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PubMed2002

Impact of the "belly board" device on treatment reproducibility in preoperative radiotherapy for rectal cancer.

BACKGROUND: The use of the belly board device (BBD) in the prone position has gained acceptance to spare small bowel in rectal cancer patients irradiated postoperatively, but there are few data in the preoperative setting, and the advantages of the BBD regarding normal tissue sparing may be counteracted by problems of patient positioning. This study was undertaken to investigate prospectively the influence of the BBD on treatment reproducibility in patients irradiated preoperatively in the prone position. PATIENTS AND METHODS: 23 patients with rectal carcinoma in clinical stages II/III were included in this study. Axis displacement was evaluated in 14 patients treated without the BBD and nine with. The BBD is a commercial device (Belly Board, Radiation Products Design, Albertville, MN) made of a 17-cm thick hard sponge with an opening of 42 x 42 cm2. No specific patient immobilization devices were used. During radiotherapy, twelve patients had four control films, while eleven patients had three. The mean treatment position deviation was calculated for the medio-lateral, cranio-caudal and antero-posterior directions. RESULTS: When comparing the first control film to the corresponding simulation film for patients without the BBD and with the BBD, the mean lateral displacements were 1.5 mm and 3.2 mm (p = 0.26), the mean cranio-caudal displacements were 1.55 mm and 4.2 mm (p = 0.13), and the mean antero-posterior displacements were 1.8 mm and 4.5 mm (p = 0.04), respectively. When considering all control films, for the three directions, the amplitudes of the displacements were greater when using the BBD, particularly for the antero-posterior direction where the difference was highly significant (p = 0.0006). CONCLUSIONS: Our data show that, in patients treated prone for rectal cancer, the use of the BBD in the preoperative setting without immobilization devices was associated with problems of patient position reproducibility, particularly for the antero-posterior direction. Thus, the use of patient immobilization devices and/or individual custom-made BBD may be recommended if a decision to treat the patient with a BBD is taken.

Adult↗

PubMed1987

Lack of efficacy of thickened feeding as treatment for gastroesophageal reflux.

The efficacy of thickened feedings for the treatment of gastroesophageal reflux in infancy was evaluated. Fifty-two infants were examined with prolonged pH monitoring of the distal esophagus after feedings of apple juice or apple juice thickened with rice cereal. All infants had a minimum of three feedings of both thickened and unthickened juice. The recordings of distal esophageal pH were analyzed for the percent of time the pH was less than 4 in the first 2 hours after each feeding. The infants were maintained in the following positions after feeding: prone (n = 29), prone-board with the head elevated 30 degrees from horizontal (n = 29), supine (n = 7), and unrestricted (n = 21). We found no significant difference in the percent of time with reflux with thickened versus unthickened feedings except in those infants maintained in the 30-degree prone position. In the first 2 hours after eating thickened juice, infants maintained in this position had increased esophageal reflux time (P less than 0.006). Further analysis revealed that 33% of the infants had a greater than 30% increase in esophageal reflux time after thickened feedings. Our study suggests that the immediate effect of thickened feedings on gastroesophageal reflux in infants is unpredictable.

Gastroesophageal Reflux↗

PubMed2002

Percutaneous radiofrequency ablation of renal tumors: technique, limitations, and morbidity.

OBJECTIVES: To evaluate our evolving experience with percutaneous radiofrequency (RF) renal tumor ablation and focus on our technique to ensure maximal treatment efficacy and reduce the possibility of complications. METHODS: Fifteen patients with small (less than 4 cm) posterior or lateral contrast-enhancing (more than 10 Hounsfield units) renal tumors were candidates for RF treatment. Of these patients, 12 (13 tumors) received computed tomography-guided percutaneous RF ablation. General anesthesia was administered in all but our first 2 patients, who received intravenous sedation. After treatment, patients were closely followed up with computed tomography scans at 6 weeks and 3, 6, and 12 months, and every 6 months thereafter. Successful ablation was defined as a lesion along with a margin of normal parenchyma that no longer enhanced (less than 10 Hounsfield units) on follow-up contrast imaging. RESULTS: The mean tumor size was 2.4 +/- 0.6 cm. The average procedure time was 95 minutes (range 60 to 150) and length of stay 0.9 days. All patients underwent the procedure without any major complications. At a mean follow-up of 4.9 months, 12 (93%) of 13 tumors were successfully ablated. In 3 patients, the procedure was not performed because of intervening bowel or lung parenchyma when positioned in the prone position before the procedure. Computed tomography-guided percutaneous RF ablation of small renal tumors is a viable minimally invasive treatment option with a high short-term success rate and low morbidity. This new technology must be uniformly applied to assess its long-term efficacy.

Adult↗

PubMed2004

Management of post traumatic respiratory failure.

Acute respiratory distress syndrome (ARDS) is a severe and common complication of major trauma. The most important early management principle is to identify the inciting event and remove the ongoing insult aggressively. It is important to immediately resuscitate the patients and prepare them for a complex and difficult hospitalization. Avoiding secondary insults is the cornerstone of supportive care, and this is based primarily on aggressive immune surveillance, full nutrition, and unrelenting oxygen delivery. The use of aggressive immune surveillance, nutritional support, and fluid management is critical to support ventilator management for oxygenation and ventilation. In general, although essential, the ventilator has great potential for harm in patients who are compromised seriously with ARDS. Physicians must establish reasonable therapeutic goals based on oxygen delivery rather than arbitrary normal values of blood gas measurement. The impact of the ventilator should be limited with regard to aspiratory pressure, tidal volume, inspired oxygen, and levels of expiratory end expiratory pressure. Use of pulmonary toilet, including therapeutic bronchoscopy; patient positioning, including intermittent prone positioning, and recruitment maneuvers are useful therapeutic complements for maintaining functional residual capacity and decreasing shunt. Overall, ARDS represents a clear indication that the patient is failing to meet the demands of their stress and without prompt attention likely will die. It is a challenge and an opportunity to identify the underlying situation and to manage the patient while not causing additional harm as the patient's intrinsic resources can bring about the healing necessary to recover from the situation of extremis.

Critical Care↗

PubMed1991

[Verification of bacteriological safety of PCM 40 air conditioner].

This study assessed the bacteriological safety of the bedside air conditioner PCM 40 (Howorth Airtech), used for prevention of intraoperative hypothermia, by blowing filtered warm air through a special mattress. The 3 microns bacterial filter of the device released 2,968 +/- 5,618 particles of diameter less than 3 microns per m3 of room air, containing 78,798 +/- 37,243 of such particles per m3. The amount of bacteries in the air pulsed from the mattress was 30 +/- 41 cfu/m3 vs 120 cfu/m3 in the ambient air and in the hot air supply tubing it reached 6 +/- 5 cfu/m3 vs 175 +/- 77 cfu/m3. It is concluded that bacteriological data do not contra-indicate the use of this air conditioner in the operating theater. The only limitations for use are the position (prone or lateral position) and type of surgery (neurosurgery).

Air Conditioning↗

PubMed2000

The effect of position and mattress on interface pressure.

The aim of this investigation was to determine which positions resulted in the lowest pressures to the skin of persons lying in bed. Pressures were recorded in 10 different lying positions on 2 mattresses in 62 healthy volunteers. The study revealed that the 30 degrees semi-Fowler position and the prone position resulted in the lowest interface pressures. The 30 degrees laterally inclined position had lower pressure readings than the 90 degrees side lying position; 90 degrees side lying position gives the highest pressure readings and thus should be avoided. A Tempur polyethylene-urethane mattress reduces interface pressures by 20 to 30% in comparison to a standard hospital mattress (12-cm-thick cold foam).

Adult↗

PubMed1989

Removal of salivary stones with the aid of a lithotriptor.

The feasibility of removal of salivary calculi with the aid of high energy shock waves was investigated. The postulation was, that salivary stones can be fragmented and no harm will be done to the surrounding tissues. An in vitro experiment was done with a lithotriptor to test the effect on a salivary stone and an extracted upper molar containing an amalgam restoration. Also investigated was whether a patient can be positioned in a prone position on the lithotriptor. In the in vitro experiment, the salivary stone was fragmented very quickly, but the amalgam restoration also fragmented. The patient could be positioned in the correct position on the lithotriptor, but because of the expected damage to the dentition, the experiment was not carried out on the patient.

Dental Amalgam↗

PubMed2003

Acute respiratory distress syndrome: lessons from computed tomography of the whole lung.

OBJECTIVE: This review aims to show how computed tomography of the whole lung has modified our view of acute respiratory distress syndrome, and why it impacts on the optimization of the ventilatory strategy. DATA SOURCES: Computed tomography allows an accurate assessment of the volumes of gas and lung tissue, respectively, and lung aeration. If computed tomographic sections are contiguous from the apex to the lung base, quantitative analysis can be performed either on the whole lung or, regionally, at the lobar level. Analysis requires a manual delineation of lung parenchyma and is facilitated by software, including a color-coding system that allows direct visualization of overinflated, normally aerated, poorly aerated, and nonaerated lung regions. In addition, lung recruitment can be measured as the amount of gas that penetrates poorly aerated and nonaerated lung regions after the application of positive intrathoracic pressure. DATA SUMMARY: The lung in acute respiratory distress syndrome is characterized by a marked increase in lung tissue and a massive loss of aeration. The former is homogeneously distributed, although with a slight predominance in the upper lobes, whereas the latter is heterogeneously distributed. The lower lobes are essentially nonaerated, whereas the upper lobes may remain normally aerated, despite a substantial increase in regional lung tissue. The overall lung volume and the cephalocaudal lung dimensions are reduced primarily at the expense of the lower lobes, which are externally compressed by the heart and abdominal content when the patient is in the supine position. Two opposite radiologic presentations, corresponding to different lung morphologies, can be observed. In patients with focal computed tomographic attenuations, frontal chest radiography generally shows bilateral opacities in the lower quadrants and may remain normal, particularly when the lower lobes are entirely atelectatic. In patients with diffuse computed tomographic attenuations, the typical radiologic presentation of "white lungs" is observed. If these patients lie supine, lung volume is preserved in the upper lobes and reduced in the lower lobes, although the loss of aeration is equally distributed between the upper and lower lobes. This observation does not support the "opening and collapse concept" described as the "sponge model." In fact, interstitial edema, alveolar flooding, or both, not collapse, are histologically present in all regions of the lung in acute respiratory distress syndrome. Compression atelectasis is observed only in caudal parts of the lung, where external forces (such as cardiac weight, abdominal pressure, and pleural effusion) tend to squeeze the lower lobes. When a positive intrathoracic pressure is applied to patients with focal acute respiratory distress syndrome, poorly aerated and nonaerated lung regions are recruited, whereas lung regions that are normally aerated at zero end-expiratory pressure tend to be rapidly overinflated, increasing the risk of ventilator-induced lung injury. CONCLUSION: Selection of the optimal positive end-expiratory pressure level should not only consider optimizing alveolar recruitment, it should also focus on limiting lung overinflation and counterbalancing compression of the lower lobes by maneuvers such as appropriate body positioning. Prone and semirecumbent positions facilitate the reaeration of dependent and caudal lung regions by partially relieving cardiac and abdominal compression and may improve gas exchange.

Aged↗

PubMed2000

Child care practices in nonindustrialized societies.

OBJECTIVE: To described child care practices associated with an increased risk of sudden infant death syndrome (SIDS) in nonindustrialized 19th and 20th century societies. METHODOLOGY: The Human Relations Area Files collection is a unique source of information on the cultures of the world. The electronic version of the Human Relations Area Files represents 200 000 pages of fully indexed cultural material on a stratified random sample of 60 nonindustrialized societies. Using various keyword combinations, texts containing information related to sleeping conditions, social interaction, temperature regulation, feeding, and smoking were identified and using structured questionnaire practices were recorded as being present, absent, or not stated. RESULTS: Relevant information was identified for 53 societies. None of 4 societies mentioning sleep position used the prone position. Swaddling and restraint were commonly practiced, often for extended periods of time. Most information was available on infant feeding and the predominant pattern was of demand breastfeeding for long periods. In many of the cultures, infants are seen as being the focus of attention, in close contact with and under the constant supervision of the mother, siblings, and other relatives. CONCLUSIONS: The study produced no clear evidence that these primarily nonindustrialized societies followed child care practices likely to protect against SIDS. Despite limitations, the information presented should be of interest to those involved in developing reduce the risks programs for SIDS prevention, because it highlights the considerable variation in child care practices and emphasizes that health education messages may not always be cross-culturally valid.

Child, Preschool↗

PubMed2000

Subepicranial varix mimicking sinus pericranii: usefulness of three-dimensional computed tomography angiography and bone window computed tomography--case report.

A 16-year-old female presented with a rare case of subepicranial varix in the left temporal area manifesting as a soft mass in the left temporal area when she laid down in the left lateral position. Bulging of the mass was observed when intracranial venous pressure was raised by the Valsalva maneuver, the left lateral position, or the prone position. Bone window computed tomography (CT) revealed a tiny hole, 1 mm in diameter, in the outer bone table. Three-dimensional CT (3D-CT) angiography clearly visualized a mass with a diameter of approximately 10 mm connected to the diploic vein. The mass was totally resected by operation. Venous bleeding was observed from the tiny hole. Histological examination revealed a venous lesion mimicking sinus pericranii and containing endothelial cells. No communication with the intracranial venous sinuses was identified, so the diagnosis was subepicranial varix. Radiological examination by direct injection of contrast medium is usually performed to identify subepicranial varix, but 3D-CT angiography is a non-invasive preoperative examination that can visualize this small venous lesion. Adjustment of the CT acquisition conditions may allow 3D-CT angiography to identify sinus pericranii in the future.

Adolescent↗

PubMed2004

Virtual colon dissection with CT colonography compared with axial interpretation and conventional colonoscopy: preliminary results.

OBJECTIVE: The aim of this study was to determine whether a new virtual colon dissection 3D visualization technique for CT colonography has a shorter analysis time and better sensitivity for detection of colonic polyps than interpretation of axial CT images. SUBJECTS AND METHODS. CT colonography was performed in 22 patients using 4-MDCT followed by conventional colonoscopy on the same day. The CT colonography data sets were analyzed by virtual colon dissection, which virtually bisects and unfolds the colon along its longitudinal axis to inspect the inner colonic surface for polyps. The same CT data sets were independently evaluated using axial interpretation. All data sets were independently interpreted by two radiologists in a blinded manner. RESULTS: Conventional colonoscopy revealed 31 colonic lesions in 20 patients. Twenty two of the lesions were smaller than 10 mm; nine were 10 mm or larger. Two of the original 22 patients were excluded, one because of residual stool and fluid and the other because of an impassable stenosing rectal wall cancer. For virtual colon dissection, the per-lesion sensitivity was 42% for observer 1 and 68% for observer 2; for axial interpretation, the respective sensitivities were 48% and 61%. For polyps 10 mm or larger, the respective sensitivities were 67% and 89% for virtual colon dissection and 89% and 100% for axial interpretation. The average time for reconstruction and analysis of virtual colon dissection was 36.8 min versus 29.2 min for axial images. Virtual colon dissection was feasible in both the supine and the prone positions in 45.5% of colonic segments, in either the supine or the prone position in 24.5%, and in neither position in 30% of segments. CONCLUSION: Although virtual colon dissection may facilitate detection of colonic polyps in isolated cases, its detection rate is not superior to axial interpretation, which is mainly attributable to failed rendering of insufficiently distended colonic segments or regions with residual feces. Virtual colon dissection is also the more time-consuming of the two procedures. With further improvement of path-finding and image segmentation, however, virtual colon dissection has the potential to be a useful interpretation tool for CT colonography.

Adult↗

PubMed2001

[Intensive care management of ARDS].

The acute respiratory distress syndrome (ARDS) is characterized by (1) intrapulmonary right-to-left shunting, (2) permeability edema of the lung, and (3) alterations in pulmonary compliance. The clinical features of ARDS are due to an acute inflammatory reaction of the lung. Current clinical management of patients with ARDS aim at implementation of lung protective ventilatory strategies with adequate PEEP and low tidal volumes, diagnosis and treatment of underlying infections, and a negative fluid balance together with positional maneuvers like prone positioning.

Critical Care↗

PubMedDate not supplied

Radiological examinations in the morpho-functional evaluation of the esophago-gastric junction in gastro-esophageal reflux disease.

PURPOSE: The aim of our paper is to define, on the basis of a long experience, the anatomical and radiological classification of the progressive phases of the axial intrathoracic migration of the esophago-gastric junction (EGJ), through a standardised radiological method that allows precise identification of the anatomical structures involved. MATERIALS AND METHODS: From 1981 to 2001, 1388 patients with gastro-esophageal reflux disease (GERD) were examined by traditional contrast techniques that consisted in taking single contrast radiograms of the patients in different positions after administering a small high-density bolus of barium: with the patient standing up in frontal position, at rest, during forced inspiration, and during straining; standing up in a right front 30 degrees oblique position; and in prone position, in a right posterior 30 degrees oblique projection. On the basis of previous radiological and manometric studies aimed at verifying the diagnostic reliability of the radiological examination [8], the distance of the esophago-gastric junction from the esophageal hiatus was indirectly evaluated in an anterior-posterior projection, according to the criteria introduced by Monges [3]. The sling fibers, which form a radiologically detectable cut at the apex of the angle of His, are the lowest portion of the EGJ. RESULTS: On the basis of the radiological findings, and in agreement with the radiological classifications reported in the literature, we evidenced five groups, with pathologically characteristic signs: - 1(st) group (63%) patients who in orthostatic position have an EGJ regularly placed within the abdomen (16%), and patients with the EGJ regularly placed within the abdomen, but with a small sliding intermittent hiatus hernia (47%); - 2(nd) group (13%) cardial tuberosity malposition; - 3(rd) group (7%) concentric hiatus hernia; - 4(th) group (8%) acquired short esophagus; - 5(th) group (9%) massive incarcerated gastric hiatus hernia. CONCLUSIONS: Traditional radiography, performed with an adequate technique and with the necessary expedients, allows for the correct interpretation of the anatomical disoder called GERD, and is therefore the first diagnostic approach in defining correct patient management.

Adolescent↗

PubMed1986

[Esophageal pH measurement in newborn infants under 1,700 gms].

Esophageal pH was systematically recorded for 3 hours in 30 neonates under 1,700 g, of which 18 were under assisted ventilation. Gastric acid secretion occurs early. Varying degrees of gastroesophageal reflux were observed in 21 neonates. Positioning in the prone position at 30 degrees allowed for the disappearance of reflux in 19 and an improvement in the remaining 2. We recommend the adoption of this position in all premature infants including those under assisted ventilation.

Esophagus↗

PubMed1995

[Severe impairment of peritoneal cavity muscles in intensive care patients (comparative anatomic studies of respiration)].

The vital function respiration is kept up by the modifiable basal activity of the thin muscles of the abdominal cavity. The diaphragm is an important part of the respiratory muscular system. The muscular system of the 'splanchnocranium' exhibits a normal spontaneous activity, which is mostly open in the laryngeal region and mostly closed in the anorectal continence organ. In animals missing an abdomen, e.g. turtles, we find that the complete abdominal muscle system is connected to the lungs functioning as respiratory muscles. The most powerful lungs that exist are found in birds. Their lungs, which are situated in a stiff thorax are only ventilated through the air compartments, mostly by the abdominal muscles. By this, the role of abdominal muscles for respiratory function is shown. We studied intensive care patients requiring ventilatory support and found that the electromyogram of the external abdominal oblique muscle can be impaired or extinguished. In some cases the cause is a polyneuropathy, which can be reversible. In consequence, positioning measures, as prone positioning are capable of preventing progressive deterioration of ventilation/perfusion relationship.

Abdominal Muscles↗

PubMed1993

[X-ray VTR analysis for the inflowing movement of the contrast medium in the esophagocardiac region: the inflowing movement of contrast medium on healthy people].

The application of S-VHS video system has made it possible to easily detect the functional disease. Among several position, left posterior prone position where gravitational force could be ignored, and spontaneous, physiological movement could be registered in the recording of the esophagocardiac movement. Through the observation and the classification of the movement at this position, we evaluated the contribution of this method to the assessment, and the study of the functional diseases such as achalasia, hiatus hernia, and the study of the organic diseases such as carcinoma. In our present study on normal 60 cases, the time from the inflowing first phase to the inflowing interrupted phase in the last period becomes longer as the age of the subjects gets older. The continuous contractive period was divided into three types, shorter type, medium type and longer type. The shorter type seems to correspond to the type closer to hernia. The longer type is regarded as the type closer to achalasia.

Cardia↗

PubMed1995

Retroperitoneoscopy.

From October 1992 to June 1994, 12 nephrectomies (all for benign diseases), one nephropexy and 7 adrenalectomies (one pheochromocitoma, three adenomas, one cyst) were performed. In all the cases the retroperitoneal working space was created with direct CO2 insufflation (without balloon) with the patient in prone position. Four 10-12 mm ports were always inserted in the lumbar area. Eighteen procedures were successful (90%), 2 failed (one nephrectomy and one adrenalectomy) and underwent open surgery. Twelve procedures were carried out with the patients in prone position, six (one nephropexy and 5 nephrectomies) were performed with the patients in lateral de cubitus. The removal of organs was managed either through an enlarged port (phi 2 cm.) or by joining vertically the stabs of the two ports lateral to the sarcospinalis muscle. The average operative time was 4.10 hours) range 2.30-5.20). Both CO2 absorption and blood loss were negligible. No major complications were observed. Postoperative pain never required medications. All patients were able to stand on the 1st postoperative day. Mean postoperative hospitalisation was 4 days. Direct retroperitoneal approach provides optimal access for laparoscopic renal, proximal ureteral and adrenal surgery, avoiding extensive dissection and handling of intraperitoneal structures.

Absorption↗

PubMed2001

Effect of sleep position on apnea and bradycardia in high-risk infants.

OBJECTIVE: The purpose of this investigation was to investigate, in high-risk infants, the occurrence of abnormalities in documented monitor downloads during the side versus prone position. STUDY DESIGN: Forty infants admitted to the A. I. duPont Hospital for Children with diagnoses associated with sudden infant death syndrome were included in this investigation. During an overnight hospitalization, infants were placed on home apnea monitors, with computer memory to capture alarms for apnea > 20 seconds, age-defined bradycardia, and tachycardia. Infants were studied for 12 hours. Each infant was assigned to 6 hours of prone and side during the 12-hour period, with order of position randomly assigned by random number generation. Differences between the two positions in alarm frequency and significant events, as determined by a blinded interpreting physician were analyzed by Fisher exact test, with p < 0.05. Power analysis necessitated 20 patients in each group, with beta error of 0.2. RESULTS: Eleven episodes of apnea occurred in the prone position, and 16 in the side position (p = NS). The mean numbers of apnea events per tracing in the prone position was 0.27 +/- 0.84 and 0.39 +/- 1.1 in the side position (p = 0.58). The mean number of bradycardia events per tracing in the prone position was 0.44 +/- 1.45 and 0.49 +/- 1.94 in the side position (p = 0.9). CONCLUSION: Clinicians need to be cautious when recommending the side or prone position in this group of high-risk infants. The results in this investigation provide support for the Back to Sleep Campaign recommendations to be applied, not only to healthy term infants, but higher risk infants as well. Studies of the high-risk infant in the supine position are warranted.

Bradycardia↗