RESUMO
AIM: Risk factors for adverse outcome after decalcification and patch-reconstruction of the mitral annulus during mitral valve surgery are yet to be defined. For this purpose and for the report of long term results we reviewed our institutional data from over 10 years of mitral valve surgery in the presence of mitral annulus calcification. METHODS: A total of 109 consecutive patients with a mean age of 66.4±14 years (Mean logistic EURO-Score: 18.6%) underwent mitral valve surgery in the presence of extensive calcification of mitral annulus between 1996 and 2008. After decalcification and patch-reconstruction of the mitral annulus, mitral valve repair was performed in 53 cases (49%) and the remaining 56 patients (51%) received a mitral valve replacement. Multivariate logistic regression analysis was performed to identify independent predictors of adverse outcome. RESULTS: Inhospital-mortality was 8.3% and the actuarial survival rate at 8 years 76.2%. Echocardiographic follow up was complete. 65 survivors (94.5%) showed none or only trivial mitral valve insufficiency. The freedom of reoperation at 8 years was 91.8%. We found hypertension, diabetes mellitus, age older than 65 years, NYHA class IV, end stage renal failure, failure to preserve the subvalvular apparatus as well as concomitant aortic valve replacement to be associated with a significant increase of early or/and late mortality. CONCLUSION: Despite the complexity of this pathology, decalcification and patch-reconstruction of the mitral annulus during mitral valve surgery can be performed with low technical risk and acceptable long-term results.
Assuntos
Calcinose/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Valva Mitral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Calcinose/diagnóstico , Calcinose/mortalidade , Intervalo Livre de Doença , Feminino , Alemanha , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/mortalidade , Análise Multivariada , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia , Adulto JovemRESUMO
OBJECTIVE: The aim of this study was the analysis of long-term results in patients with hemodynamically significant mitral valve disease due to extensively calcified mitral annulus who underwent decalcification and patch reconstruction. PATIENTS AND METHODS: Between 1996 and 2008 a total of 109 patients underwent surgery for extensive calcification and severe mitral insufficiency and mitral stenosis. The mean age of the patients (65 women and 44 men) was 66.4 ± 13.8 years. In 53 patients (49%) mitral valve repair was performed and the remaining 56 patients (51%) received a mitral valve replacement. Of the patients 64 (59%) required concomitant surgery. The mean follow up time was 96 ± 48 months. RESULTS: The in-hospital and late mortality was 8.3% (9 patients) and 25.6% (28 patients), respectively. The actuarial survival rates at 5, 8 and 12 years were 88.1%, 76.2% and 66.1%, respectively. Echocardiographic follow-up presented a mitral insufficiency grade III in 4 patients (6%). None of the patients had a mitral insufficiency grade IV. A significant reduction of left atrium diameter, of the LVEDD as well as the mean transvalvular gradient was observed. Freedom from reoperation at 5 and 8 years was 96.4% and 91.8%, respectively. Systemic hypertension, diabetes mellitus, age older than 65 years, concomitant aortic valve replacement, concomitant procedures, chronic renal insufficiency and cardiac decompensation in the medical history were found to be predictors for significantly increased early or late mortality. CONCLUSION: The long-term results strongly suggest that en bloc decalcification and patch reconstruction of the mitral annulus can be safely undertaken in high risk patients.
Assuntos
Calcinose/epidemiologia , Calcinose/mortalidade , Ecocardiografia/estatística & dados numéricos , Anuloplastia da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/epidemiologia , Insuficiência da Valva Mitral/mortalidade , Idoso , Comorbidade , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Estenose da Valva Mitral , Prevalência , Fatores de Risco , Análise de Sobrevida , Taxa de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: The aim of this study is the analysis of long-term results in patients with hemodynamically significant mitral valve disease due to extensive calcified mitral annulus who underwent decalcification and patch reconstruction. PATIENTS AND METHODS: Between 1996 and 2008 a total of 109 patients underwent surgery in the presence of extensive calcification, severe mitral insufficiency and mitral stenosis. The mean age of patients (65 women, 44 men) was 66.4±13.8 years. Mitral valve repair was performed in 53 patients (49%), while the remaining 56 patients (51%) received a mitral valve replacement. In all, 64 patients (59%) required concomitant surgery. The mean follow-up time was 96±48 months. RESULTS: Inpatient and late mortality rates were 8.3% (nine patients) and 25.6% (28 patients), respectively. The actuarial survival rates at 5, 8 and 12 years were 88.1%, 76.2% and 66.1%. Echocardiographic follow-up demonstrated mitral insufficiency III in four patients (6%). No patients had mitral insufficiency IV. We observed a significant reduction in left atrium diameter, LVEDD as well as mean transvalvular gradient. Freedom from reoperation at 5 and 8 years was 96.4% and 91.8%, respectively. We found systemic hypertension, diabetes mellitus, age above 65 years, concomitant aortic valve replacement, concomitant procedures, chronic renal insufficiency and cardiac decompensation in the medical history as predictors for significantly increased early or late mortality. CONCLUSION: The long-term results strongly suggest that en bloc decalcification and patch reconstruction of the mitral annulus can be safely undertaken in high-risk patients.
Assuntos
Calcinose/mortalidade , Calcinose/cirurgia , Anuloplastia da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/epidemiologia , Insuficiência da Valva Mitral/mortalidade , Idoso , Calcinose/diagnóstico por imagem , Ecocardiografia/estatística & dados numéricos , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Insuficiência da Valva Mitral/diagnóstico por imagem , Prevalência , Fatores de Risco , Análise de Sobrevida , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Children with evidenced spondylolysis of the lumbar spine should not practice sport with axial compression strain forces or carry out hyperextensional or rotational movements exercises up to the age of eight to ten years, as this could lead to considerable shearing strain to the still cartilaginous disposition of the vertebral arch and therefore initiate an ossification with resulting incomplete closure of the bony elements of the spine (spina bifida occulta). The associated instability of the dorsal vertebral column may yield spondylolisthesis requiring surgical intervention. Competitive sport should be avoided if possible, or carried out in close collaboration with a coach and a physiotherapist under continuous medical supervision with regular radiological monitoring.
Assuntos
Vértebras Lombares , Espinha Bífida Oculta , Espondilólise , Esportes , Adulto , Dor nas Costas/etiologia , Criança , Pré-Escolar , Feminino , Humanos , Vértebras Lombares/diagnóstico por imagem , Modalidades de Fisioterapia , Radiografia , Fatores de Risco , Espondilolistese/diagnóstico por imagem , Espondilolistese/terapia , Espondilólise/diagnóstico por imagem , Espondilólise/cirurgia , Espondilólise/terapiaRESUMO
Manubriosternal dislocation caused by indirect flexion-compression trauma is an extremely rare condition. Two forms of manubriosternal luxation are distinguished: in type I the sternum is dislocated posterior and in type II anterior to the manubrium. Direct or indirect trauma may cause manubriosternal dislocation. Mode of injury in direct trauma is mostly a head-on collition in a motor accident resulting either in type I or type II luxation. The unusual origin of manubriosternal dislocation by indirect trauma is put down to flexion-compression injuries of the thoracic spine and results in a type II dislocation. Predisposition to manubriosternal dislocation by indirect trauma consists in rheumatoid arthritis or extreme forms of kyphosis. Outcome of many patients treated conservatively after initial reposition with adhesive tape, symptomatic pain therapy, cryotherapy and prohibition of any physical training over several weeks is subluxation or complete luxation of the manubriosternal joint. This condition may lead to chronic pain, periarticular calcification with ankylosis and progredient deformation. Lacking a controlled study for treatment of manubriosternal dislocation a standard therapeutic regime could not be established yet. In the literature only a few case-reports of patients undergoing operative therapy are published. We report a type II dislocation of the manubriosternal joint caused by indirect flexion-compression trauma. We achieved a very good long-term result using a 8-hole 1/3 tubular plate for fixation of the manubriosternal joint after reposition.
Assuntos
Luxações Articulares , Manúbrio , Esterno , Adulto , Seguimentos , Humanos , Luxações Articulares/etiologia , Luxações Articulares/cirurgia , Masculino , Manúbrio/diagnóstico por imagem , Dispositivos de Fixação Ortopédica , Radiografia Torácica , Fatores de Risco , Esterno/diagnóstico por imagem , Fatores de TempoRESUMO
OBJECTIVE: To evaluate the effect of adjunctive C1-esterase inhibitor substitution therapy on clinical characteristics and outcome of patients with streptococcal toxic shock syndrome (TSS). DESIGN: Observational. SETTING: Medizinische Poliklinik, University of Bonn, Germany. PATIENTS: Seven patients with direct or indirect evidence of streptococcal TSS. INTERVENTION: In addition to conventional and supportive therapy, all patients received 2-3 single doses of C1-esterase inhibitor totaling 6,000-10,000 U within the first 24 h after admission. MEASUREMENTS AND RESULTS: All patients developed fulminant septic shock, multiorgan failure and/or capillary leak syndrome and necrotizing fasciitis within 10-72 h following the onset of first symptoms. Between 1 and 4 days following administration of C1-esterase inhibitor, a marked shift of fluid from extravascular to intravascular compartments took place in all but one patient, accompanied by a transient intra-alveolar lung edema and rapidly decreasing need for adrenergic agents. Six of seven patients survived. CONCLUSIONS: These clinical observations in a small series of patients and the favorable outcome point towards a positive effect of early and high-dose administration of C1-esterase inhibitor as adjunctive therapy in streptococcal TSS. The possible mechanism involved may be the attenuation of capillary leak syndrome (CLS) via early inactivation of complement and contact systems. Controlled studies are needed to establish an improvement of the survival rates of patients with streptococcal TSS following administration of C1-esterase inhibitor.
Assuntos
Proteínas Inativadoras do Complemento 1/uso terapêutico , Choque Séptico/tratamento farmacológico , Infecções Estreptocócicas/tratamento farmacológico , Streptococcus pyogenes , Adulto , Idoso , Síndrome de Vazamento Capilar/microbiologia , Terapia Combinada , Proteínas Inativadoras do Complemento 1/farmacologia , Cuidados Críticos/métodos , Feminino , Deslocamentos de Líquidos Corporais , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Choque Séptico/metabolismo , Choque Séptico/mortalidade , Choque Séptico/fisiopatologia , Infecções Estreptocócicas/metabolismo , Infecções Estreptocócicas/mortalidade , Infecções Estreptocócicas/fisiopatologia , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
Peripheral opioid receptors have been found in inflamed synovia and the analgesic effect of intra-articularly administered morphine after arthroscopic knee surgery has been proven. There is controversy about efficacy of intraarticular morphine after shoulder arthroscopy. Thirty-two patients with impingement syndrome underwent subacromial decompression in the course of arthroscopic shoulder surgery. At the end of the operation morphine (5 mg) or saline was injected periarticularly. Pain intensity (rest and passive mobilisation) was recorded after recovery and after 1,2,4, and 24 hours (Numeric Rating Scale); the use of rescue medication (piritramide by patient controlled analgesia) was noted. No relevant pain reduction was apparent in the morphine group. Piritramide consumption was identical in both groups (19.7 +/- 16 mg vs. 19.8 +/- 19 mg). We conclude that periarticularly administered morphine in arthroscopic subacromial decompression in the dosage applied in this study does exert no relevant analgesic effect. This is possibly due to the fact that either subacromial tissue, despite of chronic inflammation, does not show the same reagibility as synovia or it is a problem of the nearly complete resection of the subacromial bursa.
Assuntos
Analgésicos Opioides/uso terapêutico , Artroscopia , Morfina/uso terapêutico , Ombro/cirurgia , Adulto , Analgésicos Opioides/administração & dosagem , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Morfina/administração & dosagem , Medição da Dor/efeitos dos fármacosRESUMO
PURPOSE: To compare MR imaging features of stress fractures, simulating malignancies, and Ewing sarcomas. MATERIALS AND METHODS: MR imaging studies of 4 patients with longitudinal stress fractures of the tibia (n = 2) and the femur (n = 2) simulating malignancy were retrospectively compared with the MRI scans of 10 patients with histologically proven Ewing sarcoma (femur n = 5; tibia n = 3, fibula n = 1, humerus n = 1). The diagnosis of stress fractures was confirmed by follow-up examinations. An additional biopsy was performed in two patients. RESULTS: Despite negative x-ray examinations, MRI showed the fracture line in all patients with stress fractures. In these cases marrow edema was irregular and there was no well defined margin towards normal fatty marrow. In contrast Ewing sarcomas were sharply demarcated in 9/10 cases. Extraosseous enhancing soft tissue was found in Ewing sarcomas as well as in stress fractures. In stress fractures the enhancing mass was repair tissue. Areas of necrosis within the enhancing mass was seen in (8/10) Ewing sarcomas, only. In follow-up studies we observed a decrease of the marrow edema in patients with stress fractures. Occurrence of low signal areas in T1- and T2-weighted sequences within the initial enhanced extraosseous tissue corresponded to bony callus on x-rays films. CONCLUSIONS: Repair tissue in stress fractures can imitate malignancy. The irregularity of the marrow edema without well defined margins, the lack of necrosis in the small enhancing tissue and the proof of the fracture line in the MRI are criteria to differentiate stress fractures from Ewing sarcomas. Short-term follow up studies are helpful to underline the diagnosis.
Assuntos
Neoplasias Ósseas/diagnóstico , Fraturas de Estresse/diagnóstico , Imageamento por Ressonância Magnética , Sarcoma de Ewing/diagnóstico , Adolescente , Adulto , Criança , Diagnóstico Diferencial , Feminino , Fraturas do Fêmur/diagnóstico , Neoplasias Femorais/diagnóstico , Fêmur/patologia , Fíbula/lesões , Fíbula/patologia , Humanos , Masculino , Estudos Retrospectivos , Tíbia/lesões , Tíbia/patologiaRESUMO
Vibrio vulnificus, a marine vibrio, has recently been recognized as a potential human pathogen. It causes human infections with mortality rates up to 60%. Until 1991, most human isolations were reported from the USA, Japan and Taiwan. The second strain isolated in Germany is documented and a significant case of V. vulnificus infection acquired in Turkey is published for the first time.
Assuntos
Fasciite Necrosante/microbiologia , Vibrioses/microbiologia , Vibrio/isolamento & purificação , Idoso , Diagnóstico Diferencial , Fasciite Necrosante/diagnóstico , Feminino , Alemanha , Humanos , Turquia , Vibrioses/diagnósticoRESUMO
PURPOSE: Clinical and radiological evaluation of labral tears remains challenging. It has been shown that intravenous administration of contrast agents produces an MR arthrographic effect without the need for intraarticular injection. This is the first study evaluating this new technique of indirect MR arthrography in diagnosis of glenoid labrum tears. METHODS: 28 patients with clinically suspected labral injuries were prospectively investigated (1.5 Tesla, flexible surface coil). A native MR exam of the shoulder (transverse and oblique-coronar orientation, T1-weighted spin-, proton density- and T2*-weighted gradient echo sequences) and indirect MR arthrography (transverse and oblique-coronar orientation, fat-suppressed T1-weighted spin-echo sequences, intravenous injection of gadopentetate dimeglumine [0.1 mmol/kg], followed by 10-15 min of joint movement) were performed. Results were confirmed by arthroscopy and/or open surgery. Additionally sensitivity evaluation of clinical tests for investigation of labral tears were performed. RESULTS: Indirect MR-Arthrography improved delineation of the glenoid labrum and hyaline cartilage significantly (p < 0.05). Sensitivity and specificity of indirect MR arthrography in diagnosis of labral injuries were 90% and 89% respectively, compared to 79% and 67% of the native MR exam. The reliability of the checked clinical tests is not sufficient enough to determine labral lesions (predictive value between 50 and 70%). CONCLUSION: Indirect MR-arthrography is a promising non-invasive technique in the evaluation of the glenoid labrum.
Assuntos
Instabilidade Articular/diagnóstico , Imageamento por Ressonância Magnética , Luxação do Ombro/diagnóstico , Adulto , Artrografia , Meios de Contraste , Feminino , Humanos , Instabilidade Articular/cirurgia , Masculino , Pessoa de Meia-Idade , Sensibilidade e Especificidade , Luxação do Ombro/cirurgiaRESUMO
Gaseous insufflation of the abdomen (i.e., pneumoperitoneum) is used routinely during laparoscopic surgery to allow the surgical team members to view the patient's viscera and to perform indicated procedures. Pneumoperitoneum has varying effects on the patient. The initiation and maintenance of pneumoperitoneum causes most of the complications seen with laparoscopic surgery. The perioperative nurse must understand the physiological effects of pneumoperitoneum on the patient to plan appropriate nursing interventions that ensure safe patient care.
Assuntos
Laparoscopia/efeitos adversos , Laparoscopia/enfermagem , Enfermagem Perioperatória , Pneumoperitônio Artificial/efeitos adversos , Pneumoperitônio Artificial/enfermagem , Idoso , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos , Feminino , Humanos , Laparoscopia/métodos , Pulmão/fisiopatologia , Masculino , Fatores de RiscoRESUMO
PURPOSE: It has been shown that intravenous administration of contrast media produces an MR arthrographic effect without the need for intraarticular injection. This is the first study evaluating this new technique of indirect MR arthrography in the diagnosis of glenoid labrum tears. METHODS: 28 patients with clinically suspected labral injuries were prospectively investigated (1.5 Tesla, flexible surface coil). A plain MR examination of the shoulder (transverse and oblique-coronal orientation, T1-weighted spin- [TE/TR 15/675], proton density- and T2*-weighted gradient echo [TE/TR/Flip 14,32/600/30 degrees] sequences) and indirect MR arthrography (transverse and oblique-coronal orientation, fat-suppressed T1-weighted spin-echo sequences [TE/TR 15/675], intravenous injection of gadopentetate dimeglumine [0.1 mmol/kg], followed by 10-15 min of joint movement) were performed. Results were confirmed by arthroscopy and/or open surgery. RESULTS: Indirect MR arthrography significantly improved delineation of the glenoid labrum and hyaline cartilage (p < 0.05). Sensitivity and specificity of indirect MR arthrography in the diagnosis of labral injuries were 90% and 89%, compared to 79% and 67% of the native MR examination. CONCLUSION: Indirect MR arthrography is a promising non-invasive technique in the evaluation of the glenoid labrum.
Assuntos
Cartilagem Articular/patologia , Ligamentos Articulares/patologia , Imageamento por Ressonância Magnética/métodos , Escápula/patologia , Adulto , Cartilagem Articular/lesões , Meios de Contraste , Feminino , Gadolínio , Gadolínio DTPA , Humanos , Injeções Intravenosas , Ligamentos Articulares/lesões , Imageamento por Ressonância Magnética/instrumentação , Masculino , Pessoa de Meia-Idade , Compostos Organometálicos , Ácido Pentético/análogos & derivados , Estudos Prospectivos , Manguito Rotador/patologia , Lesões do Manguito Rotador , Sensibilidade e EspecificidadeRESUMO
Real progress in the treatment of necrotizing fasciitis depends on correct and early diagnosis. On the basis of our own experience in treatment of 15 patients with necrotising fasciitis and on information from the literature, we sketched out a pathophysiology model of this sickness. This model centres around local thromboembolic ischemia which makes development of a less invasive radiological diagnosis possible.
Assuntos
Fasciite Necrosante/cirurgia , Cuidados Críticos , Desbridamento , Fasciite Necrosante/diagnóstico , Fasciite Necrosante/fisiopatologia , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/fisiopatologia , Isquemia/cirurgia , Masculino , Equipe de Assistência ao Paciente , Prognóstico , Pele/irrigação sanguínea , Tromboembolia/diagnóstico , Tromboembolia/fisiopatologia , Tromboembolia/cirurgia , Resultado do TratamentoRESUMO
A 53-year old patient with diabetes mellitus presented with a painful swelling of the left thigh in an out-of-town hospital. Because of the slow progression associated with multiorgan dysfunction, a soft-tissue infection with sepsis was suspected. Strains of streptococcus of serogroup B were isolated from specimens, taken from certain areas of the affected skin. After transferring the patient to our hospital the diagnosis of a B-streptococcal associated necrotizing fasciitis was confirmed. Despite intensive medical treatment and several surgical interventions the patient deceased due to an acute severe liver failure as a consequence of a secondarily developed septic shock. In comparison to the well-known cases caused by streptococcus group A, the B-streptococcal associated necrotizing fasciitis is a rather rare occurring disease.
Assuntos
Fasciite Necrosante/diagnóstico , Insuficiência de Múltiplos Órgãos/diagnóstico , Choque Séptico/diagnóstico , Streptococcus agalactiae , Diagnóstico Diferencial , Evolução Fatal , Humanos , Masculino , Pessoa de Meia-Idade , Coxa da PernaRESUMO
Fibromatosis is the nonmalignant proliferation of fibroblasts that aggressively invade adjacent tissues. The cause of this abundant growth is unknown. When fibromatosis develops in the mandible or adjoining tissues, its aggressive growth can compress the trachea and cause death. Resection is the treatment of choice. Mandibular reconstruction is performed to prevent displacement of the remaining mandibular segment or segments and consequent difficulties in eating and speaking. Perioperative nurses who care for children with oral or paraoral fibromatoses must understand the special physical and psychological needs of these patients to effectively plan their care.