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PubMed1994

The small bowel follow-through: time to sit up.

It is common practice for patients to lie on their right side during small bowel barium follow-through examinations. The rationale is that this speeds up transit time and improves diagnostic usefulness. The results of a randomized, prospective study of 105 patients are presented. There was no significant difference in either transit time or diagnostic usefulness when the examination was carried out with the patient erect (sitting or ambulant) or when adopting the decubitus position. Abandoning the use of the right side down decubitus position allows a longstanding fiction to be discarded. Furthermore, lack of reclining space has been one factor which may limit the number of patients booked for this examination during a single session. Space for couches and trolleys need no longer be a barrier to the efficient organization of a small bowel screening session.

Adolescent↗
PubMed1983

Computed tomography for diagnosis of persistent hyperplastic primary vitreous (PHPV).

Leucocoric eyes with persistent hyperplastic primary vitreous (PHPV) were studied by computed tomography (CT). Maximum information was derived from use of an intravenous contrast agent and repetition of the scanning in the lateral decubitus position. Eight diagnostically helpful radiologic findings were noted, some for the first time. (1) Radiodense retrolental soft tissue can be demonstrated along Cloquet's canal. (2) The retrolental tissue enhances after administration of intravenous iodine-containing contrast material. (3) Congenital nonattachment of the retina is demonstrable by CT. (4) There may be localized or generalized increased radiodensity of the vitreous body. However, some minimally affected cases have vitreous chambers with normal attenuation values, and CT evidence for PHPV may be lacking in such patients. (5) There may also be layered, high density fluid (blood) in the retrohyaloid space, which shifts location in the lateral decubitus position. Thus far, this finding appears to be unique to PHPV, but computed scanning of other neonatal ocular conditions will be necessary before concluding it is pathognomonic. (6) There is absence of ocular and intraorbital calcification. (7) Abnormalities in configuration of the eyeball, including microphthalmos, can be demonstrated. (8) Retrobulbar tissues and other orbital structures appear normal, and the optic nerves appear normal or minimally reduced in size.

Adolescent↗
PubMed1999

Risk factors for development of proteinuria in chronic spinal cord injury.

A retrospective, case-control study was performed to investigate the risk factors that may contribute to the development of proteinuria in patients with chronic spinal cord injury (SCI). During an 18-month period, 31 subjects with a 24-hour protein excretion of 1.0 g or greater were identified. Three control subjects with SCIs with a 24-hour urinary protein excretion of less than 1.0 g during the same time period were randomly selected for each study subject with proteinuria. Clinical data, including level and duration of injury, age, presence of indwelling bladder catheter, number of decubitus ulcer procedures, serum albumin and creatinine concentrations, hematocrit, creatinine clearance, and the presence of hypertension and diabetes mellitus, were obtained from medical records. Subjects with proteinuria had other evidence of renal dysfunction with greater serum creatinine concentrations and reduced creatinine clearances, serum albumin concentrations, and hematocrits. Proteinuric subjects were older, had a longer duration of injury, had undergone a greater number of decubitus ulcer procedures, and were more likely to have hypertension and indwelling bladder catheters. The independent predictors for the development of proteinuria using logistic stepwise multiple linear regression analysis were the use of chronic indwelling bladder catheters, number of decubitis ulcer procedures, presence of hypertension, and older age. These data suggest that inflammatory complications associated with complications of chronic SCI, rather than SCI per se, contribute to the development of proteinuria. SCI patients with proteinuria have more impaired renal function and increased mortality compared with SCI patients without proteinuria.

Catheters, Indwelling↗
PubMed2002

Surgical strategy in adrenal masses.

OBJECTIVE: Endoscopic adrenalectomy represents the "New Golden Standard" in the surgical treatment of benign adrenal lesions up to 6 cm. Open adrenalectomy is recommended for patients with suspected malignant disease and tumors larger than 6 cm. METHODS AND MATERIAL: The surgical technique of trans- and retroperitoneal adrenalectomy is described. Reviewing literature the importance of the endoscopic approach and its role in the surgical treatment of adrenal lesions is analyzed. RESULTS: As in open adrenalectomy different endoscopic approaches to the adrenals were developed: adrenal tumors can be removed endoscopically using a transperitoneal (patient in a supine or lateral decubitus position) or extraperitoneal route (patient in a lateral decubitus or prone position). Reviewing literature the endoscopic transperitoneal adrenalectomy is documented in 1425 patients. 4.6% (66 patients) had to be converted to an open procedure. Five hundred and forty-four tumors were removed by an extraperitoneal access. The conversion rate was 4.4% (24 patients). CONCLUSION: The basis of excellent results are careful patient selection, evaluation and preoperative preparation in a center with experience in the open techniques and at least 20 endoscopic adrenalectomies per year.

Adrenal Gland Neoplasms↗
PubMed1998

Aerobic and anaerobic microbiology of infection after trauma.

Clinical and laboratory data from 1973 to 1988 were retrospectively reviewed to study the microbiology of infection following trauma. A total of 368 specimens obtained from 340 trauma patients showed bacterial growth. The traumas included lacerations (163), blunt trauma (76), penetrating trauma (65), bites (20), and open fractures (10). Anaerobic bacteria only were isolated in 119 (32%) specimens, aerobic bacteria only in 58 (16%), and mixed aerobic-anaerobic flora in 191 (52%). A total of 444 anaerobic (1.2 isolates per specimen) and 267 aerobic or facultative (0.7 per specimen) were recovered. The predominant anaerobic bacteria included Bacteroides fragilis group (119 isolates), Peptostreptococcus spp (113), Clostridium spp (78), Prevotella spp (58), and Fusobacterium spp (23). The predominant aerobic bacteria included Escherichia coli (83), Staphylococcus aureus (61), Streptococcus pyogenes (27), Streptococcus group D (16), and Klebsiella pneumoniae (16). The types of infections included abscesses (109), bacteremia (32), bites (13), empyema (10), osteomyelitis (21), peritonitis (52), thrombophlebitis (12), and wounds (116, including posttraumatic wounds, cellulitis, stump wound, decubitus ulcers, myositis, and fasciitis). S. aureus was isolated at all sites. However, organisms of the oropharyngeal flora predominated in infections that originated from that location (ie, head and neck wounds, and abscesses or bites), and those of the gastrointestinal flora predominated in infections that originated from that site (ie, peritonitis, abdominal abscesses, decubitus ulcers). This study showed the polymicrobial nature of many infections that follow trauma.

Adolescent↗
PubMed1996

Partial liquid ventilation provides effective gas exchange in a large animal model.

PURPOSE: The purpose of this study was to show the ability of partial liquid ventilation (PLV) to sustain gas exchange in normal large (50 to 70 kg) adult animals. METHODS: Ten adult sheep (53.7 +/- 2.8 kg) were anesthetized and mechanically ventilated. Sequential dosing of perflubron (LiquiVent, Alliance Pharmaceutical Corp, San Diego, CA) was performed to cumulative doses of 10 mL/kg, 20 mL/kg, 40 mL/kg, and 60 mL/kg. Physiological data were assessed at baseline and after each dose. Five animals were rotated through the left decubitus, right decubitus, supine, and prone positions while five animals remained prone throughout the experiment. RESULTS: PaO2 and PaCO2 did not change significantly from baseline during administration of perflubron except for the PaO2 in rotated animals when supine (rotated-supine PaO2: baseline = 519 +/- 64 mm Hg; 60 mL/kg = 380 +/- 109 mm Hg, P = .0131). In both groups, static lung compliance (CT) decreased steadily with each successive perflubron instillation (nonrotated CT: baseline = 1.55 +/- 0.22 mL/cm H2O/kg; 60 mL/kg = 0.52 +/- 0.10 ml/cmH2O/kg, P = .0003). CONCLUSIONS: These data show that during PLV in this normal animal model, effective gas exchange is sustained and CT decreases with increasing perflubron dose.

Animals↗
PubMed2000

Ultrasonographic evaluation of the influence of different postures on diaphragmatic motion in mechanically ventilated patients.

We confirmed a diaphragmatic motion during mechanical ventilation in four patients with central nervous system damage. The right hemidiaphragm were visualized with 3.5 MHz ultrasound, and motion was measured using time-motion analysis in separate postures. The dome was most impaired during the right decubitus posture. The crural region was most improving during the left decubitus posture. The costal region was most impaired during the sitting posture. The motion of the dependent region was impaired.

Adolescent↗
PubMed1996

Anesthetic management of patients undergoing unilateral video-assisted lung reduction for treatment of end-stage emphysema.

OBJECTIVES: Nonanatomic resection of peripheral areas of lung is being performed via sternotomy for the treatment of end-stage emphysema. Recent technologic advances have allowed the resection of lung tissue using video-assisted thoracic surgery (VATS) techniques. The study was performed to document the physiologic changes that occur during unilateral VATS lung reduction in hopes of determining appropriate monitoring and intraoperative management strategies. DESIGN: Prospective trial of unilateral VATS lung reduction. SETTING: Tertiary care university hospital. PARTICIPANTS: Twenty patients with end-stage emphysema. INTERVENTIONS: Participants underwent unilateral VATS lung reduction. MEASUREMENTS AND MAIN RESULTS: Invasive hemodynamic monitoring was performed using radial and pulmonary artery catheters. Hemodynamic and respiratory gas exchange data were collected at four intraoperative points: (1) supine, two-lung ventilation; (2) lateral decubitus, two-lung ventilation; (3) lateral decubitus, one-lung ventilation, and (4) end of surgery, supine, two-lung ventilation. Data were compared with that collected at the first point. Patients tolerated lengthy surgical procedures and remained hemodynamically stable with no episodes of hypoxemia requiring treatment. Extubation was tolerated by 19 of 20 patients at the conclusion of surgery without further requirement of mechanical ventilation. CONCLUSIONS: VATS lung reduction under general anesthesia with one-lung ventilation is well tolerated. Permissive hypercapnia was well tolerated by all patients. Early extubation can be routinely accomplished in these patients.

Adult↗
PubMed1999

Pulmonary air trapping during two-lung and one-lung ventilation.

OBJECTIVE: Evaluation of the magnitude of pulmonary air trapping during routine thoracic surgery and single-lung transplantation. DESIGN: Prospective study on consecutive patients. SETTING: Single institution, university hospital. PARTICIPANTS: Sixteen patients with no or moderate obstructive lung disease undergoing routine thoracic surgery (group 1), six patients with severe emphysema (group 2), and six patients with severe fibrosis (group 3) undergoing single-lung transplantation. INTERVENTIONS: Occlusion maneuver timed at the end of expiration to measure auto-positive end-expiratory pressure (auto-PEEP) and trapped volume (delta FRC). The maneuver was performed during two-lung ventilation in supine (2LV supine) and lateral decubitus (2LV lateral) positions and during one-lung ventilation (OLV) in lateral decubitus position. At the same time, airway pressures and PaO2 measurements were performed. MEASUREMENTS AND MAIN RESULTS: In group 1, consistent values of auto-PEEP and delta FRC occurred only during OLV: 4.8 +/- 2.5 cm H2O and 109 +/- 61 mL (mean +/- standard deviation). In group 2, auto-PEEP and delta FRC values were 11.7 +/- 6.9 cm H2O and 355 +/- 125 mL during 2LV supine, 8.8 +/- 5.7 cm H2O and 320 +/- 122 mL during 2LV lateral, and 15.9 +/- 3.9 cm H2O and 284 +/- 45 mL during OLV. In group 3, pulmonary air trapping was low. For the three groups together, auto-PEEP and delta FRC (p < 0.0001) related inversely to the ratio of forced expired volume in 1 second (FEV1) to forced vital capacity (FVC) expressed in percent (FEV1/FVC%) during OLV. In contrast, there was no correlation between PaO2 and auto-PEEP or delta FRC. CONCLUSION: Pulmonary air trapping must be suspected in patients with no or moderate obstructive lung disease during OLV and in those with severe obstructive disease as soon as 2LV is initiated.

Adult↗
PubMed1993

Social support and health status in spinal cord injury.

In a mailed survey, 125 persons with spinal cord injury responded to questions on the SCI Quality of Life Index (QOLI), and the Reciprocal Social Support Scale. The results indicated that people with SCI who believe that they receive support from the community, compared to those who believed they received less support (1) perceived themselves to be better adjusted to their injury, and (2) had significantly fewer health problems (fewer spinal cysts, lower blood pressure, shorter recovery time from decubitus ulcers, less pain below the level of injury, and fewer hospital admissions). The results also showed that people who believe that they contribute to the community in some way, compared to those who believed they contributed little or nothing (1) perceived themselves to be better adjusted to their injury, and (2) had significantly fewer health problems (fewer urinary tract infections, fewer decubitus ulcers, less severe decubiti, less pain above the level of injury, and fewer hospital admissions). A community support score, a summary score of support given and received, was also related to adjustment and health.

Adaptation, Psychological↗
PubMed2001

The variability of the apnoea-hypopnoea index.

This study was designed to evaluate the variability of the apnoea-hypopnoea index (AHI) in 20 patients with obstructive sleep apnoea-hypopnoea syndrome (OSAHS) and to determine possible relationships of this variability with other polysomnographic parameters. The subjects were recorded on four consecutive nights. The mean AHI values were not significantly altered throughout the four recording nights (P=0.67). The intraclass correlation coefficient of the AHI on the four nights was 0.92. However, the Bland and Altman plot showed that, individually, the AHI presented an important variability, which was not related to its initial value. In regard to the OSAHS severity, 50% of the patients changed the classification from the first to the subsequent nights. Thirteen of the 20 patients (65%) presented a variation in the AHI value equal or higher than 10 events h(-1). When we evaluated the AHI mean values for a specific body position and sleep stage, no difference was observed among the nights. In both supine and lateral-ventral decubitus, higher AHI was observed during Stages 1 and 2 than the other stages. Additionally, the AHI during Stages 1 and 2 and REM sleep was higher on the supine than on the lateral-ventral decubitus. The AHI in OSAHS patients presented a good correlation among the four recording nights; however, a significant individual variability should be considered, especially when AHI is applied in OSAHS classification or as a criterion of therapeutic success.

Adult↗
PubMed2000

Stromelysin-2 is upregulated during normal wound repair and is induced by cytokines.

Stromelysin-2 is a matrix metalloproteinase that degrades in vitro several protein components relevant to wound repair such as collagens III and IV, gelatin, nidogen, laminin-1, proteoglycans, and elastin. Furthermore, it can activate other matrix metalloproteinases, such as collagenase-1 (matrix metalloproteinase-1) and collagenase-2 (matrix metalloproteinase-8), as well as 92 kDa gelatinase. The aim of this study was to determine in a large variety of wounds (normally healing dermal and mucosal wounds, suction blisters, ex vivo cultures, diabetic, decubitus, rheumatic, and venous ulcers) and keratinocyte cultures, which factors contribute to stromelysin-2 expression and how it is induced in relation to other matrix metalloproteinases. Our results show that stromelysin-2 mRNA and protein are upregulated later (at 3 d) than matrix metalloproteinase-1 in normally healing wounds and ex vivo explants, in which stromelysin-2 is invariably expressed by keratinocytes migrating over dermal matrix. The number of keratinocytes expressing stromelysin-2 was greatest in chronic inflamed diabetic and venous ulcers compared with rheumatoid and decubitus ulcers, six of which had no signal. In keratinocyte cultures, tumor necrosis factor-alpha, epidermal growth factor, and transforming growth factor-beta1 induced stromelysin-2 expression as measured by quantitative reverse transcriptase-polymerase chain reaction, whereas different matrices did not upregulate the mRNA. Immunostaining demonstrated stromal transforming growth factor-beta1 in contact with the stromelysin-2-positive keratinocytes. Our results suggest that stromelysin-2 expression is important for the normal repair process and is upregulated by cytokines rather than cell-matrix interactions. Stromelysin-2 is most likely to participate in the remodeling of the newly formed basement membrane, and is not overexpressed in retarded wound healing.

Cell Adhesion Molecules↗
PubMed2002

Improvements in artery occlusion by low-density lipoprotein apheresis in a patient with peripheral arterial disease.

Peripheral arterial disease (PAD; arteriosclerosis obliterans) shows ischemic symptoms along the peripheral arteries due to reduced blood flow, and the number of patients with PAD is increasing. Several papers have reported on the clinical effect of low-density lipoprotein apheresis (LDL-A) on PAD, but there has been no report so far on the improvement of total peripheral artery stenosis by LDL-A. We report on the clinical course of a female PAD patient with intractable decubitus in her heel due to the complete occlusion of anterior tibial artery who was treated by a series of LDL-A sessions. The complete occlusion of the anterior tibial artery improved as seen on angiography, and the decubitus in her heel also markedly improved after LDL-A therapy. This report supports the clinical benefit of LDL-A for the treatment of PAD.

Aged↗
PubMed2001

Evaluation of transesophageal atrial pacing in the prone and lateral positions.

OBJECTIVE: To develop recommendations for positioning the second-generation pacing esophageal stethoscope for transesophageal atrial pacing in patients positioned prone (P), right lateral decubitus (RLD), and left lateral decubitus (LLD). DESIGN: Prospective; patients assigned consecutively. SETTING: Tertiary and university hospitals. PARTICIPANTS: Thirty (10 in each position group) adult patients undergoing surgery. INTERVENTIONS: The optimal depths of insertions (DOI) where pacing current threshold was minimal (THmin) were determined first when supine, then after positioning. MEASUREMENTS AND MAIN RESULTS: Transesophageal atrial pacing was successful in all patients supine and after positioning. The optimal DOI varied from 2 cm less deep to 4 cm deeper in positioned patients compared with supine patients. Patients positioned P required equal or up to 8 mA greater current outputs to achieve transesophageal atrial pacing; LLD and RLD patients may require up to 8 mA greater or lesser current compared with supine patients. CONCLUSION: Transesophageal atrial pacing can be used safely and effectively in patients positioned P, RLD, and LLD. Recommendations are presented for positioning the pacing esophageal stethoscope. Emphasis is given to using the lowest DOIs and smallest currents to reduce the chance of transesophageal ventricular pacing.

Adolescent↗
PubMedDate not supplied

Spinal anesthesia with hypobaric bupivacaine for knee arthroscopies: effect of posture on motor block.

BACKGROUND AND OBJECTIVES: The clinical impact of patient positioning on motor block during unilateral spinal anesthesia was the focus of our study. It was assumed that a 45 degrees rotation toward the prone position would minimize blocking the ventral motor roots compared with using the conventional lateral decubitus position. METHODS: Spinal anesthesia with 3.4 mL of hypobaric 0.18% bupivacaine via a 27-gauge Whitacre needle was administered to 70 patients undergoing knee arthroscopy. The patients were kept either in a lateral decubitus position (group I) or rotated approximately 45 degrees toward the prone position (group II). No prophylactic vasopressors or infusions were used. The intensity of motor block (modified Bromage scale) was assessed for both the operative and the contralateral side. RESULTS: The patients in group I had a slightly more pronounced motor block, but statistical significance could be shown only 20 minutes following the block. There was no statistical difference between the groups in the need of additional analgesics during the operation. None of the patients needed general anesthesia. The hemodynamics were stable and none of the patients developed postspinal headache or backache. CONCLUSIONS: The position of the patient affects the spread of the spinal anesthesia when clearly hypobaric agents are used. However, this small modification in positioning of the patient did not lead to a clinically meaningful difference in the spread of the motor block.

Anesthesia, Spinal↗
PubMed2001

[Community health documentation as an instrument for further developing recommendations in community health].

The local health conference in a North Rhine-Westphalian county of Germany has made proposals to improve immunisation rates against measles, mumps and rubella. Another target was to prevent decubitus by elderly patients in hospitals, nursing homes and in the outpatient nursing. Local public health reports were the basis for the development of (local) health targets in the health conference. The data of 12,830 immunisation papers from 11-19-year old students showed immunisation rates against measles, mumps and rubella from 44% to 14% depending on the type of school. Virus hepatitis B immunisation rates are 32% in the county. There were also great differences between local towns of the county. The decubitus data showed rates from 2.3% in nursing homes to 5.1% in the outpatient sector. It is also shown that health reports and health conferences help to improve local conditions in public and individual health.

Adolescent↗
PubMed2002

[Minimal incision abdominal aortic aneurysm repair].

OBJECTIVE: The use of a limited incision for abdominal aortic aneurysm (AAA) repair was evaluated, and its outcome was analyzed in comparison to standard open repair. PATIENTS AND METHODS: Between February 2000 and August 2001, 20 patients with an AAA underwent minimal incision repair (MINI) for tube graft implantation. The minimal skin incision was made after localization of aneurysm neck and aortic bifurcation by CT and DSA. For repair of the upper part of the AAA the abdominal incision was retracted toward the head of the patient who was in a jackknife decubitus position. Conversely, when the peripheral portion of the AAA was treated, the abdominal incision was retracted caudally with the patient in a flat or slightly bent decubitus position. The operation itself was performed using the standard conventional technique. The length of the abdominal incision was 10 cm. Clinical characteristics and in-hospital outcome of this procedure were compared to a group of patients who underwent repair of AAA by means of a standard open technique (OPEN). RESULTS: Patients age in the MINI and OPEN groups were similar (69 +/- 11 vs. 69 +/- 9 years). However, there were significant differences between the MINI and OPEN groups in the time for starting oral intake of food (2,4 +/- 1,2 vs. 7,4 +/- 5,5 postoperative days, p = 0,003), time for starting to walk outside the room (2,2 +/- 0,7 vs. 4,6 +/- 2,2 postoperative days, p = 0,01) and operation times (197 +/- 37 vs. 294 +/- 83 min, p = 0,0004). CONCLUSION: Minimal incision repair is technically feasible and combines the benefits of a minimal incision with those of conventional open repair, reducing patient recovery time.

Aged↗
PubMed1981

[Congenital left-sided pericardial defects (author's transl)].

Left-sided pericardial defects appear to be more common than is generally thought. Five such patients have been seen in the last two years. The typical findings on x-ray, CT and cardiac ultrasound are described. Proof of the condition is the increased mobility of the left cardiac contour and of its dorsal margin as shown by left and right decubitus films, by films of the supine patient taken with a horizontal beam, fluoroscopy in inspiration and expiration and computer tomography of the heart in left and right decubitus position. Recognition of the anomaly is of importance, since it may spare the patient surgical treatment.

Adult↗