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A Mayfield neurosurgical headrest positioned at the end of a standard operating room table may be utilized to achieve the prone positioning necessary to perform certain types of ophthalmic procedures, such as the unfolding of the inverted flap of a giant retinal break. We describe the technique of employing this readily available headrest.
The usefulness of computed tomography (CT) in the diagnosis of an intracardiac mural thrombus was examined by comparing with two-dimensional echocardiography (2-DE), left ventricular cineangiography (LVG), and operative findings. The following results were obtained: 1) Left atrial thrombi: Among 43 cases of valvular disease with mitral stenosis, left atrial thrombi were noted in 10 cases (13 regions) by CT. Out of these 13 regions, 2-DE detected six regions (Fig. 2). Among 11 patients who underwent operation, thrombi were present in four (six regions). Of these six regions, thrombus was suspected in one region and another one was undetectable, but detected in the remaining four regions by CT and was in good accord with the operative findings (Table 1). Left atrial thrombi were detected in two of 138 cases of coronary heart disease, and in one of 26 cases of cardiomyopathy by CT. 2) Left ventricular thrombi: Left ventricular thrombi were detected in 26 of 122 cases of myocardial infarction (21%) by CT, and had a particularly high incidence in the cases having a ventricular aneurysm (Fig. 4). Of 81 cases in which 2-DE was performed, left ventricular thrombi were detected in 13 cases by both CT and 2-DE, and were not detected in 59 cases by both methods. In nine cases 2-DE diagnosis was not consistent with CT (Table 2). Of 76 cases in which left ventricular cineangiography was performed, left ventricular thrombi were detected in 12 cases by both CT and LVG, and were not detected in 58 cases by both methods. There were six cases of disaccord between 2-DE and CT (Table 2). In two of five cases of congestive cardiomyopathy, left ventricular thrombi were noted by CT. CT was able to detect thrombi in the left atrial appendage, the left atrial lateral wall (Fig. 6), and the regions near the left ventricular apex, which were difficult to be investigated by 2-DE (Fig. 8). CT was, in particular, superior in depicting the size, location and property of thrombi. In addition, CT was able to depict clearly a small thrombus in the left ventricular apex to the extent of, or better than, left ventriculography. Therefore, contrast enhanced CT is a useful diagnostic method for the detection of intracardiac mural thrombi.
The third phase in the use of radio-isotopes for radical surgery of cervical carcinoma, using 99m Technetium antimony sulphide to localise pelvic lymph nodes on the operating camera table has yielded results which indicate good progress. The potency of lymphadenectomy was increased from an original level of 52.5 per cent to 81.6 per cent. Recurrence mortality went down over the first three years after treatment, according to preliminary results.
Thirty children presenting to the dental clinic of a pediatric hospital who required brief but urgent dental care, and who could not be satisfactorily examined or treated, were administered one of three medications--ketamine (Ketalar), 3 mg/kg; midazolam (Versed), 0.4 mg/kg; or sufentanil (Sufenta), 1.5 or 1.0 micrograms/kg--intranasally in a randomized, double-blinded protocol. The patients were brought to the day surgery area following appropriate fasting and administered one of the medications diluted in a dose of 0.1 mL/kg normal saline while sitting in a nurse's arms. Cardiorespiratory monitors were applied when tolerated, and the child was placed on the operating room table. Each child was injected locally with up to one dental cartridge of 2% lidocaine with 1:100,000 epinephrine before dental extractions. A sedation score was recorded using a scale where 1 = hysterical/untreatable, 5 = ideal sedation, and 10 = obtunded and desaturated, requiring airway management assistance. Midazolam administration resulted in acceptable sedation (mean score: 4) with no desaturations below 90% as measured by pulse oximetry and a mean recovery room observation time of only 3 +/- 2 min (+/- SD). Ketamine also had a mean sedation score of 4 and a short recovery period (7 +/- 7 min); however, two children experienced brief desaturations. Sufentanil at 1.5 micrograms/kg was noted to produce much more heavily sedated children (mean score 7), with a high incidence of significant oximetry desaturation (80%) and prolonged recovery room duration (58 +/- 40 min). Use of 1.0 microgram/kg sufentanil resulted in no desaturations, less sedation (mean score 4), and a brief recovery time (7 +/- 13 min).(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: Patients undergoing cardiovascular surgery are at high risk for sores because of impaired perfusion, the time spent on the operating room table, and restricted mobility in the immediate postoperative period. OBJECTIVE: To identify risk factors for sores. METHODS: In a 900-bed teaching hospital, 163 patients who underwent cardiovascular interventions were enrolled. Risk measurement included skin assessment, Braden and Norton scales, physic and biologic data and specific risk factors. The development of the most severe stages of pressure sores was followed (Stages II and III). RESULTS: Forty-eight (29.5%) patients totalized 75 pressure sores. In univariate analyses, Norton and Braden scores, hemoglobin concentration, presence of ulcers at admission, use of antihypertensive drugs, systemic use of corticosteroids, nosocomial infection, re-intervention and readmission in intensive care units were associated with sores. In a logistic regression model, hemoglobin concentration at admission (p=0.0007), postoperative Braden score (p=0.0002), and postoperative steroid therapy (p=0.020) were the only predictors of sores. Total length of stay was 6 days higher (p=0.03) for patients with pressure sores. CONCLUSIONS: The detection of risks is recommended during the entire stay. Identification of patients at risk is required to provide preventive resources appropriately, which can lessen the incidence of pressure sores and reduce patient discomfort, length and costs of hospital stay.
STUDY DESIGN: This study is a prospective evaluation of the effects of commonly used spinal tables on lumbar sagittal alignment. OBJECTIVES: The objective was to determine the differences, if any, in lumbar sagittal alignment produced by different positions on routinely used spinal operating tables. SUMMARY OF BACKGROUND DATA: Earlier studies have documented the advantages of the knee-chest position in lumbar decompressive procedures. When simultaneous fusion is performed and augmented with internal fixation, intraoperative position is the critical determinant of sagittal plane balance. Other investigators have documented an association between the knee-chest position and decreased lumbar lordosis. METHODS: Ten asymptomatic volunteers underwent a series of four lateral lumbar radiographs, as follows: standing, prone on the Jackson (Orthopaedic Systems, Inc., Hayword, CA) spinal table, and prone on the Andrews (Orthopaedic Systems, Inc.) table with the hips flexed 60 degrees and 90 degrees, respectively. Intervertebral body angle measurements were obtained from L1 to S1. Lordosis values were compared and analyzed for each of the positions. Standing lordosis was assumed to be physiologic. RESULTS: Physiologic lordosis values were produced only on the Jackson operative table. Both positions on the Andrews table resulted in a statistically significant decrease in lumbar lordosis. Decreasing hip flexion on the Andrews table from 90 degrees to 60 degrees produced a statistically significant increase in lumbar lordosis. However, this change did not reproduce physiologic values. CONCLUSION: When instrumentation is used to augment lumbar fusions, positions incorporating hip flexion should be avoided to ensure maintenance of sagittal plane balance.
Clinical databases typically contain a significant amount of temporal information, information that is often crucial in medical decision-support systems. Most recent clinical information systems use the relational model when working with this information. Although these systems have reasonably well-defined semantics for temporal queries on a single relational table, many do not fully address the complex semantics of operations involving multiple temporal tables. Such operations can arise frequently in queries on clinical databases. This paper describes the issues encountered when joining a set of temporal tables, and outlines how such joins are far more complex than non-temporal ones. We describe the semantics of temporal joins in a query management system called Chronus II, a system we have developed to assist in evaluating patients for clinical trials.
Considerable confusion appears to exist in the metabonomics literature as to the real need for, and the role of, preprocessing the acquired spectroscopic data. A number of studies have presented various data manipulation approaches, some suggesting an optimum method. In metabonomics, data are usually presented as a table where each row relates to a given sample or analytical experiment and each column corresponds to a single measurement in that experiment, typically individual spectral peak intensities or metabolite concentrations. Here we suggest definitions for and discuss the operations usually termed normalization (a table row operation) and scaling (a table column operation) and demonstrate their need in 1H NMR spectroscopic data sets derived from urine. The problems associated with "binned" data (i.e., values integrated over discrete spectral regions) are also discussed, and the particular biological context problems of analytical data on urine are highlighted. It is shown that care must be exercised in calculation of correlation coefficients for data sets where normalization to a constant sum is used. Analogous considerations will be needed for other biofluids, other analytical approaches (e.g., HPLC-MS), and indeed for other "omics" techniques (i.e., transcriptomics or proteomics) and for integrated studies with "fused" data sets. It is concluded that data preprocessing is context dependent and there can be no single method for general use.
The aim of this study was to determine characteristics of personal exposure to inorganic and organic dust during manual harvest operations of California citrus and table grapes. Personal exposures to inhalable dust and respirable dust were measured five times over a 4-month period of harvesting season. We analyzed components of the dust samples for mineralogy, respirable quartz, endotoxin, and total and culturable microorganisms. Workers manually harvesting were exposed to a complex mixture of inorganic and organic dust. Exposures for citrus harvest had geometric means of 39.7 mg/m(3) for inhalable dust and 1.14 mg/m(3) for respirable dust. These exposures were significantly higher than those for table grape operations and exceeded the threshold limit value for inhalable dust and respirable quartz. Exposures for table grape operations were lower than the threshold limit value, except inhalable dust exposure during leaf pulling. Considered independently, exposures to inhalable dust and respirable quartz in citrus harvest may be high enough to cause respiratory health effects. The degree of vigorous contact with foliage appeared to be a significant determining factor of exposures in manual harvesting.
We previously reported that the working and health conditions of vibrating tool operators in an iron foundry were investigated in 1975 and vibration hazards were observed to occur frequently in workers operating chipping-hammers powered by compressed air. After that, we instituted medical treatment for the afflicted workers and improvement of working conditions in the foundry, and have performed annual medical examinations for four years. In this paper, the course of hygienic control and the change in the medical findings of twenty-four chipping-hammer operators are reported. 1. The following measures were taken to improve the working conditions of chipping-hammer operators and therapy for patients (Table 1): (1) The operating time of vibrating tools, including chipping-hammer, was limited to two hours per day. The casting process was improved to diminish the flashes that are the objects of chipping-hammer operation. For the purpose of reducing the vibration transmitted to the operator, a servo-arm that has a servomechanism for the chipping-hammer was developed and introduced. (2) Infrared lamps in the foundry and air curtains at the doorway were installed for keeping the chipping-hammer operating area warm. A warm room was set up in the foundry for providing warmth during rest periods and protective clothing against the cold was provided. (3) Workers who displayed health disturbances by medical examinations were treated during the cold season from November to April by periodic visits to the clinic or extended hospitalization, or transferred to job without vibration exposure, according to their stage of disease. Preventive treatment with vasodilator and bubble bath was performed in winter for the chipping-hammer operators. 2. In order to estimate the effect of these countermeasures, annual medical examinations were conducted in March 1975, March 1976, April 1977 and March 1978. Such subjective symptoms as Raynaud's phenomenon, finger numbness, finger listlessness, heavy-headedness, forgetfulness, irritability and hearing disorder showed a tendency for improvement, but other complaints did not (Tables 2-4). The improvement of Raynaud's phenomenon is considered to be due not merely to the countermeasures but also to reducing the chance of provocation and therefore the countermeasures should not be overestimated as a factor of recovery of vibration hazards. Of the functional tests, a tendency for improvement was recognized in sensory functions and peripheral circulatory functions, but not in motor functions (Tables 5, 6). However, the course of recovery was not fast and some advanced cases, especially those using chipping-hammers for more than ten years, showed less improvement after hospital treatment (Table 7, Fig. 1). This indicates the importance of hygienic control which enables vibration hazards patients to have early diagnosis and treatment. Furthermore, in order to eradicate the vibration hazards in the cast metal industry, a drastic reform of the finishing process is considered to be necessary.
OBJECTIVES: To determine whether performing reamed intramedullary nailing of the femur without the use of a fracture table decreases the length of operation. DESIGN: Retrospective. SETTING: Level 1 trauma center, Nashville. Tennessee. PATIENTS/PARTICIPANTS: Consecutively treated patients with fractures of the femoral shaft were treated with intramedullary nails from June 1986 to March 1996. INTERVENTION: Reamed intramedullary nailing of the femoral shaft was performed with the use of a fracture table or with the leg draped free on a radiolucent table. MAIN OUTCOME MEASUREMENTS: Length of anesthesia time, prep and drape time (from the point the anesthetized patient is turned over to the surgeons until incision), and intramedullary nailing time (from incision until end of surgery) for reamed intramedullary nailing of the femoral shaft performed with and without the use of a fracture table were compared. RESULTS: Univariate analysis showed statistically significant decreases in the length of prep and drape time, operative time, and anesthetic time when fractures were treated without the use of a fracture table. Multivariate analysis showed that use of a fracture table prolongs prep and drape time (plus twenty minutes), operative time (plus seventeen minutes), and anesthesia time (plus seventy-three minutes) when the covariates of age, sex, fracture location, learning curve, position of the patient, nail brand, and number of distal bolts are controlled. CONCLUSIONS: Reamed intramedullary nailing of the femoral shaft performed without the use of a fracture table is significantly faster than when the procedure is performed with a fracture table.
Off-Pump Coronary Artery Bypass (OPCAB) allows myocardial revascularization without use of cardiopulmonary bypass and may be associated with fewer postoperative complications. A retrospective review was undertaken to assess the value of this new strategy in our surgical practice. The records of all our patients (n = 259) undergoing isolated coronary artery bypass (CAB) operations from January 1 through December 31, 1999, were reviewed (Table 1). Patient characteristics and comorbidities were similar in both groups with the exception of age and diabetes (Table 2). Mean operating room time, blood products transfused, morbidity, mortality, and length of stay (LOS) were all significantly less in the OPCAB group. We conclude that OPCAB techniques may offer significant benefits to our population of patients undergoing myocardial revascularization.
A 76-year-old man was admitted to the surgical department with acute abdominal pain and impaired sensation of the lower extremities. An aneurysm of the abdominal aorta (AAA) was diagnosed already in the past. There were no signs of cardiovascular failure. Examination (sonography, CT) did not show intraabdominal bleeding. Nevertheless AAA rupture was suspected. A decision on an urgent operation was taken. Despite permanent resuscitation the patient died on the table before the operation began. In the discussion four type of AAA rupture are mentioned: into the open abdominal cavity, into the retroperitoneum, into surrounding organs such as gut or vena cava and so-called "sealed rupture". In every symptomatic AAA connected with circulatory instability rupture is suspected. An urgent operation is necessary in these cases. Rupture of AAA into the vena cava inferior is rare. A syndrome including a history of aneurysm, abdominal pain, continuous abdominal murmur and heart failure is pathognomic for this type of rupture. Computer tomography, sonography or arteriography could be helpful the diagnose determination. However, correct preoperative diagnosis is difficult. Other causes of circulatory failure, especially heart attack, must be differentiated. Treatment of such cases is surgical, using a stent graft is rare and determined only for indicated cases.
PURPOSE: We investigated the relationship between the amount of radiation exposure to the operator during table-side manual-injection angiographic procedures including digital subtraction angiography (DSA) and the operator's position, as well as a simple means to decrease radiation exposure. METHODS: Measurement of radiation exposure was carried out with thermoluminescent dosimeters (TLDs) in nine abdominal angiographies. In the first study, radiation exposure during DSA or during fluoroscopy was measured using TLDs placed near the angiographic table. In the second study, radiation exposure to the interventional radiologist was measured during manual-injection DSA at a near and a far operator position. RESULTS: Radiation exposure to the operator received during manual-injection DSA accounted for more than 90% of the total procedural exposure. The exposure to the operator markedly decreased at the far position compared with that at the near position when performing DSA. CONCLUSION: Manual-injection DSA is the largest contributor to radiation exposure received by the interventional radiologist, therefore, the use of a power injector is always recommended when performing DSA. When manual-injection DSA is necessary, radiologists should position themselves as far away from the patient as possible.
The Mosaic bioprosthesis is a stented porcine aortic valve, which combines the zero pressure differential fixation technique (by applying equal pressure to the in- and outflow ends of the valve, the aortic root is pressurized to maximize the flow area while no pressure is exerted on the leaflets) and an antimineralization treatment with alpha amino oleic acid for improved tissue durability. The device is in clinical use since February 1994. The purpose of this study was to collect intermediate term data of the Mosaic bioprosthesis in the aortic position to evaluate its clinical and hemodynamic function. From February 1994 to May 1999, 100 patients underwent aortic valve replacement with the Mosaic prosthesis at our department. There were 49 female patients, mean age at implant was 73.4 +/- 7.3 years (range 31 to 87). Concomitant procedures were done in 40%. Preoperative and operative clinical data are shown in Tables 1 and 2. When assessing the size of the bioprosthesis, it is important to use the original Mosaic sizer. Because of the possibility of the so-called supra-x placement, the specific construction of the sizer and the Mosaic valve often allow the implantation of a 1-size larger valve compared to the conventional supra-annular placement. By this a significant increase in the effective flow orifice is possible. This proceeding is depicted in Figure 1. All patients have been anticoagulated with phenprocoumon at least for 3 months postoperatively, INR was aimed at 2.5 to 3.5. Patients have been followed up prospectively, within the initial hospitalization for valve replacement, 6 months postoperatively and at annual intervals including an hematological check and transthoracic echocardiography. The mean follow-up was 2.7 years with a total follow-up of 273.7 patient years. The follow-up was 100% complete. After 5 years the mean systolic pressure gradient was 15.2 +/- 3.0 mm Hg for the 21-mm, 13.1 +/- 4.6 mm Hg for the 23-mm, 10.0 +/- 3.1 mm Hg for the 25-mm valve size, the effective orifice area 1.6 +/- 0.3 cm2 (21-mm), 1.9 +/- 0.3 cm2 (23-mm) and 2.5 +/- 0.8 cm2 (25-mm) (see Table 3). The freedom from prosthesis-related event rates, calculated according to Kaplan-Meier, at 5 years were: 97.3 +/- 1.9% for permanent neurological, 99.0 +/- 1.0% for transient neurological, 95.9 +/- 3.2% for thrombosed prosthesis, 95.6 +/- 2.2% for antithromboembolic related hemorrhage, 96.2 +/- 3.7% for structural valve deterioration, 96.9 +/- 3.0% for non-structural dysfunction, 100% for endocarditis and 92.0 +/- 4.9% for explant (see Table 4). The total operative mortality (within 30 days) was 3.0%, the late postoperative mortality was 4.4% per patient year and included a valve related mortality rate of 0.7%/patient year. In Figure 2 the survival function after aortic valve replacement is depicted, arranged in freedom from all deaths, from Mosaic-related deaths and from Mosaic-related plus sudden/unexplained deaths. Before implantation of the Mosaic bioprosthesis 95% of the patients were in NYHA Classes III and IV, whereas 6 months postoperatively 98% could be classified in NYHA Classes I and II (see Figure 3). In relation to other biological prostheses (Intact, Carpentier-Edwards Pericardial and Porcine, Hancock Modified Orifice, Biocor, Freestyle) the Mosaic bioprosthesis showed very satisfactory and predominantly better hemodynamic results than the compared stented valves and approached the performance of stentless prostheses. The freedom rates from prosthetic-related adverse events of the Mosaic bioprosthesis were at least equivalent to the compared prostheses. However, the satisfactory freedom rates, especially from structural valve deterioration, should be qualified by considering the experience that most incidences appear from the 5th year on after implantation. The clinical and hemodynamic performance of the Mosaic prosthesis has been very satisfactory during the first 5 years after clinical introduction. Further data will be necessary to confirm long-term durability.
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One-stage adjustable suture for strabismus correction, with the whole operation done under topical anaesthesia and adjustment done on the table, was performed on 45 consecutive patients. The stability of the post-adjustment result was studied by comparing the post-adjustment deviation on the operating table to that at six weeks and three months after operation. The stability was comparable to that following the usual two-stage adjustable suture. The original angle of deviation and the fusion status were found to have no bearing on the stability of the procedure.