little is known about the characteristics of patients with Fabry disease that initiate dialysis in the United States, although data from Europe suggests these individuals have a poor survival. METHODS.: Using the United States Renal Disease System database, we first studied in detail 42 Fabry patients who initiated dialysis between April 1995 (following the introduction of the new detailed HCFA 2728 form) and July 1998. To examine crude survival in a larger cohort, 95 Fabry patients were studied who initiated dialysis between 1985 and 1993, similar to the European Registry. Diabetic and non-diabetic controls matched by age, gender, race, year of dialysis initiation, and initial dialysis modality were examined for comparison. RESULTS.: During the years 1995 to 1998, the mean age of Fabry patients that initiated dialysis was 42 years, 83% were Caucasian, and 10% were African American. Despite the X-linked inheritance of Fabry disease, 12% of Fabry patients on dialysis were female. At initiation of dialysis mean serum albumin and creatinine were significantly higher and mean body mass index was significantly lower among Fabry patients, but mean glomerular filtration rate was similar to controls. Fabry patients tended to have a lower three-year survival compared to non-diabetic controls, but the results were not significantly different. In a larger cohort of Fabry patients who initiated dialysis between 1985 and 1993, the three-year survival of Fabry patients was significantly lower than non-diabetic controls: 63% (95% CI, 50 to 75%) versus 74% (95% CI, 67 to 80%; P=0.03). CONCLUSION.: End-stage renal disease is associated with significant morbidity and mortality among patients with Fabry disease. Recent evidence that progression of Fabry disease may be attenuated by enzyme replacement therapy necessitates increased awareness of Fabry disease and its comorbidities.     

Entrapment of pacemaker lead by a large netlike Eustachian valve within the right atrium

Summary During pacemaker implantation in a patient with permanent atrial fibrillation, it remained impossible to advance a passive fixation lead with fins through the right atrium. However, a lead with a retractable screw easily passed the right atrium and was positioned in the right ventricle. Transesophageal echocardiography revealed an extensive net–like perforated Eustachian valve within the right atrium that had caused entrapment of the anchor fins during lead implantation. Remnants of embryonal structures within the right atrium should be considered a rare possible barrier during pacemaker implantation.     

Risk of Respiratory Complications and Wound Infection in Patients Undergoing Ambulatory Surgery: Smokers versus Nonsmokers

Background: Smoking is considered to be a risk factor for patients undergoing surgery and anesthesia, but it is unclear whether this is applicable to patients undergoing ambulatory surgery. The aim of this study was to determine the risk of respiratory complications and wound infection among smokers.

Methods: The authors studied a random selection of 489 adult patients undergoing ambulatory surgery. Smoking status was determined by self-report and confirmed with end-expired carbon monoxide analysis. The risk of respiratory complications (i.e., desaturation, cough, laryngospasm, bronchospasm, breath-holding, or apnea) and wound infection (i.e., wound redness or discharge +/- positive microbial culture, requiring antibiotic therapy) in smokers versus nonsmokers was ascertained. Odds ratios were estimated from multivariable logistic regression and adjusted for age, gender, body mass index, partner's smoking status, domiciliary smoking exposure, and extent and duration of surgery.

Results: Most smokers continued to smoke up until the day of surgery. Smokers had a higher rate of respiratory complications (32.8%vs. 25.9%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.84;P = 0.038) and wound infection (3.6%vs. 0.6%; odds ratio, 16.3; 95% confidence interval, 1.58-175;P = 0.019). Odds ratios comparing current plus ex-smokers with nonsmokers were of similar magnitude for most of these complications.     

A comparison of presenting characteristics of patients with intracapsular and extracapsular proximal femoral fractures.

The presenting characteristics of 1423 consecutive admissions with proximal femoral fractures were prospectively studied, to determine any differences that may exist between patients, dependent on the radiological site of the fracture. Patients with intracapsular fractures were of a lower average age, more mobile, less likely to use walking aids or live in residential accommodation, they also had a considerably shorter length of hospital stay than for those patients with extracapsular fractures. Comparison against previous series shows that the average age of hip fracture patients and the proportion of trochanteric fractures is increasing.     

Cost of illness studies: no aid to decision making: Reply to Shiell et al. (Health Policy, 8 (1987) 317-323).

Efficient resource allocation in health care requires adequate techniques of collective decision making. In a recent article Shiell, Gerard and Donaldson (Health Policy 8 (1987) 317-323) claim that cost of illness studies only confuse, mask and mislead, while cost-benefit analysis provides the relevant framework for decisions in health care. We do not agree with their naive approach to decision making in health care. In comparing the two alternative methods, their respective importance for decision making becomes apparent. None of the two techniques may be considered as the one and only means to ultimately solving the problem of efficient resource allocation in health care. Yet, both techniques can provide relevant information on which policy makers can base their decisions in health care.