bluuebunny/crossref_metadata_2025 huggingface dataset:
Gene Therapy for Cardiovascular Disease
Authors: Meyerson Shari L. , Skelly Christopher L. , Curi Michael A. , Schwartz Lewis B.
Published: October 2008

During the past decade, gene therapy for the treatment of many inherited and acquired medical problems has become the subject of increasing focus in both the scientific litera ture and the lay press. This review examines the history and current status of gene therapy for advanced chronic periph eral and myocardial ischemia.
Preoperative Pulmonary Rehabilitation
Authors: Wilson Donna J.
Published: October 2008

The incidence of lung cancer continues to increase and now represents the most common fatal malignancy in adults. At the present time, surgery is the most optimal form of therapy for patients with non-small-cell lung cancer. Unfortunately, many of these patients have significant underlying respiratory diseases including emphysema and airway hyper-reactivity that clearly increase the incidence of perioperative morbidity and mortality. Although many approaches have been de signed to select those candidates best suited for sur gery, there exists a significant number of patients who, in spite of advanced comorbid pulmonary disease, could benefit from surgical resection. The question that now exists is how best to manage their pulmonary disease in the preoperative period to minimize postop erative morbidity and mortality. Cessation of smoking, bronchodilator, and steroid therapy are helpful, but limited in their ability to improve overall pulmonary function. Pulmonary rehabilitation programs have tradi tionally been designed for nonsurgical candidates with chronic lung disease. Randomized, controlled trials of graded exercise have shown potential benefit with improved quality of life and functional status. Similar preoperative programs have not been systematically explored in the surgical population. Described is an attempt to evaluate, in a randomized fashion, a home- based exercise program specifically applied to high-risk thoracic surgical patients.
Isolation Techniques
Authors: Brodsky Jay B. , Mackey Sean
Published: October 2008

The development of the specialty of thoracic surgery has closely paralleled the evolution of anesthetic tech niques that have allowed for effective, safe isolation of the lungs. A great number of different, often innovative, techniques have been used in the past to achieve lung isolation. This article will review many of these tech niques, but will emphasize the use of modern plastic double-lumen endobronchial tubes (DLT) and bronchial blockers. These are the two most popular ways of isolating the lungs today. The availability of fiberoptic bronchoscopes (FOB) to help confirm accurate place ment of these tubes and blockers has made functional isolation of the lungs not only safe, but relatively easy for any anesthesiologist to perform.
Physiology of One-Lung Ventilation
Authors: Fisher Meredith L. , Body Simon C.
Published: October 2008

The understanding of the physiology and management of one-lung ventilation (OLV) has advanced over the last two decades. OLV induces an obligatory shunt through the nonventilated lung that causes varying degrees of arterial hypoxemia. Shunt may also occur in the venti lated lung. The optimal mode of ventilation of the dependent lung has not been well defined. The optimal tidal volume, respiratory rate, inspired oxygen concen tration, and positive end-expiratory pressure (PEEP) during OLV are not known. Functional residual capacity (FRC) of the ventilated lung can be lower than during two-lung ventilation, causing atelectasis and arterial hypoxemia. Patients who desaturate might be expected to show improvement in oxygenation with dependent lung PEEP, because of increased FRC and reduced V/Q mismatch. Not all patients have low lung volumes, and not all patients who have low lung volumes will desatu rate. Therefore, prophylactic PEEP is not usually neces sary or appropriate. Because the predominant cause of hypoxemia during OLV is shunt in the nondependent lung, therapies to improve arterial oxygenation during OLV should be primarily directed toward the nondepen dent lung. Partial reinflation of the nondependent lung with O2will reduce the physiological shunt fraction of the lung. Continuous positive airways pressure (CPAP) is an effective prophylactic and therapeutic treatment for hypoxemia. All studies examining CPAP have found it to be effective, provided it is preceded by lung reinflation.
Postoperative Cardiac Arrhythmias: Prevention and Management
Authors: Amar David
Published: October 2008

Supraventricular arrhythmias or supraventricular tachy cardias (SVT) frequently occur after thoracic surgery and have been associated with prolonged hospital stays. The reported incidence of supraventricular ar rhythmias in this patient population ranges from 9% to 40%, with factors such as extent of surgery markedly influencing the incidence. SVT has been reported to be 12% to 16% after lobectomy, 20% to 30% after pneumo nectomy, and as much as 40% after extrapleural pneu monectomy for malignant pleural mesothelioma. Pa tients who develop SVT have a higher rate of intensive care unit admission and higher 30-day mortality. SVT occurrence appears to be an important marker of poor cardiopulmonary reserve in patients who developed significant morbidity after thoracic surgery. It is pos sible that the rate of SVT occurrence increases propor tionally with extent of neural trauma to cardiac plexus structures in older patients. The timing of SVT onset is likely related to the high adrenergic activity of the postsurgery state and the resolution of a graded inflam matory process corresponding to the amount of blunt or sharp surgical trauma to sympathovagal nerve fibers innervating the sinus node. This article will focus on new issues leading to improved understanding of the pathophysiology and mechanisms of SVT after surgery. New approaches directed at prophylaxis and acute therapy of SVT are also discussed.
Pain Management
Authors: Datta Samyadev , Jain Subhash
Published: October 2008

Postoperative pain management is essential and must be approached as an integral part of the perioperative care. It should be systematic and based on sound physiological and pharmacological principles. The intra operative management of pain is crucial, because there is perhaps an important role for preemptive analgesia. Because of its unique nature, pain is difficult to assess; for good results, adequate and repeated assessment are vital. The literature also points to the detrimental ef fects of inadequate pain control. There are a variety of methods available for pain management. In choosing a method, various factors need to be considered includ ing: (1) physician skill, (2) knowledge of analgesics and routes of administration, (3) patient and clinically re lated circumstances, (4) the availability of an environ ment supportive of effective pain management, and (5) the knowledge and skill of staff to assess and monitor patients. These need to be considered along with the risk-benefits and cost-benefit of the various drugs and techniques. The cornerstone of therapy is opioids, which can be administered by a variety of routes. The use of thoracic epidural analgesia (TEA) with opioids and local anesthetics is highly beneficial, especially in high-risk patients. The aim should be to provide all patients a balanced analgesic regimen based on the identification of multiple mechanisms involved in postoperative pain.
Novel Insights Into the Pathogenesis and Therapy of Circulatory Shock
Authors: Steingrub Jay S.
Published: October 2008

Several lines of evidence suggest central roles for nitric oxide, oxygen free radicals, cytokines, and adhesion molecules in circulatory shock. Lipid peroxidation fre quently accompanies ischemia-reperfusion injury; re cruitment of leukocytes exposed to ischemia-reperfu sion injury is largely dependent on leukocytes and endothelial cell adhesion interaction, enhanced nitric oxide stimulation by proinflammatory cytokines contrib utes to increased gut mucosal permeability in sepsis, and tumor necrosis factor (TNF) administration mimics the hemodynamic changes characteristic of circulatory shock. Recent advances in molecular and cellular biol ogy have paved the way for innovative approaches to the treatment of circulatory shock. Novel pharmaco logic approaches are being directed at three distinct levels of the inflammatory cascade: the inciting insult (ie, endotoxin), the mediators (ie, TNF, interleukin-1, oxygen free radicals), and the effector cells (ie, neutro phils). The intent of this review is to discuss the biology of mediators in circulatory shock as well as the experi mental and clinical evidence implicating their role in development and pathogenesis of the injury. Current status of novel adjunctive therapies for circulatory shock is reviewed.
The Role of Pulmonary Artery Catheterization in the Management of Cardiothoracic Surgical Patients
Authors: Colombo James A. , Tuman Kenneth J.
Published: October 2008

Pulmonary artery catheterization (PAC) is a commonly used method for assessment of perfusion in critically ill patients, especially cardiothoracic surgical patients. A vast amount of clinical experience indicates that PAC provides clinicians with information about the cardiovas cular system that is otherwise not readily available at the bedside. This information is then used for the diagnosis of various hemodynamic abnormalities and subsequently to guide and judge the efficacy of thera peutic interventions. A number of small, but highly controlled, studies have suggested that outcome can be improved when data from PAC are used to guide therapy in a specific manner. Studies that have not defined specific treatment endpoints based on findings derived from PAC have failed to demonstrate outcome differences, especially when relatively small numbers of low-risk patients have been studied. A large number of other factors have precluded formal scientific validation of definitive outcome differences with PAC, and, until data are available from appropriately designed, ad equately powered trials without randomization break down, rigorous analysis of available data does not justify any immediate change in the use of PAC. Hemo dynamic monitoring with PAC remains an important aspect of care during and especially after major cardio vascular surgery, and selective use in high-risk patients appears to be the most prudent and cost-effective application of this technology.
Mechanical Support After Cardiac Surgery
Authors: Smedira Nicholas G. , Hlozek Christopher C. , McCarthy Patrick M.
Published: October 2008

The need for mechanical circulatory support after car diac surgery is uncommon despite an older and increas ingly sicker patient population. From September 1992 through January 1997, surgeons performed 21,000 car diac operations at the Cleveland Clinic Foundation, and mechanical support postcardiotomy was required in only 75 patients (0.3%). Aggressive management of cardiac and pulmonary dysfunction usually results in successful weaning from cardiopulmonary bypass. How ever, when mechanical support is needed, it can tax the resources of the institution and requires integrated patient management from the entire health care team. Management of postcardiotomy circulatory failure will be discussed in detail, along with the devices commer cially available for both short- and long-term support. Copyrighr© 1998 by W. B. Saunders Company.
Myocardial Ischemia During Weaning From Mechanical Ventilation
Authors: Manthous Constantine A. , Zarich Stuart
Published: October 2008

Coronary artery disease (CAD) affects more than 11 million Americans and is the leading cause of death in the United States. Both CAD and critical illness occur more frequently in older patients. However, the contri bution of myocardial ischemia to morbidity and mortal ity in critically ill patients has not been well studied. Weaning from mechanical ventilation is expected to be a period of significant cardiopulmonary stress during recovery from critical illness. However, few studies have examined the epidemiology of and clinical risk factors for weaning-related myocardial ischemia. In this review, the pathophysiology of myocardial ischemia during weaning is outlined, the studies examining this entity are analyzed, and a systematic approach to diagnosis and management is suggested.
Anesthesia for Liver Transplantation
Authors: Gabrielson George V.
Published: October 2008

Advances in surgical and anesthetic techniques have provided great success in liver transplantation, with more than 4,000 liver transplantations performed annu ally in the United States. Indications for transplanta tions include the various forms of cirrhosis, commonly resulting from hepatitis B or C, alcoholism, or acute hepatic failure from drug toxicity or poisoning. Cadav eric donor livers are resected and may be transplanted up to 24 hours later while the recipient is prepared for surgery. These operations may last 10 hours and require large amounts of blood products. Extrahepatic prob lems from their end-stage liver disease are common and affect nearly all organ systems. Intraoperative monitor ing of acid-base status, electrolytes, intravascular vol ume, and coagulation parameters is essential. Preexist ing coagulopathies from liver disease, complications of massive transfusions and fibrinolysis from the new liver create complex coagulation disturbances requiring prompt diagnosis and treatment. Metabolic (lactic) aci dosis is common and severe. Reperfusion of the donor liver can result in a dramatic and rapid fall in blood pressure as well as hyperkalemia.
Anesthesia for Heart Transplantation
Authors: Dickstein Marc L.
Published: October 2008

Although several new surgical therapies hold promise for changing the surgical approach to heart failure, the most effective therapy currently for patients with end- stage congestive heart failure is heart transplantation. The challenges posed to the anesthesiologist caring for these patients are great, and are increasing as a result of a shift toward transplanting medically unstable pa tients. The anesthetic management of patients undergo ing heart transplantation requires a knowledge of the pathophysiology of heart failure, the altered pharmacody namics of anesthetics in the patient with heart failure, treatment of right heart failure, as well as the impact of new surgical therapies on cardiovascular function.
Aspects of Anesthesia for Lung Transplantation
Authors: Myles Paul S.
Published: October 2008

Anesthesia for lung transplantation is both a demand ing and rewarding experience. Success requires team- work, experience, knowledge of cardiorespiratory patho physiology and its anesthetic implications, appropriate use of noninvasive and invasive monitoring, and the ability to respond quickly and effectively to life- threatening perioperative events. Specific issues in clude management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation, perioperative respiratory failure, pulmonary hyperten sion, and acute right ventricular failure. Recent ad vances include greater understanding of dynamic hyper inflation ("gas-trapping") during mechanical ventilation, perioperative use of inhaled nitric oxide and treatment of acute right ventricular failure. Successful anesthetic management leads to greater hemodynamic stability, improvement in gas exchange and a reduction in need for cardiopulmonary bypass, all of which should lead to improved patient outcome.
Pharmacologic Management of Chronic Heart Failure: A Review
Authors: Abraham William T.
Published: October 2008

Standard drug therapy of systolic heart failure has been evaluated in large-scale randomized clinical trials and includes angiotensin-converting enzyme (ACE) inhibi tors, which should be used as first-line therapy, diuret ics for the management of extracellular fluid volume excess, and digoxin. In combination with ACE inhibitors and diuretics, with or without digoxin, some β-adrener gic receptor blockers attenuate disease progression and improve outcome in mild-to-moderate systolic heart failure. The pharmacologic management of chronic dia stolic heart failure is largely empirical and directed at reducing symptoms. Symptoms caused by increased ventricular filling pressures may be diminished by diuret ics and nitrovasodilators. Some calcium channel antago nists and most β-blockers prolong diastolic filling time by slowing heart rate, thereby improving the symptoms of diastolic heart failure.
Endovascular Cardiopulmonary Bypass for Port-Access Minimally Invasive Cardiac Surgery
Authors: Siegel Lawrence C.
Published: October 2008

Port-Access (Heartport, Inc, Redwood City, CA) mini mally invasive cardiac surgery systems with the EndoCPB (Heartport, Inc) endovascular cardiopulmo nary bypass (CPB) system allow a variety of cardiac procedures to be performed on a quiescent, decom pressed heart through small incisions without the need for a median sternotomy. The catheter-based EndoCPB system uses a modified extracorporeal circuit to accom plish the same functions as a standard CPB system for open-chest cardiac surgery. Femoral and jugular cannu lae and catheters are positioned into the coronary sinus, pulmonary artery, and ascending aorta to arrest and vent the heart, deliver antegrade or retrograde cardiople gia, drain venous blood into a modified heart-lung machine, and return oxygenated blood into the periph eral circulation. Cannulae and catheter placement are guided by fluoroscopy and transesophageal echocardi ography (TEE) imaging. Specific monitoring techniques are used to continually evaluate the functioning of all system components to ensure safe and adequate CPB and myocardial protection. As of July 1998, a registry of clinical experience includes more than 1,800 Port- Access cases performed at more than 100 centers worldwide. The majority of procedures (57%) com pleted include coronary artery revascularization with multiple-vessel (up to six) distal anastomoses and mi tral valve replacements (17%) and repairs (10%). With experience, surgeons have begun to perform other intracardiac repairs on a wider range of patients than initially believed possible. Ongoing clinical experience and investigation will further elucidate the safety, effi cacy, and benefits of Port-Access minimally invasive cardiac procedures and the monitoring techniques and perioperative care methods best used to optimize clini cal care, reduce patient suffering, and facilitate rapid rehabilitation.
Neurobehavioral Outcomes of Cardiac Surgery
Authors: McKhann Guy M. , Goldsborough Maura A. , Borowicz Louis M. , Enger Cheryl , Quaskey Shirley , Selnes Ola A.
Published: October 2008

Since the inception of cardiac surgery, postoperative neurobehavioral complaints have prompted intensive studies of neurologic and cognitive outcomes. There is now a wealth of information on the incidence of stroke, delirium, depression, and cognitive outcomes after car diac procedures. Stroke risk models have been devel oped to identify patients at high risk. Delirium, although much less objectively studied, still occurs frequently in the immediate postoperative period, but its relationship to long-term cognitive outcome has not been resolved. Postoperative depression may not be as common as was previously thought, and may be related to mood status before surgery. Cognitive decline may be short- term for some aspects of brain function, but more prolonged or delayed in others. Despite these extensive studies, it is not clear whether some of these outcomes are related to the surgical procedure itself, rather than the use of general anesthesia in an older population of patients with extensive atherosclerotic disease. Inclu sion of appropriate control groups, longer term follow- up, and larger sample sizes in future prospective studies will improve the design of intervention studies in this patient population.
Genetic Predictors of Perioperative Neurologic and Neuropsychological Injury and Recovery
Authors: Newman Mark F. , Laskowitz Daniel T. , Saunders Ann M. , Grigore Alina M. , Grocott Hilary P.
Published: October 2008

Central nervous system (CNS) dysfunction after cardio pulmonary bypass represents a continuum from coma and focal stroke to cognitive deficits after surgery. Despite the marked increase in investigation of neuro logic and neurocognitive deficits after cardiac surgery, causative factors fail to predict the majority of the variance in the observed incidence of both early and late neurocognitive decline pointing to some inherent indi vidual susceptibility to injury. The authors' investigative team recently discovered a genetic association be tween late-onset Alzheimer's disease and the apolipo protein E (APOE, gene; apoE, protein) ∈-4 gene. This finding triggered many recent studies that have shown an important role of apoE in the determination of neurologic injury and recovery following a variety of acute ischemic insults including intracerebral hemor rhage, closed-head injury, as well as acute stroke and dementia pugilistica. Most important to the current discussion is the authors' recent report documenting preliminary evidence of an association of APOE4 with neurocognitive decline after cardiac surgery. This re view discusses the authors' hypothesis that the bio chemical products coded by this gene are not available to protect and repair the neurons of the CNS during cardiac surgery resulting in deficits of memory, atten tion, and concentration. Potential mechanisms of apoE's association with acute neurologic injury are discussed including regulation of the inflammatory response. The authors have recently determined that apoE, in vivo, modulates the release of nitric oxide and tumor necro sis factor a. This may compound the autonomic dysreg ulation recently reported in the aging population. The authors' preliminary data associating APOE4 with cogni tive impairment after cardiac surgery support this hy pothesis. The different potential mechanisms of apoE function in neuronal injury and recovery are not mutu ally exclusive, and it is likely that apoE modulates the CNS injury response at several functional levels.
Microemboli and Neurologic Dysfunction After Cardiovascular Surgery
Authors: Stump David A. , Brown William R. , Moody Dixon M. , Rorie Kashemi D. , Manuel Janeen C. , Kon Neal D. , Butterworth John B. , Hammon John W.
Published: October 2008

Several recent studies have shown that cardiac surgery poses significant risks for negative neurologic and neu ropsychological outcome. Death and major stroke have become uncommon consequences of cardiac surgery, but more than two-thirds of the patients show evidence of neuropsychological dysfunction postoperatively.

The mechanisms contributing to postcardiopulmonary bypass neuropsychological deficits are uncertain, and potentially there are many possible causative factors that may play a significant role in perioperative neuro logic injury. However, two major interrelated factors, hypoperfusion and emboli, are suggested as probable culprits. Perfusion is important because the level of global and focal cerebral blood flow during periods of high embolic risk will determine the amount of brain embolization as well as the localization of the lesions. Ultrasonically detected macroemboli have been re ported to be the best predictor of neurobehavioral outcome. Microemboli found in autopsy specimens may also be important predictors of negative outcome. The relationship between microemboli and changes in brain function, as detected by magnetic resonance spectroscopy, may provide further insight into the prob ability of the clinical expression of a neurobehavioral dysfunction after cardiac surgery.

The incidence and severity of neuropsychological defi cits after cardiac surgery appear to be related to the delivery of macroemboli. The composition of the embo lus may be the most important determinant of the level and volume of focal injury, but the time of occurrence (ie, rewarming) of macroemboli during cardiopulmo nary bypass may also be important in determining the effect of emboli on neuropsychological outcome. How ever, the key variable in the manifestation of neurobe havioral dysfunction remains the location of the lesion site.
Intraoperative Echocardiography for the Patient Undergoing Minimally Invasive Heart Surgery
Authors: Han Long K. , Jacobsohn Eric , Aronson Solomon
Published: October 2008

Minimally invasive heart surgeries are commonly used to avoid large surgical incisions and facilitate early extubation and recovery after cardiac surgeries. Trans esophageal echocardiography (TEE) is especially valu able in minimally invasive cardiac surgery because the inherently limited access to the thorax and mediasti num impairs direct visualization of the heart. TEE influ ences the clinical decision making process in several ways. Changes to the anesthetic management include alteration in volume loading in the presence of diastolic dysfunction or left ventricular outflow tract obstruction, as well as augmenting coronary perfusion pressure and implementing coronary vasodilators for new regional wall motion abnormalities. Changes to the surgical plans include replacement or repair for regurgitant valves, placement of intra-aortic balloon pumps for persistent regional wall motion abnormalities, and changing the surgical approach in the presence of severe aortic disease. Currently, two approaches are commonly used in minimally invasive cardiac surgery. The first approach, port-access minimally invasive car diac surgery, continues to use cardiopulmonary bypass. This approach relies extensively on TEE to correctly place endovascular devices necessary for cardiopulmo nary bypass in addition to routine assessment of car diac function. The second approach, minimally invasive direct coronary artery bypass, involves performing the revascularization on a beating heart. Here, TEE is essen tial for assessment of ventricular function if ischemic preconditioning is used as a strategy for myocardial protection.
Interventional Cardiology: Advances in Percutaneous Techniques for the Treatment of Cardiac Disease
Authors: Chambers Charles E. , Riebel Scott T , Kozak Mark
Published: October 2008

The field of interventional cardiology began in the late 1970s and consisted primarily of balloon catheter angio plasty until the early 1990s. Although understanding of the process of coronary angioplasty has evolved signifi cantly, restenosis still remains the Achilles' heel of the interventional cardiologist. This article reviews the cur rent issues involved in interventional cardiology for coronary disease from patient selection, anticoagulant therapy, restenosis, current interventional devices (stent mania), and future devices (intracoronary radiation). Noncoronary interventional procedures, vaivuloplasty, and atrial septal defect closure are also reviewed to provide an overview of cardiac interventional proce dures for the anesthesiologist.
Management of Chronic Postthoracotomy Pain
Authors: Jain Subhash , Datta Samyadev , Tundis Debra
Published: October 2008

Postthoracotomy pain management is essential imme diately after surgery and crucial for the patient suffering from this problem for a long duration. Understanding the causative and pathophysiological basis for this condition requires frequent assessment and a multidi mensional approach. Inadequate pain control has detri mental effects on the routine activities of patients as well as on their physical and emotional well-being. During the last 2 decades, the understanding of various pain-related issues has been strengthened resulting in early intervention and pain management. Various phar macological modalities including the role of nonopiates, opiates, and adjuvant drugs are helpful in combating postthoracotomy pain. A selective group of patients will benefit from interventional techniques. The treat ment decision requires a clear understanding of the disease and its impact on the patient. There must also be an understanding of risk and benefits as well as cost and benefits for various drugs and techniques before selecting the appropriate therapy.
The Economics of Cardiac Surgery
Authors: Cross john
Published: October 2008

Health care practitioners are under increasing pressure to identify and reduce the costs of their interventions. Cardiac surgical procedures have been studied extensively to determine which factors increase costs so the costs of future interventions can be reliably predicted. Knowing the cost components of surgical interventions identifies opportunities for increased efficiency and cost reduction. New technologic advances may initially defy cost reduction efforts until randomized controlled trials and cost analyses can be performed.
Cost Accounting for Cardiothoracic Anesthesia Services
Authors: Sloop Ross M. , Rhines Geoffrey M.
Published: October 2008

Increasingly, physicians face a health care environment in which they must know the costs they incur to provide services. Although knowing the aggregate costs incurred by the entire practice is a good first step, it is much more critical physicians know what it costs to provide individual procedures. Knowing the specific costs of individual procedures allows a physician to negotiate profitable agreements with managed care companies and other third-party payers. Cardiothoracic anesthesiologists face unique challenges when attempting to implement cost accounting. This article explores some of these challenges, as well as makes recommendations on how best to calculate procedural costs for anesthesia services.
Development and Costs of an Intraoperative Echocardiography Service
Authors: Shanewise Jack S.
Published: October 2008

Intraoperative echocardiography (IOE) has become an important part of cardiovascular anesthesiology. An IOE service should provide the equipment and personnel needed to acquire and interpret echocardiographic images during surgery and communicate findings to the medical record. It also should archive images and reports, provide training in echocardiography skills, arrange for continuous quality improvement, and develop a means to bill for echocardiography services. Although the costs of providing IOE services can be estimated, the financial impact of starting such a service will vary greatly between institutions depending on the availability and use of existing resources and expertise. IOE is not a trivial skill and requires considerable training and experience to perform competently. Reimbursement for IOE services provided by anesthesiologists is highly dependent on local policies and will require continued vigilance and effort to be made fair and reasonable for all providers. The primary motivation for anesthesiologists to become involved in IOE is improved patient care.
Influence of anxiety and reported stressful life events on relapses in multiple sclerosis: a prospective study
Authors: Potagas C , Mitsonis C , Watier L , Dellatolas G , Retziou A , Mitropoulos PA , Sfagos C , Vassilopoulos D
Published: October 2008

Objective

Self-reported stressful life events and infections have been associated with relapses in multiple sclerosis. Also, anxiety has been reported to influence other diseases of unpredictable course. To study relation of self-reported stressful life events, levels of anxiety, and episodes of infection, with relapses of the disease in women with multiple sclerosis.

Methods

This is a one-year prospective study. Thirty seven women with multiple sclerosis were regularly seen every four weeks, for one year. They were keeping diaries of events they considered stressful. These events were ranked according to the Holmes and Rahe Social Readjustment Rating Scale. Their anxiety levels were assessed with the Hamilton rating scale for anxiety. Relapses and episodes of infection were verified at additional visits. Results were studied using a survival analysis model adapted for several recurrent events.

Results

A total of 291 stressful events, 37 episodes of infection, and 48 relapses, were registered. High level of anxiety were stongly related to the number and the severity of reported stressful events during the preceding period and with the advent of a relapse in the following period (Hamilton score greater than 18 is associated with 4.2 times the rate of relapsing and three or more reported stressful events with 5.7 times the rate of relapsing).

Conclusions

Anxiety and self-reported stressful events may in fact be two measures of the same underlying emotional factor, which plays an important role on the course of the disease, in addition to episodes of infection.
Correlations between plasma homocysteine and folate concentrations and carotid atherosclerosis in high-risk individuals: baseline data from the Homocysteine and Atherosclerosis Reduction Trial (HART)
Authors: Held Claes , Sumner Glen , Sheridan Patrick , McQueen Mathew , Smith Sandra , Dagenais Gilles , Yusuf Salim , Lonn Eva
Published: October 2008

Abstract

Homocysteine has been proposed as a risk factor for atherosclerosis. The association between plasma total homocysteine (tHcy) concentration and carotid atherosclerosis has not been thoroughly studied in high-risk populations with vascular disease. For this study, carotid atherosclerosis was assessed by measurements of carotid intima-media thickness (IMT) and plaque calcification in 923 patients with vascular disease or diabetes. Associations with tHcy and plasma folate concentrations were examined. The mean and single maximum carotid IMT were 1.27 ± 0.34 mm and 2.41 ± 0.83 mm, respectively. The mean segment plaque calcification score was 27.8%. tHcy correlated with mean ( r = 0.13; p < 0.001) and single maximum ( r = 0.12; p < 0.001) carotid IMT. There was a progressive increase in mean and single maximum carotid IMT across quartiles of tHcy ( p < 0.0001 for trend). These associations were no longer significant after adjusting for other CV risk factors. A trend towards an inverse association between plasma folate and mean max carotid IMT was found in both univariate and multivariable analyses. However, the plaque calcification score increased across quartiles of tHcy ( p < 0.01) and decreased across quartiles of plasma folate concentrations ( p < 0.05) after multiple adjustments. In conclusion, in high-risk individuals, tHcy and low folate concentrations were only weakly associated with carotid IMT. In contrast, we found an independent association with the plaque calcification score, a measure of more advanced atherosclerosis. The effect of tHcy lowering on carotid atherosclerosis and stroke prevention warrants further investigation.
Rectus sheath hematoma
Authors: Osinbowale Olusegun , Bartholomew John R
Published: October 2008

Abstract

Rectus sheath hematoma (RSH) is a known complication of anticoagulation therapy and a source of potential morbidity and mortality. Early diagnosis and appropriate treatment may help to prevent complications including hemodynamic instability, the abdominal compartment syndrome or multiorgan dysfunction. Although the diagnosis can be made clinically, it can be confirmed with computed tomography of the abdomen. Most patients can be managed conservatively; however, it is often necessary to suspend anticoagulation in the acute setting. Rectus sheath hematoma is not a contraindication to resuming anticoagulation once the hematoma has been adequately managed and the patient has returned to a stable clinical baseline.
The association between diabetes mellitus and the prevalence of intermittent claudication: the HUNT study
Authors: Jensen Svein A , Vatten Lars J , Myhre Hans O
Published: October 2008

Abstract

The objective of this study was to investigate the association between diabetes mellitus (DM) and the prevalence of intermittent claudication (IC). Between 1995 and 1997, all residents aged 20 years or older in Nord-Trøndelag County, Norway were mailed an invitation to participate in a health survey (HUNT 2). A total of 19,712 participants aged 40–69 years old completed and returned the questionnaire included with the invitation. They also attended an examination where brachial blood pressure was measured and non-fasting venous blood was collected. The venous blood sample was subsequently analysed for concentrations of blood lipids. Responses to 12 questions on IC were previously tested against ankle blood pressure measurements (ABPI < 0.9) and the algorithm with the best test properties was used to identify individuals with IC. Participants reported a history of DM by simple questions in the questionnaire. Logistic regression analysis was then used to compute age-adjusted prevalence odds ratios for the association between exposure variables and the prevalence of IC. Potential confounding by smoking, blood lipids and brachial blood pressure was investigated in multivariate analyses. For both sexes IC was more common in individuals with DM (ORwomen = 3.8, CI, 1.9–7.6; ORmen = 2.8, CI, 1.4–5.8) compared to participants without DM. Adjustment for smoking, blood lipids and brachial blood pressure did not substantially change these results. In conclusion, the prevalence of IC was more than three times higher in patients with DM compared to non-diabetic participants.
The association of acute exercise-induced ischaemia with systemic vasodilator function in patients with peripheral arterial disease
Authors: Joras Majda , Poredoš Pavel
Published: October 2008

Abstract

Patients with peripheral arterial disease (PAD) frequently experience ischaemic attacks of the affected tissues during exercise. The present study assesses the association of transient exercise-induced leg ischaemia with vasodilator function of the clinically unaffected brachial artery over the course of 4 hours. Thirty male patients with symptomatic PAD and 14 age- and sex-matched healthy controls were included in the study. They performed a treadmill exercise until intolerable exercise-induced ischaemic pain occurred in the affected lower extremity, or for at most 10 min. Flow-mediated dilation (FMD) of the brachial artery was measured at baseline, 30 minutes, 2 hours and 4 hours after exercise. Baseline FMD values were significantly diminished in patients (7.03 ± 1.99% vs 8.22 ± 1.60% in controls, p = 0.009). A significant decrease in FMD was observed in patients after exercise (at 30 minutes: 3.92 ± 1.78% vs 7.03 ± 1.99% at baseline, p < 0.001; at 2 hours: 6.36 ± 2.12% vs 7.03 ± 1.99% at baseline, p = 0.005), followed by a gradual return to its baseline value, whereas FMD in controls non-significantly increased after exercise. The difference in the pattern of FMD change over time between patients and controls was significant ( p < 0.001). This study shows that in PAD patients ischaemia during intermittent claudication is related to a transitory functional deterioration of the distant arteries. This indicates the harmful systemic effects of repeated ischaemic attacks during exercise and might explain the generalized and advanced nature of atherosclerotic disease in PAD patients.
Technology Becomes the Object
Authors: Isaac Gwyneira
Published: October 2008

The inaugural exhibits created for the National Museum of the American Indian (NMAI) in Washington DC were met with emotive public debates as to their success or failure to change the ways in which Native American cultures are portrayed in the USA. These debates, however, overlooked the significance of the use of electronic media in the NMAI galleries, their effect on the role of material culture and the subsequent shifts in how the collections were not only displayed, but also experienced by visitors. This inquiry draws on these exhibits for a re-examination of the categories of art/artefact and original/duplicate, exploring how electronic media has transformed the interpretation of the museum `object'. It employs interviews with NMAI staff to discuss the history and philosophy underlying the introduction of electronic media, and with visitors to contextualize these changes in the interpretation of collections from a broader perspective. In conclusion, it considers the confluence of Native, postcolonial and mediated knowledges presented by NMAI, and the possibility that media technology itself has become the museum object.
Othering through genderization in the regional press
Authors: Elsrud Torun
Published: October 2008

By far, most of the research into processes of discrimination and ethnification in Sweden considers urban settings. This article focuses on how the regional press in a rural area of south-east Sweden represents immigrants in a residential area in the outskirts of the Kalmar township. It points at the urgent need for researchers and decision-makers to take into account both subtle and palpable stigmatizing processes that meet immigrants who reside the countryside. An analysis of two local newspapers shows a continuous construction of `otherness' through pictures and texts, in which the identities of minority ethnic groups are stereotyped and subverted. One of the most persistent themes in this work of representation is the brutalization of the masculinity of `others', stressed even further by a `traditionalization' and feminization of a weak, caring female other. Both these gendered images serve a higher purpose, that of maintaining a positive image of a taken-for-granted Swedishness.
Terrorism and risk management
Authors: Ajzenstadt Mimi , Ariel Barak
Published: October 2008

Throughout the past few decades, Israel has developed a set of legal, criminal justice and other law enforcement initiatives under the broad category of 'counter-terrorism policy'. This policy attempts both to separate and manage more effectively a group of suspected and accused terrorists. This article utilizes the New Penology perspective to trace the ways in which notions of risk and dangerousness are embedded in the counter-terrorism discourse and practices developed in Israel. Additionally, this article analyzes various initiatives and, in particular, laws and the institutional mechanism that administrate the management of risk posed by terrorist groups. Our analysis reveals how such initiatives and their enforcement are legitimized and grounded in a single discourse embedded with the socially and politically constructed notions of 'dangerousness', 'risk assessment' and 'security'.
Late-modern rehabilitation
Authors: Robinson Gwen
Published: October 2008

In a number of recent analyses, rehabilitation has been portrayed as a casualty of processes of penal transformation, coming to be frequently characterized as 'dead' or 'irrelevant'. This article takes issue with such a characterization in the specific penal context of England & Wales, and seeks to explain why rehabilitation is currently enjoying a renewed legitimacy. The central argument is that rehabilitation, in this jurisdiction, has adapted and survived into the 21st century by transforming and re-marketing itself in important ways. Central to this transformative process has been a successful appeal to three dominant 'late modern' penal narratives: utilitarian, managerial and expressive. It is argued that in the contemporary (Anglo-Welsh) penal context, rehabilitation enjoys legitimacy to the extent that it is compatible with each of these narratives.
Measurement of prison social climate
Authors: Ross Michael W. , Diamond Pamela M. , Liebling Alison , Saylor William G.
Published: October 2008

We review and describe prison climate measurement studies. We compared the factor patterns and stability from three domains of the Prison Social Climate survey (PSC) (Environmental quality of life; Personal well-being; and Safety and security). Stability was compared using randomly split halves of inmate responses from 10 selected US federal prison samples ( n = 950): there were no significant differences. Factor patterns on the same instrument were compared between the US sample and an English purposive sample ( n = 186) of inmates. There were no significant differences between US and English factor patterns, although at a slightly lower level of factor constraint. Factors as factor-scored according to the US factor pattern showed significant differences between the USA and England on the Environmental quality of life scales and the Personal well-being scales, and significant differences on only two of six of the Safety and security dimensions. Data suggest that the PSC is stable within the US sample, and is also stable in its factor pattern between the US and English samples. Prison climate, as measured by the three domains of the PSC selected, appears a stable measure across similar western penal systems and inmate cultures.
The “Jacobsen Flap” for the Treatment of Stages III–IV Dupuytren’s Disease: A Review of 98 Cases
Authors: TRIPOLI M. , MERLE M.
Published: October 2008

The treatment of severe Dupuytren’s disease of the little finger is controversial: several techniques have been described with variable reported results and postoperative complications. This paper reviews 98 cases that underwent surgery between 2001 and 2006 using the Jacobsen flap procedure, a modification of the McCash technique. We found this technique relatively simple and it allowed significant correction of the contracture, with a low rate of complication. We believe this is an excellent alternative to dermofasciectomy or amputation.
The Relative Incidence of Fractures at the Base of the Proximal Phalanx of the Thumb in Children
Authors: AL-QATTAN M. M. , AL-ZAHRANI K. , AL-BOUKAI A. A.
Published: October 2008

There is disagreement in the literature about the most common fracture type at the base of the proximal phalanx of the thumb in children below the age of adolescence. In this prospective study, 58 consecutive children aged 10 years or less with isolated fractures of the base of the proximal phalanx of the thumb were included and their radiographs were reviewed. The study included 38 boys and 20 girls with a mean age of 8 (range 1–10) years. After excluding one patient, in whom the type of fracture could not be determined, the most common fracture in the remaining 57 cases was the Salter–Harris type II fracture (72%), followed by the juxta-epiphyseal type II fracture (18%).
Scaphotrapezial Arthritis after a Carpometacarpal Fusion in a Patient with Marfan’s Syndrome: Case Report
Authors: SZABO R. M. , PETERSON B.
Published: October 2008

We report a case of scaphotrapezial arthritis that developed in a patient with Marfan’s syndrome many years after a carpometacarpal fusion, which placed the thumb metacarpal in adduction. This problem was effectively treated with an abduction/opposition osteotomy, which both increased the patient’s first web space and improved her arthritic symptoms.
Endoscopic Anatomical Nerve Observation and Minimally Invasive Management of Cubital Tunnel Syndrome
Authors: YOSHIDA A. , OKUTSU I. , HAMANAKA I.
Published: October 2008

Experience with the use of the Universal Subcutaneous Endoscope (USE) system in surgical treatment of cubital tunnel syndrome in 35 patients is reported. Patients included in the study had pre- and postoperative clinical and electrophysiological data, and had undergone a minimum follow-up period of 13 months. Mean patient age was 59.5 years and the mean follow-up period was 25.9 months. The operation was performed under local anaesthesia without pneumatic tourniquet and on an out-patient basis. A 1.5 cm portal is made at the cubital tunnel and the USE system is inserted next to the ulnar nerve, first distally and then proximally. The nerve is endoscopically assessed and only the tissue that compresses the nerve is released, in keeping with the principles of minimally invasive treatment. Preoperative tingling sensations disappeared postoperatively in 63% of cases. Pain and sensory disturbance recovered to normal in 92% and 89% of cases, respectively. Abnormal motor nerve conduction velocities improved in 77%. Abductor digiti minimi weakness MMT 0, 1, 2 in 16 hands recovered to MMT 4 or 5 in eight. First-dorsal interosseous weakness in 18 hands recovered to MMT 4 or 5 in seven. There were no complications in this series. The endoscopic approach facilitates inspection of the ulnar nerve so that selective release of the tissue that compresses the nerve can readily be performed. The technique has proven effective in the treatment of cubital tunnel syndrome.