Factors affecting timing of closure and non-reversal of temporary ileostomies.

BACKGROUND: Although stoma closure is considered a simple surgical intervention, the interval between construction and reversal is often prolonged, and some ileostomies may never be reversed. We evaluated possible predictors for non-reversal and prolonged interval between construction and reversal. MATERIAL AND METHODS: In a cohort study of ileostomy patients treated in a large teaching hospital, we collected data from the surgical complication and enterostomal therapists' registries between January 2001 and December 2011. Parameters responsible for morbidity, mortality, length of stay and time interval between construction and reversal were analysed. RESULTS: Of 485 intentionally temporary ileostomies, 359 were reversed after a median of 5.6 months (IQR 3.8-8.9 months), while 126 (26%) remained permanent. End ileostomy and intra-abdominal abscess independently delayed reversal. Age, end ileostomy, higher body mass index and preoperative radiotherapy were independent factors for non-reversal. Median duration of hospitalisation for reversal was 7.0 days (5-13 days). Morbidity and mortality were 31 and 0.9%, respectively. In 20 patients (5.5%), re-ileostomy was necessary. CONCLUSIONS: A substantial number of ileostomies that are intended to be temporary will never be reversed. If reversed, the interval between construction and reversal is longer than anticipated, while morbidity after reversal and duration of hospitalisation are considerable. Besides a temporary ileostomy, there are two other options: no diversion or a permanent colostomy. Shared decision-making is to be preferred in these situations.

Magnetic resonance imaging in patients with unilateral bloody nipple discharge; useful when conventional diagnostics are negative?

BACKGROUND: Unilateral bloody nipple discharge (UBND) is mostly caused by benign conditions such as papilloma or ductal ectasia. However, in 7-33 % of all nipple discharge, it is caused by breast cancer. Conventional diagnostic imaging like mammography (MMG) and ultrasonography (US) is performed to exclude malignancy. Preliminary investigations of breast magnetic resonance imaging (MRI) assume that it has additional value. With an increasing availability of MRI, it is of clinical importance to evaluate this. We evaluated the additional diagnostic value of MRI in patients with UBND in the absence of a palpable mass, with normal conventional imaging. METHODS: All women with UBND in the period November 2007-July 2012 were included. In addition to the standard work-up (patient's history, physical examination, MMG, and US), MRI was performed. Data from these examinations and treatment were collected retrospectively. RESULTS: A total of 111 women (mean age 52 years; range 23-80) were included. In nine (8 %) patients, malignancy was suspected on MRI while conventional imaging was normal. In eight (89 %) of these patients, histology was obtained, two by core biopsy and six by terminal duct excision. Benign conditions were found in six patients (86 %) and a (pre-) malignant lesion in two patients. In both cases, it concerned a ductal carcinoma in situ, which was treated with breast-conserving therapy. Moreover, in two cases of (pre)malignancy, the MRI was interpreted as negative. CONCLUSION: In patients with UBND who show no signs of a malignancy on conventional diagnostic examinations, the added value of a breast MRI is limited, since a malignancy can be demonstrated in <2 %.

Lead extraction for device related infections: a single-centre experience.

AIMS: We report a single-centre experience of extraction of infected pacing and ICD leads. METHODS: Retrospective study of consecutive lead extractions for infection. Lead extraction was by traction, or, if unsuccessful, a laser sheath was used. All procedures were performed in the operating room. RESULTS: Leads were extracted in 82 patients including 66 patients (80%) with infection occurring after replacement of the generator or revision of the leads. Previous treatment, without lead extraction, had failed in 51 patients (62%). Major complications (tamponade or haemothorax) occurred in 6 patients, 2 patients died despite emergency surgery. One patient succumbed to ongoing sepsis. Of the patients alive, a follow-up of at least 6 months (27 +/- 17 months) was available in 76 patients. All patients were cured; none had a recurrence. In 31 patients (41%) pacing was abandoned after lead extraction; all remained asymptomatic. CONCLUSION: Lead extraction is effective in curing pacemaker or ICD related infection, even after failed conservative therapy, but with a significant complication rate. The routine replacement of the generator should be reconsidered in patients in whom the indication for pacing is no longer valid, as the majority of infections occurred after revision of the system.

Síndrome de burnout: estudio sobre agentes de salud del ßrea de emergencias del GCBA / Burnout: study on agents of health of GCBAs emergencies areas

En 1982 C. Maslach definió a este síndrome en las siguientes dimensiones: cansancio emocional, despersonalización y disminución de logros personales. En este estudio se intenta evaluar su prevalencia y distribución en los agentes de salud del ßrea de emergencia, identificar las variables de riesgo, y determinar sus efectos en el desempe±o laboral, para luego poder crear estrategias que disminuyan los factores de riesgo

Síndrome de burnout: estudio sobre agentes de salud del ßrea de emergencias del GCBA / Burnout: study on agents of health of GCBA's emergencies areas

En 1982 C. Maslach definió a este síndrome en las siguientes dimensiones: cansancio emocional, despersonalización y disminución de logros personales. En este estudio se intenta evaluar su prevalencia y distribución en los agentes de salud del ßrea de emergencia, identificar las variables de riesgo, y determinar sus efectos en el desempe±o laboral, para luego poder crear estrategias que disminuyan los factores de riesgo

Recommendations for pacemaker implantation for the treatment of atrial tachyarrhythmias and resynchronisation therapy for heart failure: A report from the task force on pacemaker indications of the Dutch Working Group on Cardiac Pacing.

Today, new pacing algorithms and stimulation methods for the prevention and interruption of atrial tachyarrhythmias can be applied on patients who need bradycardia pacing for conventional reasons. In addition, biventricular pacing as additive treatment for patients with severe congestive heart failure due to ventricular systolic dysfunction and prolonged intraventricular conduction has shown to improve symptoms and reduce hospital admissions. These new pacing technologies and the optimising of the pacing programmes are complex, expensive and time-consuming. Based on many clinical studies the indications for these devices are beginning to emerge. To support the cardiologist's decision-making and to prevent waste of effort and resources, the 'ad hoc committee' has provided preliminary recommendations for implantable devices to treat atrial tachyarrhythmias and to extend the treatment of congestive heart failure respectively.

Malfunction of endocardial defibrillator leads and lead extraction: where do they meet?

AIMS: The development of new extraction techniques has improved the success rate of intravascular extraction of pacemaker and defibrillator leads, and hence the practice of extraction is expanding. However, the indications for lead extraction of malfunctioning leads in patients with an implantable cardioverter defibrillator (ICD) are still not well established. METHODS AND RESULTS: We reviewed the literature concerning structural complications of ICD leads. The clinical presentation and detection of malfunction is discussed as well as the consequences for adequate defibrillation therapy. An overview of the current published experience of intravascular extraction of ICD leads is provided including a brief discussion of our own experience. CONCLUSION: From this overview we conclude that malfunctioning pace-sense or ICD leads can be left in situ if there are no uncovered insulation defects. Inserting a new pace-sense or ICD lead is preferable in this situation given the current known complication rate of lead extraction. Lead extraction should be reserved for damaged leads in which interference with proper detection or defibrillation of newly inserted leads cannot be excluded.

Use of a laser sheath to obtain venous access in pacemaker lead-related obstruction without extraction of the lead.

AIMS: Occlusion of the subclavian vein resulting from pacemaker leads prohibits insertion of new leads. We describe the ipsilateral insertion of a new lead without extracting the old lead using a laser sheath in a pacemaker patient with an obstructed vein. METHODS AND RESULT: A laser sheath together with an outer sheath were advanced over the malfunctioning lead just beyond the occlusion. The laser sheath was pulled back and a guide wire inserted through the outer sheath kept in position distal of the occlusion. After removal of the outer sheath a peel-away sheath was introduced and a new lead implanted next to the malfunctioning lead that was abandoned and not extracted. CONCLUSION: By avoiding using the laser along the whole length of the lead we greatly reduced the risk of the procedure but were still able to recanalize the obstructed vein. A risk of bilateral occlusion is avoided and the contralateral site saved as an entry point for future needs.

Bright light therapy and melatonin in motor restless behaviour in dementia: a placebo-controlled study.

OBJECTIVE: The purpose of this study was to evaluate the effects of bright light therapy combined with melatonin on motor restless behaviour in dementia. DESIGN: Double-blind, placebo-controlled, cross-over trial consisting of four periods. One week wash-out was followed by a 2-week period of light therapy in combination with placebo or melatonin. The second wash-out period of 1 week was followed by 2 weeks of treatment (cross-over). SETTING: Twenty-four bed medium-stay psychogeriatric ward at a Dutch psychiatric teaching hospital. PATIENTS: Ten patients, who met the criteria for dementia (DSM-IV) and motor restless behaviour (subscale 10 of the GIP), were included. Informed consent was obtained by proxy. INTERVENTION: All subjects were exposed during 2x5 consecutive days for 30 minutes to 10,000 lux bright light and randomly administered 2.5 mg melatonin or placebo at 22.00 h. ASSESSMENTS: Clinical Global Impression (CGI), Dutch version of the geriatric behavioural observation scale (GIP), Social Dysfunction and Aggression Scale (SDAS) were assessed after each wash-out and treatment period. Outcome criteria were CGI, assessing motor restless behaviour, the SDAS, measuring extrovert aggression and the GIP, assessing social, psychomotor and emotional behaviour. RESULTS: Six demented inpatients completed the trial. Positive effects were found for the treatment combined with placebo. Patients were less restless and more co-operative. The condition with melatonin showed no additional positive effects, additionally, patients became more aggressive and showed the same or more disturbed behaviour. CONCLUSIONS: Bright light therapy has a positive effect on motor restless behaviour. Light therapy in combination with melatonin has no positive effects. The results might be explained by a possible overshoot of chronobiological synchronisation or the timing of the melatonin intake.

Exchange of pacing or defibrillator leads following laser sheath extraction of non-functional leads in patients with ipsilateral obstructed venous access.

Occlusion of the subclavian or brachiocephalic vein in pacemaker or defibrillator patients prohibits ipsilateral implantation of new leads with standard techniques in the event of lead malfunction. Three patients are presented in whom laser sheath extraction of a non-functional lead was performed in order to recanalise the occluded vein and to secure a route for implantation of new leads. This technique avoids abandoning a useful subpectoral site for pacing or defibrillator therapy. The laser sheath does not affect normally functioning leads at the same site.

Experience with U-shaped catheters in angiography and angioplasty of the left coronary artery.

We developed a U-shaped diagnostic and guiding catheter for left coronary angiography and angioplasty. Angiography with a 6 French (F) diagnostic U-shaped catheter was attempted in 101 patients (pts). Primary use in 82 pts; all successful. Secondary use after failure of 6 F left Judkins diagnostic catheters to intubate the left main coronary artery in 19 pts; 17 successful. An 8 F U-shaped guiding catheter was used for percutaneous transluminal coronary angioplasty (PTCA) of left coronary artery branches in 102 pts [left anterior descending (LAD), 48 pts; circumflex (CX), 54 pts]. Stable cannulation of the left coronary artery was achieved in 96 pts (94%), but PTCA was successful in 90 pts (88%). Primary use in 70 pts (LAD, 27 pts; CX, 43 pts). PTCA was successful in 60 pts. Secondary use after failure of left Judkins and Amplatz guiding catheters in 32 pts (LAD, 21 pts; CX, 11 pts). PTCA was successful in 30 pts. No complications were seen. In conclusion, U-shaped diagnostic and guiding catheters increased the success rate of 1) left coronary angiography after failure of left Judkins diagnostic catheters; and 2) PTCA of the left anterior descending and circumflex arteries after failure of left Judkins and Amplatz guiding catheters.

Experience with a double loop guiding catheter for angioplasty of the right coronary artery.

UNLABELLED: An 8 French (F) double loop guiding (DLG) catheter was developed for percutaneous transluminal coronary angioplasty (PTCA) of the right coronary artery (RCA) and tested in 80 patients: primary use in 59 patients, and after failure of an 8 F right Judkins guiding (RJG) catheter in 21 patients. Primary use resulted in stable intubation of RCA in 55 patients (93%), but PTCA was successful in 50 (91%). Five failures resulted from inability to cross or dilate the lesion. After failure of an 8 F RJG in 21 patients, successful stable intubation of RCA with a DLG was achieved in 19 patients (90%), but PTCA was successful in 17 patients (81%). Failure of RJGs in 21 patients resulted from inability to intubate the RCA in 12 patients, or inadequate back up support by the guiding in 9 patients. CONCLUSION: DLGs increased the success rate of PTCA of the RCA after failure of RJGs.

Shearing of the plastic coating of a hydrophilic guide wire in a right femoropopliteal bypass graft: removal from the contralateral side.

The plastic coating of a hydrophilic guide wire tore off during introduction through a beveled single wall arterial entry needle in a 75 year old male. The sheared piece of coating got stuck in his femoropopliteal bypass. It was removed by means of a modified arterial filter set from the contralateral side. The technique of its removal is described.

Optimized hemodynamics by implantation of a dual chamber pacemaker after heterotopic cardiac transplantation.

A patient who underwent prior heterotopic cardiac transplantation had persistent complaints of dyspnea, palpitations, and fatigue in spite of normal pump function of the donor heart. Repeated Holter monitoring excluded paroxysmal arrhythmias. It was thought that synchronization of both heart rates might alleviate his symptoms. The intrinsic heart rate of the donor heart was 90 beats/min, the recipient heart was 60 beats/min with acceleration up to 130 beats/min on exercise. A DDD pacemaker was implanted, the atrial lead was positioned in the right ventricule of the donor heart and the ventricular lead in the atrium of the recipient heart. Search for an optimal AV interval was evaluated by echo-Doppler and intraarterial pressure recordings. By increasing the AV interval from 125 to 300 msec, the maximum aortic flow velocity of the recipient heart increased from 1.0 to 1.2 m/sec. Left ventricular end-diastolic diameter remained unchanged, left ventricular end-systolic diameter decreased from 52 to 48 mm. Wall motion of the recipient left ventricle improved. At an AV interval of 125 msec there was alternate systolic contraction of both hearts, resulting in arterial pressure waves at a rate of 180/min. This did not relieve his symptoms and he complained further of headaches. At an AV interval of 300 msec contraction of the recipient heart just preceded that of the donor heart, resulting in arterial pressure waves at a rate of 90/min, normalization of the wave form, relief of symptoms, and improvement of exercise tolerance.

Fusion or confusion on Holter recording.

Holter recording of a patient with an implanted dual chamber rate responsive pacemaker revealed an electrocardiogram, where ventricular depolarization seemed to be initiated by the atrial stimulus. In a second patient with a VVI pacemaker, Holter recording showed delay of the pacemaker impulse that was registered after the onset of ventricular depolarization. Misalignment in one of the recorder heads of the display system was responsible for this phenomenon, which in case of dual chamber pacing could have been easily misinterpreted as pacemaker malfunction.

Changes in morphology of the paced QRS complex related to pacemaker output.

The influence of pacemaker output on the morphology of the paced QRS complex was studied from standard lead electrocardiograms in 69 patients with bipolar pacemakers. In 40 of the 69 patients (58%), there was a significant (P less than 0.001) change in electrical axis, from -75 degrees at the low output setting (2.7 V, 0.15 msec) to -67 degrees at the high output setting (8.1 V, 2.29 msec). In 30 patients, these changes were also associated with changes in the QRS morphology and in the T-wave. This phenomenon may be explained by additional stimulation from the proximal electrode at high output, thus altering the pattern of depolarization.