Biomedical subjects
Publications and source records attributed to J F Mooney.
The athlete's wrist is particularly prone to injury. Although many wrist injuries are dismissed as sprains or strains, a number of these injuries involve significant ligamentous damage that can lead to chronic carpal instability. A complete knowledge of the carpal ligamentous anatomy and classification of wrist instability patterns is necessary for the adequate diagnosis and treatment of these injuries.
To determine if morphology of procedure-associated dissections could help predict clinical outcome, angiograms of 691 coronary artery dissections resulting from percutaneous transluminal coronary angioplasty were categorized according to the National Heart, Lung, and Blood Institute classification system. Classes of dissection were then correlated with clinical outcome: 543 patients with type B dissections had no increase in morbidity and mortality when compared with patients without dissection, with a similar success rate of 93.7%. Complications in this group were low and compared favorably with complication rates in procedures not associated with dissection. One hundred forty-eight procedures associated with dissections of types C to F had a significant increase in in-hospital complications, including acute closure (31%), need for emergency coronary bypass surgery (37%), myocardial infarction (13%) and repeat angioplasty (24%). The overall clinical success rate for those with types C to F dissection was 38%. The differences in clinical success and acute complications between type B and types C to F dissections were statistically significant at p less than 0.0005 for all variables studied. The angiographic morphology of a dissection during coronary angioplasty can predict clinical outcome, aiding in selection of effective therapy.
The authors of this study hypothesized that percutaneous transluminal coronary angioplasty of a stenosis at the ostium of a branch vessel, whether isolated or associated with a bifurcation stenosis, was associated with reduced procedural success and increased in-hospital complications. One hundred six patients with 119 ostial branch stenoses were compared with 1,168 patients who underwent angioplasty of nonostial branch stenoses. An ostial branch stenosis was defined as a stenosis in the proximal 3 mm of a major branch vessel (diagonal [n = 58], posterior descending [n = 21], obtuse marginal [n = 34] and intermediate [n = 6]). The ostial branch stenosis was isolated in 61% of the patients and associated with a bifurcation stenosis in 39%. Despite a balloon to artery ratio of 1.05:1, angiographic success was 74% of ostial branch stenoses versus 91% of nonostial stenoses (p less than 0.01). Furthermore, angioplasty of ostial branch stenoses resulted in a complication rate of 13 versus 5% for angioplasty of nonostial branch stenoses (p less than 0.01). Therefore, angioplasty of ostial branch stenoses results in decreased procedural success and significant residual stenosis despite adequate balloon sizing, suggesting arterial elastic recoil and a significant increase in complications.
The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) for stenoses involving ulcerative lesions were retrospectively studied. Seventy-seven patients (62 men and 15 women, mean age 62 +/- 10 years) representing 3.4% of 2,250 patients treated with PTCA during the period January 1, 1988 and June 30, 1990, had pre-PTCA stenoses defined as ulcerated. Twenty-eight (36%) of the stenoses were localized in the left anterior descending coronary artery, 9 (12%) in the left circumflex and 40 (52%) in the right coronary artery. During angioplasty, percent diameter stenosis was reduced from 73 +/- 14% to 22 +/- 13% and transstenotic gradient decreased from 48 +/- 18 to 12 +/- 6 mm Hg. Clinical success (freedom from angina at discharge without coronary bypass surgery, infarction or death) was achieved in 70 patients (90.9%). There were seven unsuccessful cases: three underwent elective coronary bypass surgery, one was managed medically, and three developed a major flow interrupting dissection during the procedure requiring emergency coronary bypass surgery. There were no deaths. At mean follow-up of 7.6 months, 45 of 61 patients (73.7%) remained asymptomatic. One patient needed an elective coronary bypass surgery and five patients had a successful repeat PTCA. In conclusion, PTCA for an ulcerated stenosis can be performed safely with a high primary success rate and a favorable early clinical course.
Chronic ulnar wrist pain is both difficult to diagnose and difficult to treat effectively. A number of anatomic derangements have been reported as potential causes of this pain. We discuss a patient with pain on the ulnar side of the wrist and an arthroscopically diagnosed disruption of the ulnolunate ligament. This was an isolated lesion, and the patient responded well to debridement.
Dislocation of the tibiotalar joint without associated fracture is rare. We have presented a case of open anterolateral ankle dislocation with complete ligamentous disruption. In contrast to reports that internal fixation is not required to maintain reduction of tibiotalar joint dislocation, we found this dislocation to be grossly unstable, requiring both a syndesmotic screw and a calcaneotalotibial transfixing pin for stabilization.
Explore the source record for details and available documents.
Emergency percutaneous cardiopulmonary bypass support was instituted in 11 patients in cardiac arrest refractory to conventional resuscitation measures. Emergency percutaneous cardiopulmonary bypass support was used in five patients in whom cardiac arrest occurred as a result of a complication in the cardiac catheterization laboratory (group 1) and in six other patients in cardiac arrest (group II). A 21F cannula and a 17F cannula were percutaneously inserted into the femoral vein and artery. Flow rates of 3 to 5 L/min were achieved with restoration of mean arterial pressure to 70 mm Hg (range 50 to 75). The status of all 11 patients was improved initially both clinically and hemodynamically with percutaneous cardiopulmonary bypass. Of the group II patients, three had anatomy unsuitable for percutaneous transluminal coronary angioplasty or coronary bypass grafting, could not be weaned from cardiopulmonary support, and died; three of these patients had coronary artery bypass grafting and two survived. All five group I patients underwent successful coronary bypass grafting and survived. Of the seven patients with anatomically correctable disease, all seven were discharged from the hospital. With conventional management nearly all seven of these patients would have died. Nine of 11 patients underwent a cardiac operation and seven of the nine survived. The operative mortality rate was 22% and the overall survival rate was 64%. At follow-up (mean 7 months), all seven patients are alive and six have resumed a normal and active life-style. In conclusion, emergency percutaneous cardiopulmonary bypass support is a powerful resuscitative tool that may stabilize the condition of patients in cardiogenic shock and cardiac arrest to allow for definitive intervention.
A cohort of 112 consecutive patients with angiographically defined intracoronary thrombi was treated with percutaneous transluminal coronary angioplasty and followed prospectively to determine early and late outcomes. Coronary angioplasty using a treatment modality of intravenous and intracoronary heparin, antiplatelet agents and prolonged inflations with oversized balloons (balloon:vessel ratio, 1.2:1) resulted in clinical success in 103 patients (92%) at hospital discharge. No periprocedural thrombolytic therapy was used and prolonged pretreatment with heparin was not routinely used. Four patients (3.5%) required elective coronary bypass surgery, and 4 patients (3.5%) required emergency coronary artery bypass grafting because of abrupt closure. Late clinical follow-up (mean 7 months) was available in 99 of the 103 successfully treated patients (96%). Seventy-three percent of patients were asymptomatic at follow-up, and 27% had class I or II angina. No patients had a late myocardial infarction. Elective coronary artery bypass surgery was required in 3 patients (3%) and repeat coronary angioplasty in 17 patients (17%). There were 2 late cardiac deaths at 7 months. Ninety-four patients (95%) had an event free follow-up defined as absence of coronary artery bypass surgery, myocardial infarction or death. In conclusion, coronary angioplasty alone, using intracoronary heparin and prolonged balloon inflations with relatively oversized balloons may be helpful to achieve a high initial success rate, low incidence of in-hospital complications and excellent long-term results in patients with intracoronary thrombus.
The Monorail Piccolino coronary angioplasty balloon catheter (MBC) was evaluated on 118 patients at two centers. Technical success was achieved in 110 patients (93%). Time for catheter exchange and total fluoroscopy time were significantly lower for the Monorail catheter than with standard equipment (exchange time 97 vs. 170 seconds P less than .05 and fluoroscopy time 17 vs. 88 seconds P less than .001). The advantages of rapid exchange and the ability of utilize 2 Monorail balloon catheters through one 9F guiding catheter for simultaneous inflations allowed for maximal flexibility in treating patients with bifurcation lesions. The double wire approach utilizing one Monorail balloon catheter with a 7F guiding catheter was also technically successful. The Monorail Piccolino balloon catheter has unique features that allow for greater ease of operator use, rapid catheter exchange, and optimal angiographic visualization. It is felt that this catheter design provides distinct advantages over standard angioplasty equipment.
Between March 1978 and July 1981, 217 symptomatic patients underwent coronary angioplasty as an alternative to coronary bypass surgery. Angioplasty was successful in 143 patients (66%), unsuccessful but uncomplicated in 65 (30%) and complicated in 9 (4%) by one or more of the following criteria: Q wave myocardial infarction (2%), emergency surgery (4%) or death (0.5%). Late follow-up evaluation was obtained in 213 patients at a mean of 9 +/- 1 years. Of patients in whom angioplasty was successful, 59 (42%) of 140 required another revascularization procedure (repeat angioplasty in 26% and bypass surgery in 16%). The actuarial survival rate at 5, 9 and 10 years after successful angioplasty was 98%, 93% and 92%, respectively. Of the 65 patients with unsuccessful and uncomplicated angioplasty (usually as a result of technical factors), 58 underwent elective bypass surgery within 2 months and 56 survived. These 56 surgical patients were compared with the 140 patients with successful angioplasty. Univariate analysis of prognostic factors did not reveal significant differences between these two groups. At late follow-up study, the successful angioplasty and the successful surgical groups had similar rates of survival (93% versus 95%, p = NS) and of death or infarction, or both (11% versus 12.5%, p = NS). Repeat revascularization was required more frequently after successful angioplasty than after surgery (42% versus 18%, p less than 0.001). Crossover from angioplasty to surgery occurred slightly more often than from surgery to angioplasty (16% versus 12.5%, p = NS). The time to crossover from angioplasty to surgery occurred earlier than from surgery to angioplasty (mean 21 versus 76 months, p less than 0.001).
Rapid diagnosis, appropriate management, and sport-specific rehabilitation are important in the management of any wrist injury in the athlete. The addition of technetium scans, CT, arthroscopy, and MRI in the evaluation of the athlete's wrist has provided valuable and powerful diagnostic tools. The versatility and relatively low invasiveness of arthroscopic intervention and the subsequent early return to activity make this technique especially attractive in the high-performance athlete. Suspicion of potential injuries, complete knowledge of wrist mechanics and anatomy, and a careful physical examination are still the most important tools in the evaluation of wrist injury. It is important to approach each athlete in a patient-oriented manner, taking into account the fact that many of these injuries have the potential to be career ending. Treatment that will provide the best possible long-term wrist function must be the physician's ultimate goal. In addition, the importance of appropriate and activity-specific rehabilitation cannot be overemphasized.
We have described the major steps required to open a new ICPCU. The unit allows for a comprehensive standardized approach to the education of patients undergoing interventional cardiology procedures and offers the optimal setting for nursing research in the field of interventional cardiology and cardiovascular nursing. Primarily, the advent of this unit has supported the implementation of primary nursing, allowed for optimal continuity of patient care, and contributed to a decrease in the length of hospital stay of these patients and an increase in patient and family satisfaction.
Explore the source record for details and available documents.
Use of intramuscular botulinum-A toxin (Botox) to produce neuromuscular blockade has been effective in treating certain ocular and facial muscular imbalances as well as spasmodic torticollis. In this preliminary open study, the effectiveness of intramuscularly injected Botox on the muscular imbalances of cerebral palsy was assessed in 27 pediatric patients. Each patient had "dynamic deformities" unresponsive to other treatment, and operation was the only other realistic alternative. The dose of Botox was calculated on a unit/body weight basis. In ambulatory patients, clinical changes in gait were assessed by a physician's rating scale. Reduction in spasticity became apparent in 12-72 h after injection; the effect of Botox after target threshold was reached lasted 3-6 months. No major side effects occurred. Botox may prove a useful adjuvant in conservative management of the spasticity of cerebral palsy. Successful management with these injections may allow delay of surgical intervention until the child is older and at less risk of possible complications, including the need for repeated surgical procedures.
In order to evaluate further the efficacy of local intramuscular injections of botulinum-A toxin (BAT-A) in the management of dynamic equinus deformity associated with cerebral palsy, a randomized, double-blind, placebo-controlled study was undertaken. When evaluated using our Physician Rating Scale, 83% (five of six) of patients receiving toxin showed improvement, versus 33% (two of six) receiving placebo. There were no major complications. BAT-A injections appear to be safe and effective in children, and merit further prospective study.
A 2.75-month-old male infant was referred to our institution due to persistent hip subluxation despite 3 weeks of treatment in a Pavlik harness. Harness treatment was continued for 2 more weeks until it was noted that his left upper extremity function, which had been normal previously, had changed. Radiographs showed no bony abnormality. A compression or traction injury to his brachial plexus from the downward pull of the harness straps, possibly related to his relatively large size, was believed to be causative. Use of the harness was discontinued immediately, and his upper extremity motor function quickly returned to normal.
Percutaneous cardiopulmonary bypass support was electively instituted prior to coronary angioplasty in 16 patients at high risk for hemodynamic collapse. In all cases the dilated artery supplied greater than 2/3 of the functioning myocardium. Eight patients had moderate LV dysfunction with ejection fraction 25-40%. Eight patients had an ejection fraction less than 20%. A 21 French cannula and a 17 French cannula were percutaneously inserted into the femoral vein and artery. Cardiopulmonary bypass support was instituted using a Bio-Medicus centrifugal pump just prior to coronary angioplasty at flow rates of 3.5-5 liters/minute. Thirteen patients had single vessel angioplasty and three patients had multivessel angioplasty. Complete loss of systolic function was observed in 9 (56%) patients. This finding when present confirms the absolute requirement for cardiopulmonary support. Technical success was achieved in all 16 patients (100%), clinical success was achieved in 14 patients (88%). Patient followup (mean 10 months) revealed 3 patients with class I-II angina and 10 patients were asymptomatic. There was one late death. In conclusion, percutaneous cardiopulmonary bypass support for carefully selected high risk patients may allow coronary angioplasty to be performed safely and effectively despite complete loss of systolic function during balloon inflation.