Utility and Safety of Axillo‐subclavian Venous Imaging with Carbon Dioxide (CO2) Prior to Chronic Lead System Revisions

Background: Prior to attempting placement of one or more electrodes to revise existing rhythm control devices, patency of the central veins should be documented, in view of a high incidence of significant chronic occlusions. Since iodinated contrast venography may be contraindicated in select situations, imaging of the axillo‐subclavian venous system with gaseous carbon dioxide (CO₂) was evaluated prospectively in 23 consecutive individuals who were considered for revision of previously implanted pacemaker or automatic cardioverter defibrillator lead systems. Methods: Approximately 20 mL of CO₂ were manually infused via CO₂ primed injection tubing into a vein at or above the level of the antecubital fossa ipsilateral to the side of prior lead placements. Digital subtraction imaging over the axillo‐subclavian region, lower neck, and mediastinum was performed. Formal interpretation was obtained from one of three interventional radiologists and at least one electrophysiologist. Results: Significant venous occlusions were identified in five (22%) patients. Vascular access utilized for the subsequent 18 revisions performed included the imaged patent ipsilateral vein in 14 patients and the contralateral, right‐sided subclavian venous system in three patients. One patient required epicardial left ventricular lead placement. There were no complications from venography. Conclusions: Axillo‐subclavian venography with gaseous CO₂ in patients undergoing pacemaker or implantable cardioverter defibrillator lead revisions is feasible and safe when use of iodinated dye is contraindicated. This technique should be employed in patients with azotemia, dye contrast allergies, or significant inflammation in the vicinity of the intravenous line insertion. (PACE 2010; 790–794)     

Inflammatory pseudotumour of the urinary bladder

An inflammatory pseudotumour that arose in the urinary bladder of a 33-year-old woman is reported. This is the twelfth reported example of this unusual non-neoplastic lesion that may be mistaken for a sarcoma. The lesion was composed predominantly of spindle cells that by routine light microscopical, ultrastructural and immunohistochemical examination had features consistent with myofibroblasts. Awareness of this unusual lesion is important to prevent its misinterpretation.     

Chemically induced or inherited myotonia?

Objective: To present a case of chemically induced myotonia occuring as a result of intentional ingestion of trifluoperazine and Defender Australia Bindi plus Clover Lawn Weeder^R (chlorophenoxy compounds present as 4-chloro-2-methylphenoxyacetic acid (MCPA) as a dimethylamine salt 15% W/V and 3,6-dichloro-2-methoxybenzoic acid (dicamba) 2.5% W/V). To discuss myotonia. Clinical features: A 38 year old man with features suggestive of dystrophia myotonica presented with severe myotonia, urinary retention and dry lips. There was no personal or known family history of this muscular disorder. Intervention: He was treated with 2mgs of intravenous benztropine mesylate, and 50 grams of activated charcoal and 150 mls of 70% sorbitol orally. An indwelling catheter was inserted. Laryngoscopy and upper gastrointestinal tract endoscopy were performed. The myotonia was managed conservatively and complete recovery occurred as evidenced by normal electromyography on day six of his admission. Conclusion: Myotonia is a rare complication of toxin ingestion. In this case, the toxins may have unmasked subclinical dystrophia myotonica or induced myotonia de novo.     

Chronic illness: the importance of support for families caring for a child with cystic fibrosis

• ? The effect of chronic life-threatening illness on the family is one of the major problems confronting the health-care system today. Increasingly, parents have the major responsibility for the daily management of their child's condition.
• ? There is evidence that many parents lack the pofessional help and support which could ameliorate some of their problems. It is important that nurses have an understanding of how families cope with the burden of caring for a chronically ill child.
• ? Health professionals need clear guidelines on how to support these families in their role as primary care-givers.
• ? This paper examines how families of children with cystic fibrosis adapt to the illness in order to provide indicators for nursing practice and to enhance the care and support provided for these families.
• ? Effective coping strategies include: assigning meaning to the illness, sharing the burden, denial of diagnosis and incorporating therapy in a schedule.

     

Type I Atrial Flutter Ablation Guided by a Basket Catheter

Atrial Flutter Ablation. Bidirectional isthmus conduction block has been associated with a low recurrence rate after atrial flutter ablation. We present the ease of a type I, typical or "counterclockwise" atrial flutter ablation guided by stimulation and recordings obtained from a basket catheter, which allowed for constant electrogram recording from splines positioned along the right lateral free wall and septum. After atrial flutter termination with radiofrequency application, the ability to record and stimulate from multiple sites in the atrium using the basket catheter was useful to detect residual bidirectional slow conduction through the isthmus. Complete isthmus block could be documented after additional radiofrequency energy applications.     

Membranous fat necrosis of the breast

To investigate the pattern and prevalence of membranous fat necrosis of the breast we examined 25 breast biopsies or mastectomy specimens performed for recurrent lumps following conservative surgery and radiation therapy. In addition, we examined 41 consecutive cases taken from our files coded as fat necrosis which were associated with several aetiologies. Our results demonstrate that membranous fat necrosis of the breast occurs in association with several aetiologies but in its florid form is most often due to radiation therapy.     

Nodular regenerative hyperplasia of the liver in a non-treated patient with mesangiocapillary glomerulonephritis

The recognition of nodular regenerative hyperplasia of the liver in patients with renal transplant is well-known. This report, we believe, is the first well-documented case of nodular regenerative hyperplasia in a patient with chronic renal disease and who had not been transplanted.