Pneumopericardium and pneumothorax contralateral to venous access site after permanent pacemaker implantation.

A 77-year-old female underwent implantation of a left-sided dual chamber permanent pacemaker for symptomatic bradycardia with active fixation leads. Eight hours after the procedure, the patient complained of shortness of breath and was found to have a 30% right pneumothorax on chest X-ray. Immediately, a chest tube was inserted, promptly relieving the symptoms. A CT scan of the chest revealed extrusion of the helix of the screw-in atrial lead, through the wall of the right atrial appendage. The helix was abutting a bulla in the right lung, the likely cause for pneumothorax and pneumopericardium. The atrial lead was explanted without incident.

Atrioventricular nodal reentrant tachycardia requiring ablation on the mitral annulus.

We report a case of initial transient success during ablation for typical AV nodal reentrant tachycardia utilizing traditional right-sided approaches, followed by recurrence of the same tachycardia and an ultimately successful ablation on the posteromedial mitral annulus.

Management of postinfarct ventricular tachycardias.

The clinical profile of patients with postinfarct VT has changed in the past two decades. Along with these changes, existing treatments have improved, and entirely new therapeutic approaches have been developed. The expanded range of treatment options has made postinfarct VT a less imposing clinical problem than it once was. Emerging therapies promise to make an even greater beneficial impact. The challenge in treating patients with postinfarct VT has changed from merely keeping patients alive to keeping up with innovations in therapy that can provide them with a better quantity and quality of life.

Rheolytic thrombectomy: a new treatment for stent thrombosis.

Coronary stent thrombosis, a rare complication after stent deployment, carries major morbidity and mortality. Traditional treatments for stent thrombosis include local or systemic delivery of thrombolytic agents and balloon angioplasty, both with far from optimum results. We report on two cases of coronary stent thrombosis successfully treated with rheolytic thrombectomy as an adjunct to balloon angioplasty.

Identification of the sites of interaction between the scaffold and outer shell in herpes simplex virus-1 capsids by difference electron imaging.

Formation of herpes simplex virus-1 capsids requires the presence of intact scaffolding proteins. The C terminus of the abundant scaffolding protein associates with the major capsid shell protein VP5 through hydrophobic interactions. After cleavage by the viral encoded protease, which removes their C-terminal 25 aa, the scaffolding proteins are released from the capsid. We have used electron cryomicroscopy and computer image processing to determine, to 13 A, the three-dimensional structures of capsids containing either cleaved or uncleaved scaffolding proteins. Detailed comparisons show that the structures of the outer icosahedral shells are almost identical in the two capsid types. Differences are apparent in the radial distribution of the density inside the capsid shell (within a radius of 460 ) which represents the scaffolding core. However, in both capsid types, the bulk of this internal density exhibits no icosahedral symmetry. Close examination revealed localized regions of icosahedrally arranged extra density at the interface between the outer shell and the scaffold of protease-minus capsids. Rod-like densities extending inwards for approximately 40 from the capsid shell are present under four of the six quasi-equivalent triplex positions. Under triplexes Tb, Tc, and Te, the major additional densities appear as pairs with the rods in each pair situated 37 apart. We propose that these rods are formed by the C-termini of the scaffolding proteins and represent the sites of interaction between the capsid shell and scaffold.

Refinement of herpesvirus B-capsid structure on parallel supercomputers.

Electron cryomicroscopy and icosahedral reconstruction are used to obtain the three-dimensional structure of the 1250-A-diameter herpesvirus B-capsid. The centers and orientations of particles in focal pairs of 400-kV, spot-scan micrographs are determined and iteratively refined by common-lines-based local and global refinement procedures. We describe the rationale behind choosing shared-memory multiprocessor computers for executing the global refinement, which is the most computationally intensive step in the reconstruction procedure. This refinement has been implemented on three different shared-memory supercomputers. The speedup and efficiency are evaluated by using test data sets with different numbers of particles and processors. Using this parallel refinement program, we refine the herpesvirus B-capsid from 355-particle images to 13-A resolution. The map shows new structural features and interactions of the protein subunits in the three distinct morphological units: penton, hexon, and triplex of this T = 16 icosahedral particle.

Insomnia in the elderly: its prevalence and correlates in the general population.

OBJECTIVE: To estimate the prevalence of persistent insomnia and its correlates in samples of people living in the community and in institutional settings. METHODS: Respondents were interviewed in their place of residence by trained interviewers using the Canberra Interview for the Elderly, a structured psychiatric examination. RESULTS: Information about sleeping habits was obtained from 874 community and 59 institutional residents. Insomnia was persistent in 16% of the community-dwelling population and 12% of the institutional residents, with 15% and 40%, respectively, regularly taking a hypnotic. Of those without insomnia, 10% in the community but over a third in institutions were using a hypnotic. Insomnia was associated with depression, pain and poor physical health. CONCLUSIONS: Persistent insomnia in the elderly, as in other age groups, is strongly associated with depressed mood, as well as with physical disease. Because of this, insomnia should not be dismissed as a normal part of ageing, and therefore ignored as a significant symptom. Continued surveillance is needed in general practice, geriatric services and nursing homes of the routine use of hypnotics by the elderly.

Age differences and interindividual variation in cognition in community-dwelling elderly.

The cognitive test performance of 897 community-dwelling elderly Ss, aged 70 years and over, was examined for age trends and interindividual variation. Data were subjected to factor analysis, and 3 factors emerged (Crystallized Intelligence, Fluid Intelligence, and Memory). Over the age span sampled, Crystallized Intelligence, Fluid Intelligence, and Memory all decreased with the decrease being greatest for Fluid Intelligence and least for Crystallized Intelligence. Interindividual variation increased for Fluid Intelligence and Memory, but not for Crystallized Intelligence. These findings give support to the view that crystallized intelligence is lower in the very old and that there is a greater degree of variability in test performance with advancing age.

A survey of dementia in the Canberra population: experience with ICD-10 and DSM-III-R criteria.

A community survey of 1045 persons aged 70 years and over was conducted to identify cases of dementia in the cities of Canberra and Queanbeyan. Cases were identified using the Canberra Interview for the Elderly, administered by lay interviewers. When diagnostic criteria were rigidly applied, the point prevalence of dementia in the combined sample of community and institutional residents was considerably lower by ICD-10 than by DSM-III-R. Both criteria showed a similar rise in prevalence with age, and no gender difference. Agreement between the two systems had a kappa of only 0.48. 'Probable' cases by either criteria were identified solely from respondent-provided information in order to include persons for whom no informant was available. The point prevalence of such 'probable' cases was more similar for the two systems, and the kappa coefficient of agreement rose to 0.80. Analysis of the various components required for a diagnosis of dementia showed that the prevalence of all increased with age. Components involving cognitive assessment were correlated with education, but other components were not. The results of the study point to important differences between ICD-10 and DSM-III-R diagnoses of dementia.

The relationship between health and cognitive functioning in a sample of elderly people in the community.

The association between health status and cognitive performance was examined in a sample of 708 community dwelling elderly people aged 70 years or over. Cognitive performance declined significantly across the age groups 70-74, 75-79, 80-84, and 85-89 years on the Mini-Mental State Examination and on measures of fluid intelligence and memory, but not on measures of crystallized intelligence. Health status declined significantly across age for five of 49 past and current medical conditions, for measures of Activities of Daily Living (ADL) and for systolic blood pressure, but did not decline significantly for global self-ratings of health, diastolic blood pressure or reports of smoking. Weak but significant correlations between health and cognitive performance were found for self-reported global ratings of health and for self-reports of some physical symptoms but not for diastolic or systolic blood pressure, or for many other physical conditions. Both self- and informant-based ratings of ADL correlated with cognitive performance. Age differences remained after cognitive performance was adjusted for health variables such as ADL, self-ratings of health and current health problems. It is concluded that, at the population level, lower levels of cognitive performance in community-dwelling elderly subjects are not strongly mediated by ill health.

The prevalence of depressive disorders and the distribution of depressive symptoms in later life: a survey using Draft ICD-10 and DSM-III-R.

The point prevalence of depressive disorders was estimated in a sample of persons aged 70 years and over, which included both those living in the community and those in institutional settings. Lay interviewers administered the Canberra Interview for the Elderly to the subjects and their informants. The point prevalence of depressive episodes as defined by the Draft ICD-10 diagnostic criteria was 3.3%. The rate for DSM-III-R major depressive disorder was 1.0%. The latter prevalence rate is similar to those reported elsewhere for the elderly. Evidence is accumulating that older persons may indeed have low rates for depressive disorders at the formal case level. Possible reasons for this finding are offered. A scale for depressive symptoms, based exclusively on those specified in Draft ICD-10 and DSM-III-R, showed that the elderly do experience many depressive symptoms. Contrary to expectation, these did not increase with age. The number of depressive symptoms was correlated with neuroticism, poor physical health, disability and a history of previous depression. Attention now needs to be directed to the clinical significance of depressive symptoms below the case level in elderly persons.

The Canberra Interview for the Elderly: assessment of its validity in the diagnosis of dementia and depression.

The Canberra Interview for the Elderly (CIE) has been developed as a field instrument for identifying cases of dementia and depression, according to the diagnostic criteria in both draft ICD-10 and DSM-III-R. It has been designed to be administered by lay interviewers and responses are assembled algorithmically to derive diagnoses. The validity of the CIE was assessed using a sample of 75 elderly patients attending a hospital clinic. The CIE diagnoses were compared with clinical judgements made at the time of recruitment into the study and later by 3 clinicians using the information collected by the lay interviewers. Agreement between the CIE and the clinicians' diagnoses was as great as agreement between the clinicians themselves, meeting or exceeding agreement observed for comparable instruments designed for lay administration.

Contamination of a multiple-use suction catheter in a closed-circuit system compared to contamination of a disposable, single-use suction catheter.

UNLABELLED: Multiple-use (M-U) closed-system endotracheal suction catheters are effective in preventing arterial oxygen desaturation in patients on positive end-expiratory pressure (PEEP) and may lessen the frequency of bradycardia and hypotension in unstable patients who are prone to these complications of suctioning. However, because M-U catheters remain attached to the ventilator circuit and are reintroduced repeatedly into the patient's airway over 24 hours or longer, they could become heavily contaminated with pathogens. We hypothesized a risk of autocontamination to the patient by re-inoculation of the respiratory tract with organisms that flourished on the M-U catheter while it was isolated from the patient's immune defenses or antibiotic therapy. METHODS: We tested this hypothesis in 30 mechanically ventilated adult patients with positive sputum cultures. We measured and compared the amount of bacteria present on an M-U catheter at the end of a 24-hour use period, the amount of bacteria present in the patient's sputum at that time, and the amount of bacteria present on a single-use (S-U) catheter at that time, after it had made one pass into the patient's airway. Organisms recovered and colony counts were also compared to results of a sputum culture obtained before the study began. RESULTS: Fourteen different pathogens or potential pathogens were recovered, in numbers of 2 x 10(1) to 2 x 10(7)colony-forming units. The greatest number of colonies was most often recovered from the sputum specimen, and statistical analysis showed no differences in rate or magnitude of contamination between M-U and S-U catheters.(ABSTRACT TRUNCATED AT 250 WORDS)