[Developing the valuable contribution of the nursing role in a palliative care mobile team]. / Valoriser la richesse du rôle infirmier en équipe mobile de soins palliatifs.

A Swiss palliative care mobile team shares its atypical experience resulting from the lack of a permanent doctor within the team because of recruitment difficulties, over a 16-month period. The positive result of this situation was the development of the nursing team's expertise and the experience of a remote constructive cross-discipline approach.

[It all started with a simple symptom and then Basic palliative medical tools for primary care physicians]. / Tout a commencé par un simple symptôme, puis Outils de base de médecine palliative à destination des médecins de premier recours.

The treatment of symptoms in palliative care is of primary importance, though this in itself is not sufficient for the relief of all aspects of a patient's suffering. Pain, dyspnea, or anxiety cannot be reduced to a single somatic characteristic, the psychological implications and the consequences on the patient's daily life being of paramount importance. A respect with regard to certain basic principles, and a full knowledge of the main therapeutic approaches available, allow for a better initial management of the symptoms.To this end we propose references as a memory aid while pointing out that the apparition of complex elements or instability in this type of case justifies having recourse to a specialised structure.

Dans l'approche palliative, le traitement des symptômes est une première nécessité, cependant il n'est pas suffisant pour répondre à toutes les dimensions de la souffrance. La douleur, la dyspnée ou l'angoisse ne sauraient se résumer à un caractère somatique ; leur retentissement psychologique et leurs conséquences sur le quotidien du patient étant primordiaux. Le respect de quelques principes de base et la connaissance des principales thérapeutiques permettent de répondre en première intention à la gestion des symptômes. Nous proposerons à cet effet des liens de référence en guise d'aide-mémoire, tout en rappelant que l'apparition d'éléments de complexité ou d'instabilité dans ce type de prise en charge justifie l'appui d'une structure spécialisée.

Improvement of migraine headaches after percutaneous closure of patent foramen ovale for secondary prevention of paradoxical embolism.

OBJECTIVES: Patent foramen ovale (PFO) has been linked to migraine, and an improvement in migraine prevalence or frequency has been reported after PFO closure for other reasons. We sought to identify whether there is a specific patient population of migraineurs which may be more susceptible to benefiting from PFO closure. DESIGN: Retrospective cohort study. SETTING: Tertiary care centre. Participants 603 consecutive patients undergoing percutaneous PFO closure for secondary prevention of paradoxical embolism. INTERVENTIONS: PFO closure using the Amplatzer PFO occluder. MAIN OUTCOME MEASURES: Improvement of migraine symptoms. RESULTS: 150 patients (25%; aged 51+/-11 years) suffered from migraine, including 96 patients with migraine with aura. All implantation procedures were successful, without procedural complications. Contrast transoesophageal echocardiography at 6 months showed complete PFO closure in 136 patients (91%), whereas a minimal, moderate or large residual shunt persisted in 11 (7%), 2 (1%) or 1 (1%) patients, respectively. During 5.0+/-1.9 years of follow-up, one TIA and one ischaemic stroke occurred. Migraine headaches disappeared in 51 patients (34%) and improved in 72 additional patients (48%). Mean subjective improvement was 69+/-35%. Overall, mean headache frequency (from 2-3x/month to 1x/month; p<0.001), duration (from 4-72 to <4 h; p<0.001) and intensity (from 7+/-2 to 3+/-3; p<0.001) improved significantly. The prevalence of any migraine headaches (from 100% to 66%; p<0.001), migraine with aura (from 64% to 19%; p<0.001) and the number of patients taking any migraine medication (from 90% to 50%; p<0.001) decreased significantly. Both the presence of aura (OR 3.2; 95%CI 1.3 to 8.2; p=0.014) and high pain intensity at baseline (pain scale >5; OR 3.3; 95%CI 1.3 to 8.4; p=0.013) were independent predictors of response to PFO closure. A residual shunt had no influence on migraine improvement (OR 0.6; 95%CI 0.1 to 2.3; p=0.42). CONCLUSIONS: These results suggest that percutaneous PFO closure durably alters the spontaneous course of shunt-associated migraine, especially but not exclusively in case of migraine with aura.

Late results after percutaneous closure of patent foramen ovale for secondary prevention of paradoxical embolism using the amplatzer PFO occluder without intraprocedural echocardiography: effect of device size.

OBJECTIVES: We sought to assess the safety and clinical efficacy of patent foramen ovale (PFO) closure under fluoroscopic guidance only, without intraprocedural echocardiography. BACKGROUND: Percutaneous PFO closure has been shown to be safe and feasible using several devices. It is generally performed using simultaneously fluoroscopic and transesophageal or intracardiac echocardiographic guidance. Transesophageal echocardiography requires sedation or general anesthesia and intubation to avoid aspiration. Intracardiac echocardiography is costly and has inherent risks. Both lengthen the procedure. The Amplatzer PFO Occluder (AGA Medical Corporation, Golden Valley, Minnesota) can be safely implanted without echocardiographic guidance. METHODS: A total of 620 patients (51 +/- 12 years; 66% male) underwent PFO closure using the Amplatzer PFO Occluder for secondary prevention of presumed paradoxical embolism. Based on size and mobility of the PFO and the interatrial septum, an 18-mm device was used in 50 patients, a 25-mm device in 492, and a 35-mm device in 78. RESULTS: All procedures were successful, with 5 procedural complications (0.8%): 4 arteriovenous fistulae requiring elective surgical correction, and 1 transient ischemic attack. Contrast transesophageal echocardiography at 6 months showed complete closure in 91% of patients, whereas a minimal, moderate, or large residual shunt persisted in 6%, 2%, and 1%, respectively. During a mean follow-up period of 3.0 +/- 1.9 years (median: 2.6 years; total patient-years: 1,871), 5 ischemic strokes, 8 transient ischemic attacks, and no peripheral emboli were reported. Freedom from recurrent ischemic stroke, transient ischemic attack, or peripheral embolism was 99% at 1 year, 99% at 2 years, and 97% at 5 years. CONCLUSIONS: The Amplatzer PFO Occluder affords excellent safety and long-term clinical efficacy of percutaneous PFO closure without intraprocedural echocardiography.

Percutaneous closure of patent foramen ovale for migraine headaches refractory to medical treatment.

BACKGROUND: Patent foramen ovale (PFO) has been linked to migraine, and several retrospective studies reported an improvement in migraine prevalence or frequency after PFO closure for other reasons, mostly for secondary prevention of paradoxical embolism or following diving accidents. We investigated the outcome of patients undergoing PFO closure solely for migraine headaches refractory to medical treatment. METHODS: Seventeen patients (age 44 +/- 12 years; 76% female; one atrial septal aneurysm) underwent percutaneous PFO closure using the Amplatzer PFO Occluder (AGA Medical Corporation, Golden Valley, MN). An 18-mm device was used in two patients, a 25-mm device in 13, and a 35-mm device in two. The interventions were solely guided by fluoroscopy, without intraprocedural echocardiography. RESULTS: All implantation procedures were successful. There were no peri-procedural complications. Contrast transesophageal echocardiography after Valsalva maneuver at 6 months showed complete PFO closure in 16 patients (94%), whereas a minimal residual shunt persisted in one (6%). During 2.7 +/- 1.5 years of follow-up, no deaths and no embolic events occurred. After PFO closure, migraine headaches disappeared in four patients (24%), and improved in eight additional patients (47%). Three patients (18%) reported a decrease of their headaches by 75%, three patients (18%) a decrease of 50%, and two patients (12%) a decrease of 25%, while headaches remained unchanged in five patients (29%). No patient experienced worsening headaches. Moreover, the prevalence of migraine with aura decreased from 82 to 24% (P = 0.002). CONCLUSIONS: These results suggest that percutaneous PFO closure durably alters the spontaneous course of shunt associated migraine.