1/112. Expeditious diagnosis of primary prosthetic valve failure.Primary prosthetic valve failure is a catastrophic complication of prosthetic valves. Expeditious diagnosis of this complication is crucial because survival time is minutes to hours after valvular dysfunction. The only life-saving therapy for primary prosthetic valve failure is immediate surgical intervention for valve replacement. Because primary prosthetic valve failure rarely occurs, most physicians do not have experience with such patients and appropriate diagnosis and management may be delayed. A case is presented of a patient with primary prosthetic valve failure. This case illustrates how rapidly such a patient can deteriorate. This report discusses how recognition of key findings on history, physical examination, and plain chest radiography can lead to a rapid diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/112. An unusual procedure for the treatment of simultaneous pericardial and pleural effusions.BACKGROUND: Symptomatic posterior pericardial effusion (PE) represents a diagnostic challenge since it is not easy to quantify by echocardiography. In addition, this type of effusion is normally treated by surgery because of the difficulty in drainage. CASE: A 59-year-old male presented a symptomatic circumferential PE following mitral valve substitution. Two days after a successful percutaneous subcostal pericardiocentesis, he reported severe dyspnea with hypotension and pulsus paradoxus. At chest x-rays, he showed a left pleural effusion; echocardiography, also performed from the left posterior axillary line, showed a large posterior PE and a large pleural effusion separated by a membrane. A needle was inserted at the fourth intercostal space 2 cm medially to the left posterior axillary line and advanced into the pleural and then into the pericardial cavity under echocardiographic guidance. Serous-hemorrhagic fluid was drained from the pericardial (800 cc) cavity and, after retraction, from the left pleural cavities (600 cc), with consequent hemodynamic improvement. CONCLUSION: Pleuro-pericardiocentesis may represent a valid alternative to surgery for the treatment of cardiac tamponade due to posterior pericardial effusions, in the peculiar situation characterized by the simultaneous presence of a left pleural effusion. This procedure should be performed by qualified physicians under echographic guidance.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/112. Physician preferences for perioperative anticoagulation in patients with a mechanical heart valve who are undergoing elective noncardiac surgery.STUDY OBJECTIVE: To determine physicians' anticoagulation preferences in patients with a mechanical heart valve who are undergoing elective surgery, and to determine the effect of different risks of thromboembolism (TE) and postoperative bleeding on anticoagulation preferences. DESIGN: Mail survey of physicians who prescribe anticoagulant therapy. methods AND RESULTS: physicians were asked to provide anticoagulation preferences in four clinical scenarios of patients with a mechanical heart valve who are undergoing elective surgery. physicians were asked to select from three preoperative anticoagulation options (two aggressive, one less aggressive) and four postoperative anticoagulation options (two aggressive, two less aggressive). IV heparin was the most frequently selected anticoagulation option. Depending on the scenario, it was preferred by 39 to 79% of respondents for preoperative anticoagulation therapy, and by 44 to 84% of respondents for postoperative anticoagulant therapy. The risk of TE had a strong influence on anticoagulation preferences: more respondents preferred aggressive anticoagulant management in high-risk compared with low-risk TE scenarios (p < 0.001). Anticoagulation preferences were not influenced by the risk of bleeding: the proportion of respondents who preferred aggressive anticoagulant management did not differ in high-risk and low-risk bleeding scenarios (p > 0.05). Of respondents who preferred IV heparin for postoperative anticoagulation therapy, the risk of bleeding influenced the timing of heparin initiation: fewer respondents preferred early heparin initiation (within 12 h after surgery) in high-risk compared with low-risk bleeding scenarios (p < 0.01). CONCLUSIONS: (1) Preoperative and postoperative IV heparin were the most frequently selected anticoagulation options. (2) The risk of TE, but not the risk of bleeding, influenced the aggressiveness of anticoagulant management. (3) If IV heparin was selected, the risk of bleeding influenced the timing of heparin initiation.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
4/112. Secondary reconstruction of a giant congenital lentiginous dermal nevus with serial, large-volume tissue expansion.Giant congenital pigmented nevi pose a substantial reconstructive challenge for the treating physician. Due to the increased risk of malignant transformation in such lesions, complete excision with tissue expansion or skin grafting is the generally accepted treatment. These modalities can, however, leave the patient with secondary deformities that also require complex reconstructive procedures. The following case details a patient requiring secondary reconstruction with large-volume tissue expansion 12 years after excision of a giant nevus, and split-thickness skin grafting. This patient illustrates a severe secondary deformity and the usefulness of large-volume serial expansion in such patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/112. Possibilities of preventing osteoradionecrosis during complex therapy of tumors of the oral cavity.In recent years, there has been a dramatic increase in the number of tumors of the head and neck. Their successful treatment is one of the greatest challenges for physicians dealing with oncotherapy. An organic part of the complex therapy is preoperative or postoperative irradiation. Application of this is accompanied by a lower risk of recurrences, and by a higher proportion of cured patients. Unfortunately, irradiation also has a disadvantage: the development of osteoradionecrosis, a special form of osteomyelitis, in some patients (mainly in those cases where irradiation occurs after bone resection or after partial removal of the periosteum). Once the clinical picture of this irradiation complication has developed, its treatment is very difficult. A significant result or complete freedom from complaints can be attained only rarely. attention must therefore be focussed primarily on prevention, and the oral surgeon, the oncoradiologist and the patient too can all do much to help prevent the occurrence of osteoradionecrosis. Through coupling of an up-to-date, functional surgical attitude with knowledge relating to modern radiology and radiation physics, the way may be opened to forestall this complication that is so difficult to cure.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/112. Allergic reaction to spinal cord stimulator.OBJECTIVE: The objective was to report on the possibility of allergic reaction to the components of a spinal cord stimulator. DESIGN: We describe a severe allergic reaction after the insertion of a spinal cord stimulator in a patient with complex regional pain syndrome type 1. SETTING: The patient was being followed in an office-based pain management practice. PATIENT: The patient is a 41-year-old woman with complex regional pain syndrome type 1, posttrauma. Intervention: Insertion of a cervical and lumbar spinal cord stimulator. OUTCOME MEASURES: The outcome measures were a numerical scale of pain intensity and the ability to perform the activities of daily living. RESULTS: Adequate pain control complicated by allergic reaction. CONCLUSIONS: There exists a possibility that a patient may experience an allergic reaction to spinal cord stimulator components. Recognition of such contact sensitivity is important for physicians implanting such devices. patients may be misdiagnosed as having infections, which can delay appropriate management; definitive diagnosis can be confirmed with a patch test. Treatment consists of removal of such devices.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/112. Perioperative risk. review of two guidelines for assessing older adults. American College of cardiology and american heart association.Elective in-patient surgery is a common occurrence among older persons and primary care physicians are routinely called on to provide preoperative assessment and perioperative risk management of these patients. Older patients undergoing noncardiac surgery may be at increased risk for cardiac or cardiovascular complications, thus perioperative assessment of risk in this population is prudent. Although the range of possible screens and diagnostic tools can make this task unwieldly, the clinical practice guidelines make it more manageable. Two guidelines in particular--one published jointly by the American College of cardiology and american heart association, the other by the American College of physicians--are particularly suited to perioperative assessment and risk management.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/112. Comparison of safety and cost of percutaneous versus surgical tracheostomy.tracheostomy continues to be a standard procedure for the management of long-term ventilator-dependent patients. Traditionally the procedure has been performed by surgeons in the operating theater using an open technique. This routine practice has recently been challenged by the introduction of bedside percutaneous dilatational tracheostomy (PDT), which has been reported to be a cost-effective alternative. The purpose of this study is to evaluate and compare the safety, procedure time, cost, and utilization of percutaneous and surgical tracheostomies at a university hospital. A retrospective medical chart review was performed on all ventilator-dependent intensive care unit patients at the University of virginia Medical Center undergoing tracheostomy during a 23-month period beginning December 26, 1996. Of the 213 patients identified for review, 74 and 139 patients received percutaneous and surgical tracheostomies, respectively. Of 74 percutaneous tracheostomies, 73 reviewed were performed by general surgeons, pulmonary physicians, or anesthesiologists in the intensive care unit; all open tracheostomies were performed by surgeons in the operating room, and one percutaneous procedure was performed in the operating room. Perioperative complications occurred in five of 74 patients (6.76%) during PDT; of these, three patients (4.1%) experienced major complications requiring emergent operative exploration of the neck. Three patients (2.2%) experienced perioperative complications during surgical tracheostomy. The mean procedure time was significantly shorter for the percutaneous procedure. Average charges per patient in an uncomplicated case including professional fees, inventory, bronchoscopy (if performed), and operating room charges were $1753.01 and $2604.00 for percutaneous and standard tracheostomies, respectively. These charges do not include the charges associated with surgical intervention after PDT complications. In contrast to previously published reports showing complications clustered during a physician's first 30 percutaneous cases, our study demonstrated no relationship between complication occurrence and physician experience. That is, no learning curve associated with performing PDT was evident. In addition there was no association seen between physician specialty and complication rate. PDT in the intensive care unit costs less than surgical tracheostomy performed in the operating room and can be performed in less time. Several other studies have recommended that bronchoscopy during PDT provides additional safety; however, in our series all three major complications took place during bronchoscopy-assisted percutaneous procedures. Our series suggests that PDT carries an appreciable risk of major complications. Careful patient selection and additional experience with the procedure may decrease complication rates to an acceptable level.- - - - - - - - - - ranking = 4keywords = physician (Clic here for more details about this article) |
9/112. Late mediastinal shift after repeated aspiration of postpneumonectomy seroma.Development of a postoperative seroma is a frequent complication after muscle-sparing thoracotomy. We describe an unusual case of late mediastinal shift in a patient in whom our original plan to perform a limited muscle-sparing thoracotomy was abandoned. The procedure was converted to a standard posterolateral incision to perform a pneumonectomy for a large central carcinoid tumor with extrabronchial extension. Fluid that accumulated in her pneumonectomy space presumably shifted into the dissected tissues of her chest wall, and was then drained repeatedly by her local physician in the time interval between 2 weeks and 3 months after surgery.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/112. Detection of clinically silent infarcts after carotid endarterectomy by use of diffusion-weighted imaging.BACKGROUND AND PURPOSE: Intraprocedural transcranial Doppler sonography has identified multiple microembolic events during and immediately after carotid endarterectomy (CEA) or angioplasty, yet the rate of clinically evident stroke is small. To determine the significance of the transcranial Doppler sonography findings, we examined patients by use of diffusion-weighted imaging and fluid-attenuated inversion recovery MR imaging before and immediately after CEA for evidence of clinically silent ischemic events. methods: Twenty-five patients with atherosclerotic disease of the carotid arteries underwent diffusion-weighted imaging and fluid-attenuated inversion recovery MR imaging performed, on average, 3 days before and 12 hours after CEA. diffusion-weighted images were acquired in three orthogonal directions at b = 900. Pre- and postoperative neurologic examinations were performed by the same physician. RESULTS: After endarterectomy, 4.0% of the patients (one of 25 patients) showed a single, cortical focus of restricted diffusion and new fluid-attenuated inversion recovery hyperintensity, measuring <1 cm in diameter, ipsilateral to the CEA. The postoperative neurologic examination showed no change in status from the preoperative baseline state. This patient had an intraoperative course complicated by the development of a large luminal thrombus, necessitating thrombectomy. CONCLUSION: The use of diffusion-weighted imaging may serve to improve conspicuity of clinically silent infarcts after CEA. An important next step is to determine the risk factors that predispose to detectable parenchymal ischemic events.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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