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Objectives The purpose of this study was to determine the relationship between the changes in diastolic function and their association with cardiac biomarkers in the perioperative period in patients undergoing complex endovascular aortic repair. Design Prospective observational study. Setting Single-center academic hospital, central teaching hospital in Warsaw, Poland. Participants The study comprised 27 high-risk patients scheduled for elective endovascular repair of aortic aneurysm. Interventions Complex endovascular procedure using branched endograft of the thoracoabdominal aorta. Branches of the stent grafts included renal arteries, the superior mesenteric artery, and the celiac trunk. Measurements and Main Results The primary outcome was to evaluate changes in diastolic function parameters assessed with transthoracic echocardiography at two and 24 hours postoperatively. The major secondary outcomes were changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) and troponin I concentrations, systolic function parameters, hemodynamic parameters at two and 24 hours, length of hospital stay, and 30-day mortality. There was a reduction in e’ wave velocity on both the septal and lateral sides at two hours compared with the baseline (p = 0.041 and p = 0.05, respectively). There was an increase in both NT-proBNP and troponin I concentrations after surgery (p = 0.002 and p = 0.034, respectively), with troponin I peaking two hours after surgery and NT-proBNP peaking 24 hours after surgery. Conclusions Patients undergoing a branched endovascular aortic repair of a thoracoabdominal aortic aneurysm experience a cardiac insult that manifests with deterioration in diastolic parameters and concomitant increases of troponin and NT-proBNP concentrations. Additional large-scale prospective studies are required to confirm this phenomenon.

The use of biomarkers in medicine has become essential in clinical practice in order to help with diagnosis, prognostication and prediction of treatment response. Since Alexander Breslow’s original report on “melanoma and prognostic values of thickness”, providing the first biomarker for melanoma, many promising new biomarkers have followed. These include serum markers, such as lactate dehydrogenase and S100 calcium-binding protein B. However, as our understanding of the DNA mutational profile progresses, new gene targets and proteins have been identified. These include point mutations, such as mutations of the BRAF gene and tumour suppressor gene tP53. At present, only a small number of the available biomarkers are being utilised, but this may soon change as more studies are published. The aim of this article is to provide a comprehensive review of melanoma biomarkers and their utility for current and, potentially, future clinical practice.

Background: Spirometry is a primary tool for early chronic obstructive pulmonary disease (COPD) detection in patients with risk factors, for example, cigarette smoking. The aim of this study was to evaluate the strategy of an active screening for COPD among smokers admitted to the pulmonary and cardiology department. Methods: This prospective study was conducted between February and March 2019. All hospitalized smokers aged 40 years and older completed an original questionnaire and had spirometry measurement with a bronchial reversibility test (if applicable) performed by medical students using a portable spirometer. Results: One hundred and eighty-eight patients were eligible to participate in the study. Seventy (37%) subjects refused to participate. Eventually, 116 (62%) patients were included in the final analysis and 94 (81%) performed spirometry correctly. In total, 32 (34 %) patients were found to have COPD. Nine (28%) of these patients were newly diagnosed, 89% of them had mild-to-moderate airway obstruction. Patients with newly diagnosed COPD were significantly younger [age 63 (56–64) versus 69 (64–78) years], had a longer smoking-free period [17 (13–20) versus 9 (2–12) years], had fewer symptoms and had a better lung function compared with patients with a previous diagnosis of COPD ( p Conclusion: The proposed diagnostic strategy can be successfully used to improve COPD detection in the inpatient setting. The majority of the newly diagnosed COPD patients had mild-to-moderate airway obstruction. Patients who should be particularly screened for COPD include ex-smokers with less pronounced respiratory symptoms.

Background: Spirometry is a primary tool for early COPD detection in patients with risk factors, e.g. cigarette smoking. The aim of this study was to assess the prevalence of COPD among hospitalised smokers and to evaluate the usefulness of a portable spirometer for COPD screening in the inpatient setting. Methods: This prospective study was conducted in two departments of a large multidisciplinary teaching hospital between Jan and Apr 2019. Hospitalised smokers (at least 10 pack-year smoking history) aged at least 40 years who gave their consent to participate in the study were included. All subjects completed an original questionnaire and had spirometry measurement with a bronchial reversibility test (if applicable) performed by medical students using a portable spirometer. Results: Out of 485 hospitalised patients, 188 were smokers aged ≥40 years. Only 116 (62%) subjects agreed to participate in the study. Overall, 95 (82%) spirometry measurements were performed correctly. In total, 32 (34%) subjects had COPD diagnosis, of those, 9 (28%) subjects were newly diagnosed. Patients newly diagnosed with COPD were significantly younger (age 63 (56-64) vs. 69 (64-78) years), had a longer smoking-free period, 17 (13-20) vs. 9 (2-12) years, had less symptoms and had a better lung function compared to patients with a previous diagnosis of COPD (p Conclusions: Patients with COPD risk factors are reluctant to perform spirometry and COPD is highly prevalent among these patients. COPD screening can be successfully performed at patient’s bedside using a portable spirometer and it should also be considered in subjects who have a long smoking-free period and do not report respiratory symptoms.

Introduction: Malignant spinal cord compression (MSCC) is one of the most devastating complications of cancer. This event requires rapid decision-making on the part of several specialists, given the risk of permanent spinal cord injury or death. The goals of treatment in spinal metastases are pain control and improvement of neurological function. There can be challenges in delivering prompt diagnosis and treatment in a secondary care setting. We have reflected on the experience of managing MSCC in a district general setting. Aim: Our retrospective audit identified 53 patients with suspected MSCC who entered the relevant pathway from April 2017 to March 2018 at Medway, United Kingdom (UK). Our audit standards were set out by Medway Maritime Hospital and Maidstone and Tunbridge Wells NHS Trust MSCC working group members, using a combination of published evidence and best practice. Results: The patients with suspected MSCC were 53 and 29 of them (54.7%) had confirmed MSCC. The most common malignancies within the confirmed MSCC were lung (11 patients, 37.9%), breast (5 patients 17.2%), and renal (3 patients, 10.3%), followed by prostate, myeloma and carcinoma of unknown primary (2 patients (6.9%) each), as well as pancreatic, colorectal, lymphoma and, bladder (1 patient (3.4%) each). A magnetic resonance imaging (MRI) scan was performed in 48 patients (90.5%), the majority (31 patients, 64.6%) underwent the MRI within the first 24 h, whereas 3 patients had the investigation between 24 and 72 h from the admission. Among the 29 patients with confirmed MSCC, 6 (20.6%) were treated with surgical decompression, while 20 (69%) received radiotherapy (RT) and 3 (10.3%) best supportive care, respectively. Median time to surgery was 5 days (ranged between 2 and 8 days), whereas for RT 44.4 h (ranged between 24 and 72 h). Finally, all 3 patients that decided on symptom control were referred to a palliative care team within the first 24 h following the MRI scan. Conclusions: MSCC is frequently presented outside tertiary care. This may cause subsequent delays in investigation, diagnosis, and treatment, which can be improved by following a fast track referral pathway.

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

Summary Objective Evaluate the sensitivity and specificity of Indium 111 -labeled leukocyte scans as used in a general, tertiary care hospital. Methods Retrospective review of electronic medical records from all patients who underwent Indium 111 scan at two large Veterans Affairs Medical Centers, 1999–2005, to determine congruence between Indium 111 scan readings and final clinical diagnoses, using all available data with at least 6 months of follow-up. Results Of 145 indium scans done for possible skeletal infection, infection was judged to be present in 52 cases. The sensitivity was 83%, and the specificity was 90%, with a diagnostic accuracy of 88%. Fifty-nine scans were done for indications other than skeletal infection. In 20 instances, when specific foci were suspected, the suspicion was correctly confirmed by indium scan in every case, without false positives or negatives (sensitivity and specificity, 100%). In 39 scans done to search for a possible source of nonspecific findings of infection (fever, leukocytosis, bacteremia), the sensitivity and specificity were 81% and 87%, respectively, with a diagnostic accuracy of 85%. Conclusion Except as a means to confirm an already-suspected clinical focus, the indium scan appears to offer relatively little definitive information that can be used for diagnosis or treatment of infection.

Aims A substantial proportion of patients with heart failure have preserved left ventricular ejection fraction (HF-PEF). Previous studies have reported mixed results whether survival is similar to those patients with heart failure and reduced EF (HF-REF). Methods and results We compared survival in patients with HF-PEF with that in patients with HF-REF in a meta-analysis using individual patient data. Preserved EF was defined as an EF ≥ 50%. The 31 studies included 41 972 patients: 10 347 with HF-PEF and 31 625 with HF-REF. Compared with patients with HF-REF, those with HF-PEF were older (mean age 71 vs. 66 years), were more often women (50 vs. 28%), and have a history of hypertension (51 vs. 41%). Ischaemic aetiology was less common (43 vs. 59%) in patients with HF-PEF. There were 121 [95% confidence interval (CI): 117, 126] deaths per 1000 patient-years in those with HF-PEF and 141 (95% CI: 138, 144) deaths per 1000 patient-years in those with HF-REF. Patients with HF-PEF had lower mortality than those with HF-REF (adjusted for age, gender, aetiology, and history of hypertension, diabetes, and atrial fibrillation); hazard ratio 0.68 (95% CI: 0.64, 0.71). The risk of death did not increase notably until EF fell below 40%. Conclusion Patients with HF-PEF have a lower risk of death than patients with HF-REF, and this difference is seen regardless of age, gender, and aetiology of HF. However, absolute mortality is still high in patients with HF-PEF highlighting the need for a treatment to improve prognosis.

The use of bioabsorbable plating systems for rigid fixation after cranial remodeling surgery has become the standard of care in the treatment of syndromic and nonsyndromic craniosynostoses at pediatric craniofacial centers in North America. The advantages of these absorbable plating systems over metallic plates and screws have been well documented. The absorbable plates have been used with remarkable safety and efficacy for more than 15 years. An unusual case of repeated early failure of an absorbable plating system in a patient with syndromic brachycephaly complicated by the development of hydrocephalus is reported. The reoperative rates for cranial remodeling surgery at our institution and the possible causes for this failure are discussed.

Background: Advances in technique and instrumentation have enabled surgeons to perform an increasing number of complicated procedures through laparoscopy. However, these efforts have often been compromised by the exertion of excessive force when anatomical structures are retracted to create a clear view of the anatomy. Here, we present a comparative study of human and robotic performance in force-controlled organ retraction during laparoscopic Nissen fundoplication (LNF). Methods: Six female pigs (20–25 kg) were anesthetized, intubated, and placed on mechanical ventilation; pneumoperitoneum (13 mmHg CO2) was established. A force-sensing retractor (FSR) was constructed to record the forces applied in retracting the stomach during dissection of the esophageal hiatus. The FSR was calibrated using known forces and then operated by either human alone or robot under human guidance using the FSR data. The esophageal hiatus was visualized and dissected, and LNF was completed. Results: Less force was needed for robotic (74.3 ± 10.5 g; mean ± standard deviation) than for human (108.9 ± 34.3 g) retraction (p= 0.007) to obtain an optimal view of the esophageal hiatus. No significant differences were observed for retraction setup time (robot, 14.3 ± 0.8 min; human, 13.7 ± 9.9 min; mean ± SD) or hiatal dissection time (robot, 14.0 ± 3.0 min; human, 14.0 ± 6.1 min; mean ± SD). Conclusions: These preliminary results illustrate our continuing effort to develop and evaluate an automated surgical assistant for laparoscopy. As more personnel-intensive advanced laparoscopic procedures are performed, robotic retraction is likely to offer a superior alternative to human retraction; it minimizes the forces exerted on the organs while maintaining excellent anatomical view.

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p

Congestive heart failure (CHF) is the most common discharge diagnosis for elderly patients. The survival of elderly (age greater than or equal to 75 years) patients with CHF has not recently been reported, especially with reference to left ventricular ejection fraction (LVEF). A patient database was searched for the diagnosis of CHF and then screened for age greater than or equal to 75, Framingham Criteria for CHF and an LVEF evaluation. Ninety-four men fitted all criteria, including a minimum potential follow-up of 3 years. Life-table analysis was employed to compare their survival experience to an expected survival based on a sex- and age-equivalent subset of the 1980 Census data. Causes of death were determined from autopsy, medical records or death certificates. Mean age at onset of CHF was 82.5. Forty-three per cent had an LVEF greater than or equal to 0.45. There was no difference in the prevalence of potential aetiologies between those with LVEF greater than or equal to 0.45 versus LVEF less than 0.45. Life-table analysis revealed that CHF patients had a worse survival than controls for the first 5 years after diagnosis, attributable primarily to a high first-year mortality (28%) for the CHF group. There was no difference in survival between the LVEF greater than or equal to 0.45 and LVEF less than 0.45 groups.

Background: Hypercapnia and local pressure effects unique to CO 2 base minimally invasive surgery alter renal blood flow. We have demonstrated laparoscopic antireflux surgery to have an additional impact upon hemodynamics (decreased cardiac output), potentially extending known effects upon renal blood flow. Methods: We measured renal blood flow with radioactive microspheres during laparoscopic antireflux surgery in a porcine model. Six pigs were anesthetized, monitoring lines were placed, and microspheres injected five time points associated with a laparoscopic antireflux operation. After euthanasia kidneys were retrieved and fixed, and representative samples counted for radioactivity specific for each of the five time points. Results: The greatest reduction in renal blood flow was 36% below baseline (p0.05). Concurrently, cardiac output had a maximum reduction of 39%. Conclusions: Laparoscopic Nissen fundoplication in this pig model is associated with a significant reduction in renal blood flow, probably related to reduction in cardiac output. Caution is warranted when considering laparoscopic antireflux surgery in patients with a compromised renal blood flow. © 2002 Excerpta Medica, Inc. All rights reserved.

Advances in technique and instrumentation have enabled surgeons to perform a growing array of procedures through laparoscopy. However, these efforts have often been compromised by exerting excessive forces during retraction of the structures necessary for anatomical view. Here, we present a comparative study of human and robotic performance in force controlled organ retraction during laparoscopic Nissen fundoplication (LNF). Six female pigs (20–25 kg) were anesthetized, intubated, placed on mechanical ventilation, and pneumoperitoneum (13mm Hg CO2) was established. A force sensing retractor (FSR) was constructed to record the forces applied in retracting the stomach during dissection of the esophageal hiatus (EH). The FSR was calibrated using known forces and then operated by either human alone or robot under human guidance using the FSR data. The EH was visualized, dissected, and LNF completed. Less force was utilized with robotic (74.3±10.5 grams) versus human (108.9±34.3 grams) retraction (p=0.007) to obtain proper anatomical view of the EH. No significant differences were observed for retraction setup time (robot 14.3±0.8 minutes and human 13.7±9.9 minutes) or hiatal dissection time (robot 14.0±3.0 minutes and human 14.0±6.1 minutes). These preliminary results present our continuing effort to develop and evaluate an automated surgical assistant for laparoscopy. As increasingly advanced, personnel-intensive laparoscopic procedures are performed, robotic retraction may present a superior alternative to human retraction by minimizing the forces exerted on organs yet maintaining excellent anatomical view.

Background. Laparoscopic Nissen fundoplication (LNF) is gaining popularity. Although the hemodynamic effects of the typical pneumoperitoneum have been studied, the additional consequences of the hiatal dissection necessary for LNF have not. Methods. Seven female pigs were anesthetized, intubated, and ventilated with a volume ventilator and hemodynamic and mechanical pressure monitoring devices were placed. Pressures were recorded every 15 minutes for 1 hour after each of four interventions: (1) anesthesia induction, (2) CO2 pneumoperitoneum (15 mm Hg), (3) LNF, and (4) release of pneumoperitoneum (and removal of ports). Results. Right atrial, inferior vena caval, mediastinal, pleural, airway, and pulmonary capillary wedge pressures all increased after pneumoperitoneum (p < 0.05). Only mediastinal pressure (8.6 vs 13.7 mm Hg, pneumoperitoneum vs LNF; p < 0.05) and pleural pressure (2.6 vs 3.5 mm Hg, pneumoperitoneum vs LNF; p < 0.05) showed a further significant increase after LNF. In addition, cardiac output fell significantly after LNF (5.9 vs. 4.6 L/min; p < 0.05). Mediastinal pressure and cardiac output remained significantly altered after the release of pneumoperitoneum. Conclusions. Surgical disruption of the esophageal hiatus during LNF causes both increased mediastinal and pleural pressure and a significant reduction in cardiac output. These findings uncover a previously unsuspected physiologic detriment that may occur during LNF.

Nonapneic, nocturnal oxyhemoglobin desaturation (NOD) during rapid-eye-movement (REM) sleep has been proposed as a predecessor and possible etiologic factor in the development of pulmonary hypertension in patients both with restrictive and obstructive chronic lung disease. The association between abnormal waking cardiopulmonary hemodynamics and NOD has not been established in patients with mild daytime hypoxemia. Gas exchange, pulmonary function, red cell mass, radionuclide gated cardiac ejection fraction, and supine cardiopulmonary hemodynamics were examined in 36 patients with chronic lung disease. All had a daytime PaO2 greater than 60 mm Hg and REM sleep-related NOD for greater than 5 minutes, to 85 percent or lower. These data were compared to those from 13 subjects with similar symptoms and objective measures of pulmonary dysfunction but without evidence of NOD. Patients with NOD showed more end organ evidence of hypoxemia and more abnormal cardiopulmonary hemodynamics than patients with similar degrees of lung disease but without NOD. The relative role of daytime vs nocturnal hypoxemia in inducing hemodynamic differences between groups cannot be determined from this study.

The results of seven laboratory tests of liver function, including spleen/liver activity ratios obtained by densitometric analysis of scans, are analyzed in 50 patients with proven Laennec's cirrhosis. In this series, the liver scan not only disclosed the liver gross anatomy and structural abnormality and established the best possible site for biopsy examination, but also, the increased splenic activity served as a useful diagnostic indication of Laennec's cirrhosis. Of 50 proven cases of Laennec's cirrhosis, 41 (82%) had abnormal spleen/liver ratios. An abnormal spleen/liver ratio in combination with abnormal results from any one or two other tests was relatively effective in the detection of cirrhosis. The accuracy is improved if the other laboratory tests are chosen from among tests for serum albumin, serum bilirubin, and SGOT. (Liver abnormalities other than cirrhosis can also present an abnormal spleen/liver ratio.) This simple determination extends the value of the liver scan commonly requested in search of metastases, primary lesions, or inflammatory processes, or in preparation for needle biopsy examination.

A 98-YEAR-OLD white male presented with a history of chronic congestive heart failure and acute compression fracture of the L-2 vertebral body. Three days following admission he developed a low grade fever and metabolic acidosis. Serum chemistry values including calcium and alkaline phosphatase, as well as hematologic indices were normal. Tc-99m oxidronate bone imaging was performed. A fan-shaped area of increased activity was identified in the left upper quadrant (Fig 1). A transverse linear focus of increased activity was seen in the lower sternum. Focal areas of increased uptake were also seen in the first metacarpal phalangeal joint of the right hand and the collecting system of the right kidney. Thin-layer chromatography demonstrated 98.5% Tc-99m pertechnetate binding to the oxidronate and no stomach or thyroid activity was seen in any other patients of that day. Therefore, the left upper quadrant uptake was thought to be located in the patient's spleen. Antero-posterior (AP) and lateral abdominal radiographs demonstrated serpigenous calcifications in the region of the splenic hilum and small curvilinear calcified flecks spreading throughout the splenic bed (Fig 2). The findings were consistent with splenic artery calcification. A compression fracture of the L-2 vertebral body was also identified. The patient died five days after the bone imaging. Gross and microscopic necropsy examination demonstrated a congested spleen without evidence of infarction, infiltration, or calcification in the splenic tissue. The patient had Grade I-II generalized atherosclerosis.

Un cas de rhabdomyelyolyse secondaire a une «fievre d'origine inconnue» a ete diagnostiquee a la scintigraphie osseuse au HDP [ 99m TC]

Presented is an unusual case of astrocytoma with diffuse multiple bony metastases in bone imaging. The classification, spread, and prognosis of astrocytoma are briefly reviewed.