Infective endocarditis following transcatheter aortic valve replacement—: Diagnostic and management challenges

Transcatheter aortic valve replacement (TAVR) can improve the symptoms and prognosis of patients with severe aortic stenosis who, due to a high expected operative risk, would not have otherwise been treated surgically. If these patients develop prosthetic valve endocarditis, their presentations may be atypical causing a delay in the diagnosis and treatment. The management is also complicated by their comorbidities, and surgical treatment may not be feasible leading to a significant morbidity and mortality. We describe a case of an 85‐year‐old man with TAVI prosthetic valve endocarditis successfully treated medically, discuss the challenges in the diagnosis and management of such patients, and review available literature on the incidence and outcome of the condition. © 2012 Wiley Periodicals, Inc.     

Intravenous fluids in minor surgery. Their effect on recovery from anaesthesia

The value of infusing a total of 2 litres of intravenous fluids intra- and postoperatively was assessed in 212 fasting patients undergoing minor surgery procedures. The treated patients (108) recovered from the effects of surgery and anaesthesia more quickly than patients without fluids (104). The results of improved quality of the postoperative recovery, a shorter hospital stay and earlier return to work, especially in those patients who had some difficulty in recovering from anaesthesia on previous occasions, encourages the more frequent use of intravenous fluids in minor surgery.     

An Australian Experience of Transdermal Oestradiol Patches in a Subtropical Climate

Summary: Tolerability and efficacy of transdermal oestradiol patches were assessed in 121 menopausal women over a period of 3 months to 2.5 years. Of particular interest, in a subtropical climate such as Brisbane, were the problems associated with adhesiveness and skin irritation during the summer months. We conducted a retrospective study with self-administered questionnaires. All patients had been selected for the nonoral route because of side-effects or relative contraindications to oral therapy. There was, overall, good efficacy and acceptability. The majority of the women found the patch very adequate in relieving symptoms of the menopause (vasomotor, genitourinary and musculoskeletal). Most preferred the patch to oral therapy. The oestradiol patch was well tolerated and few side-effects were reported. Breast tenderness and weight gain were 2 minor problems associated with its use. Skin irritation was minimal, but adhesiveness was a problem during the summer months, especially with swimming or showering. Some practical suggestions were obtained about how to overcome site of application problems.     

Thinking of the future and walking back to normal: an exploratory study of patients' experiences during recovery from lower limb fracture

Thinking of the future and walking back to normal: an exploratory study of patients' experiences during recovery from lower limb fracture ¶ Admission to hospital following a traumatic lower limb fracture is undoubtedly a stressful life event; however, few studies have detailed this from the patient's perspective. By exploring patients' experiences of hospitalization with lower limb trauma, this study aimed to explicate some of the factors impinging on the recovery trajectory. Patients' perceptions of the events influencing their strategies for coping with stress, hospitalization and temporary incapacity were investigated using a qualitative methodology. A convenience sample of nine patients was recruited from an orthopaedic ward in a district general hospital in Wales. The respondents used health diaries to document their recovery for up to 6 weeks after emergency surgery. These diaries were validated and supplemented by semi-structured interviews. Following their traumatic injuries, our respondents were subjected to a variety of stressors and uncertainties. They coped with this period of uncertainty by positive attempts to gain control over their situations, guided by an over-riding desire to 'return to normal' and assisted by the caring attributes of their nurses. From the experiences and events documented, this study was able to identify several stressors which could have been mitigated by optimization of the technical aspects of care, including the management of pain.     

Factors that influence the induction dose of propofol

Factors that influence the induction of anaesthesia with propofol were investigated in a prospective study of 1000 patients. Pre-operative albumin and urea concentrations correlated with the minimum induction dose of propofol, but less strong correlations were found with haemoglobin, globulin and total protein concentrations. Age was an important influence on the induction dose of propofol (r = -0.34) which was also closely related to ASA grade. Induction of anaesthesia with propofol is dependent on a number of variables, and this study suggests that pre-operative albumin and urea concentrations are important.     

A case of systemic nodular panniculitis associated with M1 (Val213) Z phenotype of α1-protease inhibitor

A 31-year-old woman presented with a 13-year history of tender, subcutaneous nodules on her arms, abdomen, buttocks, back, and thighs. In the most acute phase the inflammation of the subcutaneous tissue was more diffuse. Subsequently the nodules ulcerated and discharged an oily fluid. The course fluctuated, with periods of intense inflammation at several fatty sites and times of low-grade inflammation. Systemic symptoms included Raynaud's phenomenon, joint pains involving her hands, elbows, and shoulder, and morning stiffness lasting about 1–2 h. The patient was never completely free of disease in spite of almost continuous treatment, including chloroquine for 3 months which was stopped following visual problems, potassium iodide which caused asphyxic reaction and was stopped, pulse therapy with cyclophosphamide which was associated with some improvement, dapsone for 3 months which had no effect, and prednisone (up to 90 mg/day) for a few weeks which resulted in minimal improvement. The patient had previously been treated for urinary tract infections and had been investigated for primary infertility. At the time of the present examination, there were multiple depressed scars on her arms and buttocks. Some discharging sinuses with adjacent areas of inflammation were present on the buttocks. Re-examination of biopsies taken 10 years previously and diagnosed as indicative of Weber-Christian disease showed subcutaneous fat necrosis with dystrophic calcification. An inflammatory infiltrate consisting of polymorphonuclear leukocytes, lymphocytes, macrophages, and foam cells surrounded the necrotic tissue. Some of the lesions formed sinuses lined by granulation tissue extending from the subcutaneous necrotic tissue to the surface of the skin. The full blood count was normal, as were the sedimentation rate, electrolytes, and amylase. The liver function tests demonstrated a raised Gamma-glutamyl transferase (GGT), but were otherwise normal. The anti-nuclear factor (ANF) was positive, with a titre for anticentromere antibodies of > 1/640. Anti-ds-DNA and rheumatoid factor were negative. The phenotype (Pi) and genotype of α₁-protease inhibitor (α₁-PI) was determined in the patient and her family. This was performed as previously described.¹ The phenotype of the patient's mother and all her siblings was found to be (Pi) Ml (Val213)Z, while her father was (Pi) M1(Val213)M1(Val213) (Table 1). Concentrations of α₁-PI were somewhat below the normal range (2–4 g/L) in the patient and other family members with a similar phenotype, but so too was the concentration in the unaffected father. In addition, there was a modest but significant reduction in plasma elastase inhibitory capacity (EIC) in subjects with the Pi M1(Val213)Z phenotype.     

AUDIT OF THE RELATIONSHIP BETWEEN EPISIOTOMY AND RISK OF MAJOR PERINEAL LACERATION DURING CHILDBIRTH

SUMMARY The beneficial effect of mediolateral episiotomy in reducing major perineal lacerations during childbirth has been questioned. In a test of the hypothesis of no association between episiotomy and the incidence of major perineal lacerations, the incidence of major perineal laceration was determined in three cohort groups in one maternity unit between 1984 and 1991. Among those undergoing non-instrumental delivery, no reduction in the incidence of major lacerations could be demonstrated following episiotomy. Among those undergoing episiotomy, the incidence of major lacerations was significantly higher following instrumental delivery.     

Canadian contributions to the introduction and use of divinyl ether

In conclusion, Dr. Gelfan and Bell’s early work was a brief practical study, typical of the uninhibited work of many of the pioneers in anesthesia, who willingly participated as “guinea pigs“ in their continuing search to advance the body of medical knowledge in the pharmacology of anesthetic agents. Their work provides inspiring examples of how Canadian researchers have quietly contributed to advances in anesthesia for many decades. Drs. Gelfan and Bell deserve considerable credit for taking that very important first step to evaluate the use of DVE in humans, as Dr. Bourne deserves credit for popularizing the use of this historically important inhaled anesthetic in clinical anesthesia, in Canada and the United States.