Factors determining success in reambulation of the child with progressive muscular dystrophy.
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Child↗
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Results for “Preoperative Exercise”
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[Long-term evaluation of a group of patients treated with aorto-coronary bypass: prognostic value of the cycloergometric test].
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Adult↗
[Stress myocardial scintigraphy in the pre- and postoperative diagnosis of ischemic cardiopathy. The correlations between the clinical aspects and the coronary angiographic picture].
With radioisotopes it is possible to study the heart obtaining complementary or substitutive informations to those provided by the most common noninvasive methods of myocardial assessment and by coronarography. This paper aim is to report experience with thallium 201 and 99mTc isonitrile in the diagnosis and followup of ischemic heart disease, in particular correlating clinical, coronarographic and scintigraphic findings. MATERIAL AND METHODS. During the biennium 1989-91 we have used the myocardial perfusion imaging with thallium 201 in 29 patients (20 male age ranging from 40 to 60 years) injecting 2 mCi at exercise peak with immediate planar mapping, followed by a second registration at rest 4 hours later (thallium 201). Imaging with 99mTc SESTAMIBI has been carried out in 6 patients (two of whom previously studied with thallium 201) injecting 20-22 mCi both at stress peak and at rest, with SPECT mapping 60'-90' later. All these patients presented specific problems for the diagnosis of myocardial ischemia. The exercise testing has been performed by a bicycle ergometer and with a standardized procedure increasing every two minutes the workload to the maximum tolerated according to the clinical conditions and to the response. All antianginal treatments were discontinued for at least 48 hours before testing and the patients were fasted for 6 hours. The images were obtained using a small field scintillation camera with a low-energy general purpose collimator. We divided the patients in 4 groups: Group A. Six patients who had an open heart operation: in 5 coronary revascularization was carried out (plus left ventricular aneurysmectomy in one and plus aortic valve replacement in another); in 1 patient an aortic valve replacement was performed on. Group B. Six patients have been evaluated after coronary angiography. Group C. Seventeen patients with doubtful diagnosis of myocardial ischemia on the base of the symptoms and/or non invasive testing as rest or stress electrocardiogram (ECG). Group D. In 6 more patients (2 of those previously studied with thallium 201) the myocardium has been assessed with SESTAMIBI. RESULTS. In one patient of the group A the thallium 201 images detected silent ischemia; in 5 removed the diagnostic doubts of the ECG findings owing to left ventricular overload or to old infarctions in 2 patients and to electrolytes disturbances or pharmacological effects in 3 patients. In group B patients the thallium 201 further on could assess the extent of ischemic and necrotic areas suggesting the final indications to angioplasty in 3 patients, medical treatment in 2 and surgery in 1. We could not find correlations between the extent of the disease predicted by the coronarography and the findings of the thallium 201 images. In the diagnosis of myocardial ischemia, group C, the Thallium 201 has been very useful and specific excluding an ischemic origin in 4 patients with arrhythmias, in 2 patients without symptoms of angina but with doubts at rest and exercise ECG findings and in 4 with atypical thoracoalgia and doubtful ECG. On the contrary, this test could give the final diagnosis of ischemia in 6 patients displaying its sensitivity in detecting coronary artery disease. Among the patients assessed with SESTAMIBI, in 2 this test has been essential in evaluating the myocardial contractility and the segmental wall motion. DISCUSSION. The usefulness of Thallium 201 imaging, as a very sensitive mean in detecting coronary artery disease and in the assessment of myocardial viability, is well known. Although the most common indications of this technique are well standardized, in the clinical practice there are many situations in which the thallium 201 can contribute to the diagnosis and to the management. (ABSTRACT TRUNCATED)
Adult↗
Orthopaedic nursing in neuromuscular disorders.
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Braces↗
Justification of caesarean section for fetal distress.
A study was done from May 1995 to February 1996 to evaluate the justification of caesareans for fetal distress by examining the circumstances leading to operative delivery for compromised fetus. Of the 1096 caesareans, 179 (16.33%) were for fetal distress. One hundred and seven (59.78%) were nulliparas and 127 (71%) came with the clinical features of fetal hypoxia. In 142 (79%) parturients at the time of c-section, cervical dilatation varied from 0-3 cm and in 144 (80%) the presenting part remained unengaged. The method most commonly employed to diagnose fetal distress was the external cardiotocography, used in 141 (79%) patients either alone or in combination with other options. Predictivity value of the parameters used to identify the fetuses at jeopardy was found to be more sensitive when used in combination. Neonatal outcome related poorly with the preoperative diagnosis if only one parameter was used. Poorest neonatal outcome was observed in the presence of thick particulate meconium. Great care should be exercised by the obstetricians while making a decision for caesarean for fetal distress so as to avoid unnecessary procedures and neonatal complications.
Cesarean Section↗
[Rehabilitation of children following chest surgery].
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Age Factors↗
Preoperative dobutamine stress echocardiography, intraoperative events, and intraoperative myocardial injury in liver transplantation.
INTRODUCTION: The appropriate method of screening for coronary artery disease in patients who present for liver transplantation is currently uncertain. METHODS: We assessed the utility of a screening protocol using dobutamine stress echocardiography (DSE) in 119 patients who underwent liver transplantation. Patients with cardiac risk factors had DSE performed, and those with positive results were referred for coronary angiography. Outcome was myocardial injury during liver transplantation determined by an elevation of cardiac troponin T measured after transplantation. RESULTS: Seventy-three patients had DSE performed; eight were reported as positive for inducible ischemia. Seven of these patients underwent coronary angiography, and one had significant coronary artery disease. Postoperative troponin elevation occurred in 14 patients. There was no significant difference in the prevalence of troponin elevation in those patients with positive DSE versus those with negative DSE. No significant difference was identified in the prevalence of troponin elevation when comparing those patients with cardiac risk factors who underwent DSE with those patients with no risk factors and no DSE performed. DSE had a sensitivity of 0.2 and a specificity of 0.9 for myocardial injury. The prevalence of intraoperative hemodynamic instability was significantly higher in patients who had evidence of myocardial injury, but hemodynamic instability was no more common in patients who had a positive DSE. CONCLUSION: When used in accordance with our protocol a positive DSE does not reliably identify patients at high cardiac risk during liver transplantation, but a negative DSE is strongly predictive of no myocardial injury.
Adrenergic beta-Agonists↗
[Indications for coronary revascularization and the postoperative evaluations using Tl-201 exercise myocardial scintigraphy and a bull's eye display].
Tl-201 exercise myocardial scintigraphy and quantitative analysis using bull's eye display were performed in 31 cases (18 bypass cases, 13 PTCA cases) to determine the indications for coronary artery bypass surgery and PTCA, and to evaluate postoperative improvement. Regions of interest (ROI) corresponding to each revascularized area were created on a bull's eye display. Then the washout rates (WR) and % uptakes were expressed as percentages. Improvement was judged to have occurred if the revascularized coronary artery was patent and both the WR and % uptake returned to the normal range as determined from the examinations of 20 normal cases. The results were as follows: 1. The preoperative mean WR of the improved areas (30 vessels) was 19 +- 15%, while that of the unimproved areas (15 vessels) was 35 +- 7%. We assumed that the area was suitable for revascularization when the preoperative WR was less than 25% which was in the lower limit of the normal range. Then, 18 vessels were judged to be suitable for surgery, and subsequent postoperative improvement was obtained in the 17 areas. 2. In 32 scintigraphically-improved areas, 30 vessels were angiographically patent, while five vessels were obliterated angiographically in 13 scintigraphically-unimproved areas (diagnostic validity was 76% of all 45 vessels). 3. The exercise tolerance increased significantly (p less than 0.01) from 8.7 +- 2.0 min to 11.6 +- 2.5 min in the improved cases in which all the revascularized areas were improved after revascularization. There was no change of the exercise tolerance (before: 9.4 +- 3.4 min, after: 9.4 +- 2.5 min) in the unimproved cases in which all the revascularized areas were unimproved. 4. Quantitative analysis was useful for objective evaluation, because the visual evaluations did not always agree with the quantitative evaluation. We concluded that the area with the preoperative WR less than the normal range is suitable for revascularization. As the scintigraphic evaluation was in accord with improved exercise tolerance and with patency as observed by coronary angiography, our method seems useful for postoperative follow-up.
Angioplasty, Balloon↗
Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial.
CONTEXT: Postoperative pulmonary complications (PPCs) after coronary artery bypass graft (CABG) surgery are a major source of morbidity and mortality, and increase length of hospital stay and resource utilization. The prehospitalization period before CABG surgery may be used to improve a patient's pulmonary condition. The efficacy of preoperative inspiratory muscle training (IMT) in reducing the incidence of PPCs in high-risk patients undergoing CABG surgery has not yet been determined. OBJECTIVE: To evaluate the prophylactic efficacy of preoperative IMT on the incidence of PPCs in high-risk patients scheduled for elective CABG surgery. DESIGN, SETTING, AND PATIENTS: A single-blind, randomized clinical trial conducted at the University Medical Center Utrecht, Utrecht, the Netherlands, with enrollment between July 2002 and August 2005. Of 655 patients referred for elective CABG surgery, 299 (45.6%) met criteria for high risk of developing PPCs, of whom 279 were enrolled and followed up until discharge from hospital. INTERVENTION: Patients were randomly assigned to receive either preoperative IMT (n = 140) or usual care (n = 139). Both groups received the same postoperative physical therapy. MAIN OUTCOME MEASURES: Incidence of PPCs, especially pneumonia, and duration of postoperative hospitalization. RESULTS: Both groups were comparable at baseline. After CABG surgery, PPCs were present in 25 (18.0%) of 139 patients in the IMT group and 48 (35.0%) of 137 patients in the usual care group (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.30-0.92). Pneumonia occurred in 9 (6.5%) of 139 patients in the IMT group and in 22 (16.1%) of 137 patients in the usual care group (OR, 0.40; 95% CI, 0.19-0.84). Median duration of postoperative hospitalization was 7 days (range, 5-41 days) in the IMT group vs 8 days (range, 6-70 days) in the usual care group by Mann-Whitney U statistic (z = -2.42; P = .02). CONCLUSION: Preoperative IMT reduced the incidence of PPCs and duration of postoperative hospitalization in patients at high risk of developing a pulmonary complication undergoing CABG surgery. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN17691887.
Aged↗
[Experience with ambulatory, preoperative autologous blood donation in heart surgery patients with special reference to hemodynamic parameters].
Our study is based on 843 autologous blood donations that we collected from 379 patients. The coronary angiogram, the diagnosis of the ventricles and the ergometry served to judge the patients suffering from a coronary insufficiency. The complication rate could be reduced to 1% with the help of volume substitution during the donation and the contraindications we ascertained. The exercise electrocardiogram proved to be a significant parameter of the complication rate. It was not the number and the extent of stenoses, but the interpretation of the myocardial oxygen supply that proved to be helpful for the diagnosis based on the evaluation of the coronary angiogram. Our technique of collecting blood and the assessment of the patients' ability as donors give even patients with highly affected coronary vessels the possibility of a preoperative autologous blood donation.
Blood Transfusion, Autologous↗
An ultra-short perineal pad-test for evaluation of female stress urinary incontinence treatment.
We assessed the reproducibility and feasibility of a rapid perineal pad-test designed for evaluation of stress urinary incontinence treatment. In an experimental study, we included 34 women with genuine stress incontinence, 13 with urge incontinence and 10 non-incontinent volunteers for a repeated pad-test with a standardized bladder volume (300 mL) and a standardized physical activity during one minute. The pad was weighed before and after the exercise to estimate the volume of any leaked urine. In order to find out the percentage of unselected, incontinent women who had been able to perform a preoperative pad-test, we identified all 120 women operated on for stress incontinence during a one-year period in a separate retrospective analysis. In another retrospective analysis, we compared the subjective outcome of laparoscopic colposuspension with the outcome of the test performed before and after the procedure among 93 women with genuine stress incontinence. Among stress incontinent women, the median of the differences in leakage between the first and the second test was 8.5 mL (range 0-60 mL) and the repeatability coefficient was 33.6 mL. None of the 13 women with urge incontinence leaked during the tests. One of the 10 controls leaked (during both tests). Of the unselected women, 104/120 (87%) were able to perform the test. Reduction of leaking after surgery was significantly associated with subjective report of outcome (P < 0.0001). In conclusion, the described pad-test has an acceptable reproducibility and feasibility making it suitable for follow-up studies.
Bandages↗
Preoperative risk evaluation for lung cancer resection: predicted postoperative product as a predictor of surgical mortality.
We assessed the capacity to predict surgical mortality, complications, and functional loss by using the results of resting and exercise respiratory function. Measurements were made before and 4 mo after lung resection in 54 consecutive patients with bronchogenic carcinoma. Predicted postoperative (ppo) FEV1 and DLCO were derived using quantitative lung perfusion scans when baseline FEV1 was < 55% predicted, and by proportional loss of pulmonary segments (total = 19 segments) when FEV1 was > 55% predicted. The patients were aged 67 +/- 7 (mean +/- SD) yr, with an FEV1 of 76 +/- 23% predicted, FEV1/FVC of 55 +/- 13%. and DLCO of 85 +/- 22% predicted. Eleven of the patients had pneumonectomy, 29 had lobectomy, 12 had wedge resection, and two had no resection. Wilcoxon and stepwise logistic regression analyses were used to determine which indices best predicted outcome. Postoperative values were correlated (r = 0.87, p < 0.0001) with actual 4/12 postoperative values of FEV1% and of DLCO (r = 0.56, p < 0.0001). The best predictors (all p < 0.05) for each outcome, in order of usefulness, were as follows. For surgical mortality: (1) the predicted postoperative product (PPP) of ppo FEV1% x ppo DLCO%; (2) ppo DLCO%; (3) ppo FEV1%, and (4) RV, FRC, and SaO2 on the maximal step exercise test. For respiratory complications: body mass index (BMI) (for patients undergoing lobectomy or wedge resection only). For cardiac complications: (1) age; (2) SaO2 at baseline and on the maximal step exercise test; (3) PaO2; (4) PaCO2; and (5) minute ventilation at maximal exercise.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Preoperative evaluation of cardiac risk by means of atrial pacing and thallium 201 scintigraphy.
Atrial pacing and thallium 201 scintigraphy were done in 61 patients with known or suspected coronary artery disease referred for evaluation of cardiac risk before elective vascular surgery. All patients had noncardiac limitations precluding performance of an adequate exercise stress test. Before atrial pacing all were considered to be at low risk of a postoperative cardiac event based on assessment of clinical parameters. Vascular surgery was subsequently performed in 47 patients. In these patients, pacing-induced ST segment depression greater than or equal to 1 mm occurred in 18, a fixed perfusion defect occurred in 11, and a reversible defect occurred in six. Two of the six patients with reversible perfusion defects had preoperative coronary angiography; both had significant coronary artery disease (one or more lesions greater than or equal to 50%). Two patients (one of whom had a reversible perfusion defect) underwent preoperative coronary revascularization and tolerated subsequent vascular surgery well. All other patients received only medical therapy. None of the 47 patients undergoing vascular surgery had a postoperative cardiac event (unstable angina, congestive heart failure, myocardial infarction, or cardiac death). Of the 14 patients in whom vascular surgery was deferred or canceled, surgery was canceled for noncardiac reasons in seven. Six of these seven patients had a normal perfusion scan; none had a reversible perfusion defect or marked (greater than or equal to 2 mm) ST segment depression. No cardiac event occurred during a 3-month period after atrial pacing in any of these patients. Six of the remaining seven patients had reversible perfusion defects.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Sinus node function after cardiac surgery: is impairment specific for the maze procedure?
BACKGROUND: Maze surgery is a final solution for intractable atrial fibrillation (AF), but an adverse effect on postoperative sinus node function has been reported. Whether this also applies to other types of cardiac surgery is unclear. METHODS: We assessed postoperative rhythm by means of repeated exercise tolerance testing, ambulatory electrocardiography, and non-invasive testing of autonomic function between 1 and 12 months after four types of cardiac surgery. Fourteen patients without structural cardiac disease and medically refractory AF underwent the maze III procedure, 11 patients with mitral valve disease and preoperative AF underwent valvar surgery combined with a (simplified) maze III procedure, and 8 patients with mitral valve disease in sinus rhythm (SR) underwent isolated valvar surgery. The control group consisted of eight patients with sinus rhythm who underwent coronary artery bypass surgery (CABG). RESULTS: One month after surgery, the chronotropic response to exercise was depressed, mean heart rate was high, and heart rate variability (HRV) was low, especially after maze III, combined surgery, and isolated valvar surgery. Twelve months after surgery, moderate improvements were observed. After CABG, considerably fewer abnormalities were observed, and HRV parameters recovered to a large extent. Non-invasive testing of autonomic function indicated disturbed vagal modulation of heart rate in all three groups with atrial incision. CONCLUSION: Thus, attenuation of HRV and vagal modulation of sinus node function are not confined to maze surgery but also apply to isolated mitral valve surgery. Atrial incision therefore appears to be crucial and presumably produces autonomic nervous damage followed by partial reinnervation. Nevertheless, cardiac surgery in general seems initially to impair sinus node function with partial recovery in the consecutive 12 months.
Adult↗
Preoperative preparation of the patient with myasthenia gravis.
All patients who are to undergo a thymectomy should be evaluated thoroughly by a neurologist--ideally one with special training and interest in the diagnosis and management of MG. Confirmatory tests to diagnose MG and other potential diseases should be reviewed. The antibody test seems to be most specific, but there are rare cases of other diseases that are ACh-R antibody positive. In 10% of MG patients, serology is negative, and other tests are necessary to confirm the diagnosis. All patients should undergo a contrast-enhanced high-resolution CT scan with 5- to 8-mm slices because thymoma or thymic carcinoma may be present. Pulmonary function tests, including vital capacity, forced expiratory volume, maximal expiratory force, arterial blood gas, and a flow-volume loop, should be performed. Exercise testing to evaluate for hypoxia and hypotension with exercise and ambulation also may be appropriate. A thorough assessment for cardiac dysfunction, including echocardiography, nuclear medicine studies, or a formal cardiology evaluation, may be beneficial. Because MG is a complex autoimmune disease, preoperative blood tests should include thyroid function testing, antinuclear antibody, and rheumatoid factor in addition to routine preoperative studies. Plasmapheresis or intravenous immunoglobulin should be considered for patients with advanced disease, bulbar symptoms, or poor pulmonary function. Given these guidelines, careful selection of candidates for surgery should optimize the long-term results for patients with MG.
Female↗
Meningiomas with vertebrobasilar artery encasement: review of 17 cases.
Seventeen patients with petroelival and foramen magnum meningiomas encasing the vertebral or basilar arteries and their branches were surgically excised over a 3-year period. All six cases with vertebral artery encasement were totally excised. One vertebral artery was occluded, one was repaired, and one was replaced with a vein graft. None of the patients had a permanent major neurologic deficit. In one patient with vertebral and basilar artery encasement, a hypoplastic vertebral artery was occluded and the tumor was totally excised. She had a transient worsening of hemiparesis, presumably due to the dissection of tumor from the brainstem. Among the ten patients with encasement of the basilar artery and branches, injury to the basilar artery occurred in two patients, both were repaired. Injuries to one superior cerebellar artery, one anterior inferior cerebellar artery, and one perforating vessel could not be repaired. Three patients sustained major neurologic deficits, but only in two did this result in permanent functional deterioration. Three of the ten patients had a gross total resection, five had subtotal resection (90% or more of tumor volume), and two had resection of 70% of the tumor volume. Eight patients had improvement in their Karnofsky scores. None showed recurrence or regrowth on follow-up ranging from 2 to 6 years. Greater difficulty with dissection was experienced in previously operated patients, and in patients who did not have an arachnoid plane between the brainstem and the tumor. Magnetic resonance imaging was the most useful preoperative test. It is concluded that meningiomas with vertebrobasilar artery encasement can be removed successfully with modern skull base surgery techniques. The surgeon needs to exercise caution and judgment in deciding how far the removal of these lesions should be pursued.
Journal Article↗
Asymptomatic aortic regurgitation: indications for operation.
Left ventricular (LV) systolic function is an important determinant of long-term prognosis in patients with chronic aortic regurgitation. In patients undergoing aortic valve replacement (AVR), those with preoperative LV dysfunction have a greater risk of postoperative congestive heart failure and death than do those in whom preoperative LV systolic function is normal. Patients with preoperative LV dysfunction are not a homogeneous group, however, but may be further stratified according to risk on the basis of the severity of symptoms, exercise intolerance, and temporal duration of LV dysfunction. Hence, asymptomatic patients with reproducible and definite evidence of impaired LV function should undergo operation without waiting for the development of symptoms or more severe LV dysfunction. Among asymptomatic patients with normal LV systolic function (normal ejection fraction and fractional shortening), the prognosis is excellent with only a gradual rate of deterioration during conservative, nonoperative management. The long-term follow-up experience of such patients indicates that the annual mortality rate is less than 0.5% and that less than 4% per year require AVR because symptoms or LV dysfunction at rest develop. Patients likely to require operation over a 10-year period because symptoms or LV dysfunction develop can be identified on the basis of age, severity of LV dilatation by echocardiography, and progressive change in LV dimensions or resting ejection fraction during the course of serial follow-up studies. Patients at risk of sudden death before surgery is performed may be identified by extreme LV dilatation (diastolic dimension > 80 mm, systolic dimension > 55 mm).(ABSTRACT TRUNCATED AT 250 WORDS)
Aortic Valve Insufficiency↗
Late clinical outcomes of the fontan operation in patients with tricuspid atresia.
OBJECTIVE: Evaluation of the long-term clinical results of the Fontan operation in patients with tricuspid atresia. METHODS: A retrospective analysis was made at the Instituto de Cardiologia do Rio Grande do Sul (Institute of Cardiology of Rio Grande do Sul), from August 1980 through January 2000, of 25 patients with a long-term follow-up, out of a series of 36 patients who underwent the Fontan operation or one of its variants due to tricuspid atresia. Their mean age at surgery was 5.4+/-3.1 years, and their mean weight was 15.8+/-6.1 kg, the majority of them (63.9%) being males. Four patients underwent the classical Fontan operation, 12 the Kreutzer variant, 6 the Björk variant, 9 total cavopulmonary shunt with a fenestrated tube, and 5 total cavopulmonary shunt with a nonfenestrated tube. RESULTS: The patients were followed-up on an outpatient basis, with a mean long-term survival time of 5.5+/-4.2 years (50 days to 17.8 years) and a late mortality rate of 8%. Arterial saturation increased from 77.2+/-18.8% in the preoperative period to 91+/-6.7% upon the last outpatient visit (p>0.05). At the final check, most (67%) patients were asymptomatic and 87% could tolerate exercise. Ten (40%) patients experienced some kind of complication during the long-term follow-up, such as cardiac arrhythmia, cyanosis, protein-losing enteropathy, neurological events, right heart failure, intolerance to exercise and reoperation. CONCLUSION: The results indicate that, once the immediate postoperative period is over, during which the adaptations to the new circulatory physiology occur, the evolution of patients with tricuspid atresia who underwent the Fontan operation is satisfactory, in spite of a low, yet significant, morbidity.
Adolescent↗