Direct and Telemetered Lead Impedance

Objectives: We undertook this study to determine whether telemetered lead impedance measurements (LIM) can be correlated with direct LIM and to determine the stability of LIM over time when measured directly and via telemetry. Methods: Direct LIM and telemetered LIM were measured in 91 patients; 101 leads during initial implantation and 40 leads during pulse generator replacement. Differences in direct LIM measured during initial implant and pulse generator replacement (direct-direct) were compared in 41 patients (28 atrial leads and 37 ventricular leads). The stability of telemetered LIM obtained immediately postoperatively, at 1 month and 1 year, postimplantation was assessed in 50 patients (23 atrial and 49 ventricular leads). Results: In atrial leads acute direct LIM was 633.9 ± 18.4 Ω versus 575.8 ± 18.5 Ω for telemetered LIM (r = 0.58), and chronic direct LIM was 670.9 ± 49.3 Ω versus 607.0 ± 36.3 Ω for telemetered LIM (r = 0.87). In ventricular leads acute direct LIM was 747.3 ± 16.9 Ω and 684.7 ± 16.4 Ω for telemetered LIM (r = 0.69), and chronic direct LIM was 674.8 ± 29.9 Ω and 625.2 ± 28.5 Ω for telemetered LIM (r = 0.68). The mean direct–direct UM rose 124 Ω (P < 0.001) in atrial leads and 10 Ω (P = NS) in ventricular leads. Telemetered LIM for atrial leads was 581.0 ± 27.6 Ω immediately postimplantation compared to 625.7 ± 34.8 Ω at 1 month and 754.1 ± 43.0 Ω at 1 year. Telemetered LIM for ventricular leads was 661.3 ± 17.5 Ω at implant, 684.6 ± 20.7 Ω at 1 month and 724.7 ± 22.7 Ω at 1 year. Conclusions: There is a good but limited correlation between direct and telemetered LIM. Mean direct LIM obtained at initial implantation is similar to that measured at pulse generator replacement. The telemetered LIM is stable over the first month postimplantation but tends to rise during the first year of follow-up and substantial changes in impedance are not uncommon in individuals with normal function. There is a tendency for LIM to rise with lead maturation. If telemetered LIM is to be followed over time, a baseline telemetered value should be obtained immediately postoperatively.     

The fixed flexed and subluxed knee in the haemophilic child: what should be done?

Summary. Knee haemarthroses are very common in the haemophiliac and often, despite infusion of the missing coagulation factor, synovitis develops. The warm swollen joint is maintained in the most comfortable position for the haemophiliac: flexion. Ambulation is achieved by planterflexion of the ankle joint and toewalking. As the chronic synovitis persists, the range of movement of the knee is affected, with loss of full extension. Development of radiological degenerative signs develop. The quadriceps muscle usually weaken due to disuse, but the hamstrings are active in maintaining the flexion of the joint. As the process continues, the tibia subluxes posteriorly on the condyles of the femur. The posterior capsule of the knee joint soon contracts, permanently limiting knee extension. A case is described on whom an Ilizarov device was used to gradually return the limb to a function position. This will allow the patient to complete his growth prior to a definitive orthopaedic procedure.     

Ultrasound Thrombolysis: An Alternative to the Pharmacological Approach

The clinical management of intracoronary thrombosis presents a therapeutic challenge. A variety of pharmaceutical agents have been investigated as an adjunct to balloon angioplasty and stenting with no conclusive evidence to which is the best therapeutic strategy. Our group has investigated the use of therapeutic ultrasound in interventional cardiology over the last few years. Ultrasonic energy (41 KHz) is transmitted from a transducer as longitudinal vibrations of a 140-cm long solid probe, which directs the energy into the arterial system. In the ACUTE study, consecutive patients with first infarct, only acute anterior myocardial infarction, and occluded LAD were studied. Final flow of TIMI grade 3 was achieved in 93% of the patients. During the procedure, there were no clinical or angiographic adverse events. At 6-month follow-up, a significant improvement of left ventricular ejection fraction was observed. There was a low clinical event rate. The Acolysis Registry followed the ACUTE trial. The purpose of this registry was to investigate coronary ultrasound thrombolysis in the different clinical settings of intracoronary thrombosis. Preliminary data (n = 51), show that 56% of the patients were treated for acute myocardial infarction, 25% for unstable angina, and 19% for diseased saphenous vein grafts (SVG). Ninety percent of the vessels were occluded (TIMI 0-1 flow) at baseline, median age clot was 4 days. Device and procedural success was obtained in 84% and 82%, respectively. Intriguing data came from the SVG subset of patients. Angiographic analysis revealed that 75% of the SVGs were occluded prior to the procedure. Sonication led to successful recanalization in 70% of the patients. In summary, this data suggests that therapeutic ultrasound is effective and safe for inducing intracoronary thrombolysis. Ultrasound can be used to treat thrombi that are a few hours to a few weeks old. Lysis of intracoronary thrombus by ultrasound is a safe and effective procedure. Furthermore, ultrasound thrombolysis is a viable alternative to the pharmacological approach. Local application of ultrasound achieves a high success rate with minimal local or systemic adverse events.     

Ketoconazole is Effective against the Chronic Mucocutaneous Candidosis of Autoimmune Polyendocrinopathy-Candidosis-Ectodermal Dystrophy (APECED)

ABSTRACT Ketoconazole was administered as a single daily oral dose of 200 mg to 12 patients with chronic mucocutaneous candidosis (CMC) of autoimmune polyendocrinopathy-candidosis-ectodermal dystrophy (APECED). The study was double-blind and placebo-controlled, with 4-month therapy periods and crossover, and transfer to open-label ketoconazole therapy in cases of failure. During the double-blind trial, all six initially ketoconazole-treated patients showed a clear clinical and mycological improvement. In contrast there was no change or worsening in the initially placebo-treated group (p=0.001). Oral candidosis cleared up in all patients, but more rapidly (<2 weeks) in those aged <25 years than in older patients (4–10 weeks; p=0.001). Similarly, nail candidosis improved more rapidly in the younger group. All patients had a recurrence of the candidosis during 36–48 months of post-therapy follow-up. The recurrences likewise responded to ketoconazole. In one patient serum transaminase activities were transiently and marginally elevated during 2–6 weeks of therapy.