Management and outcomes of axial isolated distal deep vein thrombosis at North Shore Hospital, New Zealand: a retrospective audit.

BACKGROUND: It is standard of care to treat proximal vein deep vein thrombosis (DVT) for a minimum of 3 months. Conversely, management of isolated distal DVT (IDDVT) is controversial, with options including observation and repeat ultrasound scan within 1 week to detect and anticoagulate those with proximal propagation, or anticoagulation for periods of up to 3 months. AIM: The aim was to assess the rates of proximal propagation and venous thromboembolism (VTE) recurrence within 3 months of diagnosis of IDDVT, and to examine how the duration of treatment might influence this. METHODS: Study patients were identified by retrospective audit of data from the North Shore Hospital VTE database. All patients presenting with established axial vein distal DVT from July 2007 to June 2012 were included. A 6-week treatment duration cut-off was used to separate the treatment arms (<6 weeks vs 6 weeks vs >6 weeks), and Fisher's exact or Pearson's Chi-squared tests were used to assess between-group comparisons. RESULTS: Five hundred and seven patients were included in the study, mean age 59.7 years; 53% female. There were three cases of proximal propagation, all occurring in those receiving <6 weeks treatment. There were six VTE recurrences, three in the <6 week and three in the ≥6 week treatment groups respectively. Malignancy was the only significant predictor of VTE recurrence (P = 0.001). CONCLUSION: A 6-week duration of anticoagulation appears to be an effective and safe treatment for isolated axial distal DVT, with low rates of VTE recurrence and proximal propagation.

Management and outcomes of single subsegmental pulmonary embolus: a retrospective audit at North Shore Hospital, New Zealand.

BACKGROUND: It is unknown whether filling defects in subsegmental arteries on multidetector computed tomography pulmonary angiography correlate with clinically relevant subsegmental pulmonary embolism (PE) on pulmonary angiography. Current guidelines do not differentiate between PE in segmental and subsegmental vessels, and many patients receive at least 3 months anticoagulation. The strategy employed at North Shore Hospital in haemodynamically stable patients with single subsegmental PE is to perform bilateral lower leg compression ultrasound (CUS). Anticoagulation is withheld if CUS is negative; a bilateral CUS is repeated in 7-10 days. AIM: The aim of this retrospective audit was to ensure our current management strategy is safe. METHODS: All diagnoses of single subsegmental PE between June 2005 and June 2013 were included. The primary outcome was the rate of venous thromboembolism (VTE) recurrence within 3 months of single subsegmental PE diagnosis. Secondary outcomes were rates of major/minor bleeding and all-cause mortality. RESULTS: Thirty-two patients were included - 20 were treated with anticoagulation; 12 were managed with observation/serial bilateral lower limb CUS. None of the patients in either group had VTE recurrence by 3 months. No bleeding episodes were observed in the observation group; there was a 10% major bleeding rate (n = 2) in the treatment group. One death occurred in each group, neither of which was attributed to VTE. CONCLUSION: Withholding anticoagulation in patients with single subsegmental PE and negative serial bilateral CUS appears to be a safe and effective management strategy, with a low risk of VTE recurrence.

Implementing psychological interventions delivered by respiratory professionals for people with COPD. A stakeholder interview study.

Implementing psychological interventions in healthcare services requires an understanding of the organisational context. We conducted an interview study with UK National Health Service stakeholders to understand the barriers and facilitators for implementing psychological interventions for people with chronic obstructive pulmonary disorder (COPD). We used TANDEM as an exemplar intervention; a psychological intervention recently evaluated in a randomised controlled trial. Twenty participants providing care and/or services to people with COPD were purposively sampled from NHS primary/secondary care, and commissioning organisations. Participants were recruited via professional networks and referrals. Verbatim transcripts of semi-structured interviews were analysed using thematic analysis. Four themes were identified: (1) Living with COPD and emotional distress affects engagement with physical and psychological services; (2) Resource limitations affects service provision in COPD; (3) Provision of integrated care is important for patient well-being; and (4) Healthcare communication can be an enabler or a barrier to patient engagement. People need support with physical and psychological symptoms inherent with COPD and healthcare should be provided holistically. Respiratory healthcare professionals are considered able to provide psychologically informed approaches, but resources must be available for training, staff supervision and service integration. Communication between professionals is vital for clear understanding of an intervention's aims and content, to facilitate referrals and uptake. There was widespread commitment to integrating psychological and physical care, and support of respiratory healthcare professionals' role in delivering psychological interventions but significant barriers to implementation due to concerns around resources and cost efficiency. The current study informs future intervention development and implementation.

Oral fluconazole therapy for patients with acquired immunodeficiency syndrome and cryptococcosis: experience with 22 patients.

PURPOSE: Cryptococcus neoformans causes infections in up to 10 percent of patients with the acquired immunodeficiency syndrome (AIDS). Nearly 50 percent of AIDS patients with previously treated cryptococcal meningitis will experience a relapse within six months. To reduce the likelihood of relapse, a maintenance regimen of amphotericin B is often administered weekly. However, the drug's intravenous route of administration and considerable toxicity have led to a search for alternative antifungal agents. In this report, we document our experience with fluconazole, a new oral triazole antifungal agent. PATIENTS AND METHODS: Twenty-two patients with AIDS and various forms of cryptococcosis were treated in an open-label study with 50 to 400 mg/day of fluconazole. The following laboratory studies were done on a monthly basis: complete blood cell count, liver function tests, serum creatinine level, serum cryptococcal antigen level, and serum fluconazole level. Lumbar puncture was performed in patients with meningitis every four to eight weeks to evaluate cerebrospinal fluid cryptococcal antigen, India ink preparation findings, fungal culture, fluconazole level, and protein, glucose, and cell count. RESULTS: Of seven patients with active culture-positive infections, four showed clinical and microbiologic responses (three of four with meningitis, one of three with extraneural cryptococcosis). Fifteen patients who had already undergone successful amphotericin B therapy for either meningitis (n = 14) or pneumonia (n = 1) received fluconazole as prophylaxis against relapse. Fourteen patients remained free of infection during 11 to 64 weeks of suppressive therapy; one patient with meningitis experienced relapse after 26 weeks of treatment. Reverse reactions were limited to increases in hepatic enzyme levels in four patients. CONCLUSION: These results appear sufficiently encouraging to warrant further trials of this oral agent in the suppression of chronic cryptococcosis and perhaps in the treatment of acute infection.

Melphalan-induced pulmonary interstitial fibrosis.

Diffuse interstitial fibrosis developed in a patient receiving therapy with melphalan for multiple myeloma. With cessation of the administration of the alkylating agent and corticosteroid, we describe progressive radiographic improvement in this patient, accompanied by persistent severe impairment in gas exchange.

Laryngospasm-induced pulmonary edema.

Laryngospasm developed in a 33-year-old woman following attempted endotracheal intubation. Following establishment of the airway, the patient developed pulmonary edema which was successfully treated by conventional means. The sequence of events suggests that laryngospasm precipitated the development of the pulmonary edema in this patient.

Isolated T wave alternans progressing to QRS-T alternation after ventricular defibrillation.

A 54-year-old woman underwent replacement of a thrombosed Björk-Shiley aortic valve prosthesis. Post operative electrical defibrillation resulted in isolated T wave alternation which progressed to total QRS-T electrical alternans. This report represents the first description of such a phenomenon.

A cross-referencing method for simultaneous slow and multiple unit potential recording with implanted electrodes.

The effective pairing of a non-polarizing Ag-AgCl with an adjacent polarizing stainless steel minielectrode for simultaneous recording of slow or sustained potentials, conventional ECoG, and multiple unit potentials is demonstrated. The two types of electrode reciprocate their reference functions, the non-polarizing electrode being insensitive to the low voltage 1500-2500 kHz signal transmitted by the polarizing member and the latter being insensitive to the slow potentials (0-0.5 Hz) detected by the non-polarizing member. The method enables obtaining unambiguous information from a localized source in bipolar derivations and permits use of construction methods simpler than those required for the hybrid electrodes formerly used.

Slow and multiple unit potentials in trace and temporal conditioning controlled by electrical reward in the rat.

Rats trained to expect medial forebrain bundle electrical reward every 17 sec acquire, in their visual cortex, a linear gradient of increasing negative potential over the prereinforcement half of the interval. The postreinforcement half of the interval is occupied by a less linear reversal of the negative shift. Integrated multiple unit activity from the same electrodes shows for the same half intervals, respectively, acquisition of progressive increase and sudden decrease. Behaviorally, naive subjects are most active following the reinforcement, becoming progressively less active in the second half of the interreinforcement interval. After training, the above pattern is reversed with sudden cessation of activity following reinforcement and progressive increase beginning about 5 sec later and continuing to the time of reinforcement. Slopes for the negative anticipatory potential gradient (APG) ranged from 8 to 28 microV/sec in different subjects on the 17 sec interreinforcement interval. Doubling the interval halved the slope, the maximum prereinforcement negative voltage remaining constant. The phenomenon thus appears as a relative or pacing dynamic rather than as an absolute or fixed microvolts/second function. Making the interreinforcement interval variable caused loss of both the anticipatory gradient and the integrated multiple unit increment. Trace conditioning with variable intertrial interval restored an anticipatory gradient and multiple unit increment. The specific dissociation of unit firing activity during the APG previously reported in the quietly expectant cat is not seen in this study owing to the excited expectancy in the rat anticipating MFB reward. Although the longer periods of negative potential gradient and unit action potential activity appear associated rather than dissociated, transient dissociations in patterns were observed during shorter duration shifts in the slow potential. Resolution of these variations must await more definitive study of unit activity and sustained potential genesis.