Showing papers by "Clinical Emergency Hospital Bucharest published in 2013"

New Echocardiographic Tehniques in Pulmonary Arterial Hypertension vs. Right Heart Catheterization – A Pilot Study

Abstract: Background: Pulmonary arterial hypertension (PAH) represents an emerging pathology in modern medicine. Transthoracic echocardiography is an inexpensive and reproducible method and it is the most commonly used non-invasive diagnostic tool to asses pulmonary artery pressure (PAP) and the function of the right ventricle. Although, the right heart catheterization is still considered as the standard for the diagnosis, according to the last guidelines, the new echocardiographic methods may offer an improved value in the PAH evaluation. Aim: To evaluate if cardiac ultrasonography data correlate with catheterization results in patients with PAH (Group I Dana Point 2008), and to compare the ultrasonography evaluation of PAH patients with that of normal. Methods: 15 consecutive patients (pts) (52±15 yrs, 5 men, time from onset of symptoms 1.6±1.7 years) with PAH of different aetiologies (12 pts with idiopathic PAH, 2 pts with PAH associated with scleroderma and one with persistent PAH after atrial septal defect (ASD) closure) were evaluated through: 1. clinical examination (NYHA class); 2. exercise capacity (6 minute walking test – 6MWT); 3. conventional echocardiography (diameter of right ventricle – RVD and right atrium, fractional area shortening – FAS, TAPSE, pulmonary ascension time – PA, systolic and mean PAP -sPAP, mPAP, tricuspid E/A ratio, cardiac index-CI) and 4. Tissue Doppler Imaging – TDI (systolic and diastolic myocardial velocities at the tricuspid annulus – S, D, A); 5. right heart catheterization (sPAP, mPAP, CI, pulmonary vascular resistance – PVR) We compared classical and TDI echo parameters with those obtained from 15 normal subjects, matched in age and sex. Results: PAH patients had high sPAP and mPAP with right heart dilation (RV - 44.8±7.3 mm), depressed TAPSE (16.2±5.9 mm) and cardiac index and low TDI systolic velocities at tricuspid level (7.3±2.9 cm/s). All parameters differed statistically significant from normal. There were no significant correlations between ultrasonography and catheterization (cath) parameters (sPAP 92±28.2 echo vs. 106.4±25.8 mmHg cath; mPAP 47.9±8.4 echo vs. 65.8±17.3 mmHg cath), excepting for CI 2.3±1.2 l/min/m2 vs. 2.08±0.3 ml/min/m2) and PVR (16.5 ± 15.3 Wood U echo, vs. 19.6 ± 7.9 cath). Conclusion: Classic and TDI cardiac ultrasonography represents a good screening and monitoring tool for PAH patients, but tends to underestimate the severity of the disease, leaving right heart catheterization as the essential diagnostic method for this rare disease.

Metabolic syndrome and mean platelet volume variation in patients with chest pain and negative cardiac enzymes.

Abstract: Introduction. The mean platelet volume (MPV) is an easily measurable parameter directly correlated with platelet aggregation function, proven to be increased in acute coronary syndromes, but also in the presence of cardiovascular risk factors such as the metabolic syndrome, dyslipidemia, diabetes mellitus, arterial hypertension. Objective. This study intended to assess the role of the metabolic syndrome in MPV variation in patients presenting with chest pain. Materials and Methods. We retrospectively analyzed data from 122 patients with chest pain and negative cardiac enzymes admitted consecutively to our clinic from September 1st 2011 to January 30th 2012. Our group included 27 (22.13%) patients with stable angina (SA), 74 (60.65%) patients with unstable angina (UA) and 21 (17.22%) patients with non-coronary chest pain. Results. Patients with UA had a higher mean value of the MPV 9.31 ± 1.19 fL compared to patients with SA 8.72 ± 1.14 fL (p=0.0279) and patients with non-coronary chest pain 8.85 ± 0.90 L (p=0.0908). All the patients with metabolic syndrome had increased MPVs, regardless of the etiology of chest pain. Patients with non-coronary chest pain presented significantly higher MPVs if associated with metabolic syndrome or arterial hypertension. Conclusions. Patients with cardiovascular risk factors, especially complex ones like the metabolic syndrome had an increased MPV, as did the patients with UA whether or not associated with the risk factors. In patients without such comorbidities, the MPV could be useful in distinguishing unstable angina from non-coronary chest pain.

The impact of modern endourological techniques in the treatment of a century old disease--medullary sponge kidney with associated nephrolithiasis.

Abstract: The remarkable progresses of imagistic and interventional techniques that have been implemented during the last decades facilitated the diagnostic and allowed the treatment indication changes for numerous renal disorders. The purpose of the present lecture was to outline a data review concerning a renal anomaly first described one century ago as well as to evaluate the impact of endourologic technical progresses over the therapeutic management of the respective disease. The medullary sponge kidney (MSK) or Cacchi-Ricci disorder represents a disturbance in the renal development characterized by the cystic type dilation and diffuse precalyceal ducts ectasias. The disease is also known as precalyceal tubular ectasia, pyramidal sponge kidney or cystic dilation of the renal collecting ducts MSK patients are most often asymptomatic, the diagnosis being emphasized in light of the investigations imposed by related complications such as renal stones, urinary tract infections (pyelonephritis), renal tubes acidosis or urine concentration defects.

Intramedullary hemangioblastoma - local experience of a tertiary clinic.

Abstract: Background: Intramedullary hemangioblastomas are rare benign tumors, occurring sporadically or in von HippelLindau disease. Methods: We describe our local surgical experience with intramedullary hemangioblastomas. Clinical, imaging and surgical data from five consecutive hemangioblastoma cases identified from a series of 59 patients with intramedullary tumors treated between 2003-2009 are reviewed. Results: The mean age of the patients was 39.6 years (range 2156). All of them were symptomatic and two patients had von Hippel-Lindau disease with associated posterior fossa hemangioblastomas. All tumors were preoperatively diagnosed as hemangioblastomas based on magnetic resonance findings. All patients underwent surgery with complete removal of the tumor in 4 cases and a partial removal in a case with extension towards the anterior part of the cord. Good neurological outcome was noted in four cases while in the fifth, complicated with a significant intraoperative hemorrhage, a fully reversible aggravation of neurological status occurred. Conclusions: Spinal cord hemangioblastomas are surgically curable tumors. Microsurgical complete resection is the standard of care and can be performed with good neurological outcome in most of the cases. Ventral tumor location and important intraoperative bleeding are associated with less optimal outcome.

Transplantation of composite tissue allograft: scientific bases and clinical applications.

Abstract: Plastic surgery is by excellence a surgery in permanent search for new reconstructive options. In the last 50 years researches in the field of allotransplantation led to obtaining promising results for solving difficult cases when autologous tissues are not available for reconstruction, despite all the bioethical issues of this subject. This field of composite tissue transplantation evolved constantly, the top of it being total face transplantation, successfully accomplished while being based on the knowledge accumulated. There are many clinical applications of CTA, hand transplantation or only flexor tendon apparatus, lower limb, partial or complete face transplantations represent the most important part for us, plastic surgeons for obtaining the best reconstruction possible.

Septic remnants, a crucial factor in the outcome of suppurated pancreatitis.

Abstract: Scheduled reinterventions, or dictated by necessity in order to drain the septic foci occupy an important place in the surgery of the pancreatic suppurations. Approximately 50% of the operated patients require one or more reinterventions, in order to accomplish the debridement and evacuation of the necrotic-suppurative remnants. The authors reanalyze the retroperitoneal space as a center of the necrotic-suppurative processes, emphasizing over the insufficiency of the approach of the retroperitoneum only through the omental bursa. The anatomical considerations infirm the belief according to which the approach of the omental bursa would be the primary gesture of retroperitoneal access. The pancreas and the surrounding atmosphere are hosted within the anterior an posterior pararenal space. In order to avoid septic remnants it is insisted on six access pathways to the pararenal space. These ways of approach are dictated according to topography of the suppurated necrosis. Post surgical evolutional future of the patient is directly dependent on the presence or absence of the remnants after the first surgical intervention. Evidently, the remnants will be present where the debridement and evacuation of the sepsis didn't take place- meaning all the dependencies of the pararenal space. The large, multiple drainage, closed or opened, with or without continuous lavage, can not correct the septic omissions. Partial and incomplete debridements must not be based on the corrections through the scheduled reinterventions.

Physiopathological aspects of the subclinical alterations of thyroid function associated with acute coronary syndromes.

Abstract: The subclinical modification of thyroid function represents an important risk factor for the development of acute coronary syndromes, neglected up to this day. Knowledge of the physiopathological processes implicated in the alteration of thyroid function that induces cardiovascular dysfunction is a necessity for the understanding of the phenomena and for the finding of the adequate therapeutic solutions. While recognizing the thyroid dysfunction as a modifiable risk factor for the acute coronary syndrome, we encountered a new challenge for the clinical research regarding its implications. The ability to manage the altered thyroid homeostasis may represent a new stage of prevention at a population level for the reduction of the cardiac risk, a stage which implies a risk factor that may remain clinically mute for a long period of time if left undiagnosed, however influencing the development of the acute coronary syndromes. Keywords : subclinical thyroid dysfunction, acute coronary syndrome, cardiac risk factor

Grade IV blunt splenic injury – the role of proximal angioembolization. A case report and review of literature

Abstract: The authors present a case of grade IV traumatic spleen rupture (AAST-OIS) and an Injury Severity Score of 21 and a Revised Trauma Score RTS=7.841, which was managed without surgery, but with proximal splenic angioembolization (SAE), with a positive outcome. Indications, types and side-effects of SAE are also discussed with regard to blunt spleen trauma and the benefits of SAE as non-operative treatment approach. It is the first case of a grade IV splenic laceration non-operatively managed to be published in Romania.

Clinical, biological, echocardiographic and therapeutic determinants of the length of hospital stay of patients with acute heart failure.

Abstract: Hypothesis: The length of hospital stay (LOS) is a unanimously accepted measure of risk and treatment efficacy for in-patients. Purpose: Our aim was to identify the parameters with predictive value for the LOS of patients with acute heart failure (AHF). Methods: We analyzed 125 patients consecutively admitted to our clinic with a slight male predominance (54.4%) and a mean age of 71.54 years. Patients were divided into groups according to the clinical form at presentation and left ventricular function. Mean LOS was of 8.74 days. Results: Patients with LVEF 30% (F(2)=6.54, p 140mg (p 160ms (p<0.05) or LBBB. The linear regression equation exposed a single significant statistical model indicating that the need for vasopressor amines, mean diuretic dose and PAAT<90msec explain 56% of the variance of LOS F(3.46)=20.55, p<0.001. The highest contribution to the model was achieved by the need for vasopressor amines (β=0.66), with a unique contribution of 42% to the variance of the number of days of stay. The mean dose of diuretic had β=0.27 and a unique contribution to the model of 7.2%, followed by PAAT<90 msec with β=0.26 and a unique contribution to the model of 7%. Conclusions: LOS is influenced by numerous parameters, some specific to certain clinical forms of AHF while others are independent, which is why evaluations on larger groups of patients are further needed.

A rare cause of acute massive lower gastrointestinal bleeding.

Abstract: Even if lower gastrointestinal bleeding (LGIB) can present as trivial haematochezia, massive hemorrhage with shock may occur. Acute massive LGIB is defined as bleeding of recent duration that originates beyond the ligament of Treitz and encompasses: passage of a large volume of red or maroon blood through the rectum, haemodynamic instability and shock, initial decrease in haematocrit level of 6 g/dL or less, transfusion of at least 2 U of packed red blood cells, bleeding that continues for 3 days or significant rebleeding in 1 week. This report presents the case of a 58-year-old man with massive LGI bleeding. Colonoscopy was performed in emergency with a poor colonic preparation, but the examiner fortunately and with difficulty managed to identify the source of the haemorrhage- a Dieulafoy’s lesion of the right colon. The bleeding was successfully stopped permanently by injecting sclerosing agents into the spurting vessel. We have preferred colonoscopy as our first choice of investigation due to the facile availability and the opportunity of endoscopic haemostasis in case of finding the source of bleeding. Angiography was planned in case of failure of the first method. The definition, clinical presentation, and treatment of Dieulafoy’s lesion are further discussed.

Proximal congenital radial-ulnar synostosis and synchondrosis;pathogenic concept and a new therapeutic method

Abstract: context: Proximal congenital radial-ulnar synostosis (PCRUS) is defined by the development before birth of a bony bridge between the radius and ulna, usually at the proximal level, which blocks forearm rotation. This anomaly is rarely reported in the medical literature, because of its low prevalence, and treatment usually yields unsatisfactory results. The most commonly used surgical interventions are: forearm repositioning osteotomies with derotation of the radius and ulna, segmental resections of the middle third of the radius with muscular interposition, resection of the synostosis with the interposition of fatty tissue, tendons or fascia lata and resection of the proximal radius along with the transfer of the distal extensor carpi ulnaris tendon on the lateral edge of the radius. Purpose: To describe a new treatment method for PCRUS, which we based on a new pathogenic concept, and to present our preliminary results. Materials and method: Between 2011 and 2013 our team performed two myo-osteo-arthroplastic reconstructions of the elbow and forearm for PCRUS. The intervention involves the extraperiosteal stripping of the origins of the ventral forearm musculature, release of the interosseous membrane, resection of the proximal two thirds of the radius, reshaping of the synostosis, a double osteotomy of the ulna and the transfer and fixation of a proximal fibular graft, including the head with its articular cartilage, in place of the resected segment of the radius. Results: Our preliminary study reveals favorable postoperative results, in comparison with other published methods. At the latest follow-up, one case had -10 degrees of pronation and 68 degrees of supination, and the other had 10 degrees of pronation and 66 degrees of supination. Conclusions: Compared with other techniques, myo-osteo-arthroplastic reconstruction may seem overly invasive. However, the extent of this intervention is mandated by the pathogenic concepts of helical distortion, muscular retraction and anomalous configuration of the interosseous membrane. Benign cases do not require surgery. When there is no helical distortion, the intervention may be limited to the transfer of the proximal extremity of the fibula for the infant and small child.

Perioperative evaluation of cardiac surgical risk: particularities in the emergency surgery - from the guidelines to the clinical practice.

Abstract: Rationale: Cardiac risk in patients undergoing surgery depends on many factors from the patient's cardiovascular history to the surgical procedure itself, with its particularities, the type of anesthesia, fluid exchanges and the supervision of the patient. Therefore, this risk must be carefully considered and it determines the endorsement of perioperative measures with important medical implications. Objective: Perioperative cardiac risk evaluation guidelines were published since 2010 and they represent a highly important assessmnet tool. Emergency surgery requires an adaptation of the guidelines to the actual medical situations in extreme conditions. Methods, Results, Discussion: Analyzing the way the perioperative evaluation itself is conducted is an extremely important tool. Quantifying the clinical application of the guidelines, one can monitor real parameters and find solutions for improving medical care. The current study was conducted on a representative sample of 8326 patients, respecting the recommendation strategies for calculating the surgical risk adapted for the emergency surgery setting. The dominant conclusion is the need to develop a standardized form, summarized for quick and objective assessment of perioperative cardiac risk score. Only a complex medical team could calculate this score while the decisional team leader for the surgical patient remains the surgeon.

Prediction factors for breast reconstruction postoperative complications.

Abstract: Breast cancer is a major health problem that requires multiple forms of treatment, including surgery, adjuvant chemotherapy and radiotherapy and more recently, reconstructive surgery. The aim of this study is to determine the factors that can predict the chances of a patient having postoperative complications after breast reconstruction.

3d applications in disaster mitigation and management: core results of ditac project

Abstract: According to statistical data, natural disasters as well as the number of people affected by them are occurring with increasing frequency compared to the past. This situation is also seen in Europe Union; So, Strengthening the EU capacity to respond to Disasters is very important. This paper represents the baseline results of the FP-7 founded DITAC project, which aims to develop a holistic and highly structured curriculum for responders and strategic crisis managers. Up-to-date geospatial information is required in order to create an effective disaster response plan. Common sources for geospatial information such as Google Earth, GIS databases, and aerial surveys are frequently outdated, or insufficient. This limits the effectiveness of disaster planning. Disaster Management has become an issue of growing importance. Planning for and managing large scale emergencies is complex. The number of both victims and relief workers is large and the time pressure is extreme. Emergency response and triage systems with 2D user interfaces are currently under development and evaluation. Disasters present a number of spatially related problems and an overwhelming quantity of information. 3D user interfaces are well suited for intuitively solving basic emergency response tasks. Such tasks include commanding rescue agents and prioritizing the disaster victims according to the severity of their medical condition. Further, 3D UIs hold significant potential for improving the coordination of rescuers as well as their awareness of relief workers from other organizations. This paper describes the outline of a module in a Disaster Management Course related to 3D Applications in Disaster Mitigation and Management. By doing this, the paper describes the gaps in existing systems and solutions. Satellite imageries and digital elevation data of Turkey are investigated for detecting sites prone to natural hazards. Digital image processing methods used to enhance satellite data and to produce morphometric maps in order to contribute to the detection of causal factors related to landslides, local site conditions influencing and/or experiencing earthquake damage intensity or those of tsunami and storm surge hazard sites at the coasts.