Perioperative cardiac evaluation for noncardiac surgery noninvasive cardiac testing

Prognostic risk stratification to identify perioperative and long-term cardiac risk in selected patients undergoing noncardiac surgery is part of good clinical practice. Exercise variables associated with significant increased risk include poor functional capacity (eg, <4 metabolic equivalents), marked exercise-induced ST segment shift or angina at low workloads, and inability to increase or actually decrease systolic blood pressure with progressive exercise. Approximately 40% of patients tested before peripheral vascular surgery will have an abnormal exercise electrocardiogram (ECG). The predictive value for a perioperative event, ie, death or myocardial infarction, ranges from 5% to 25% for a positive test and 90% to 95% for a negative test. Whereas exercise cardiac imaging is the modality of choice in patients with a noninterpretable exercise ECG, pharmacological stress imaging should be used in the 30% to 50% of patients who require perioperative noninvasive risk stratification and are unable to perform an adequate level of exercise to test cardiac reserve. Myocardial perfusion variables predictive of increased cardiac events include severity of the perfusion defect, number of reversible defects, extent of fixed and reversible defects, increased lung uptake of thallium-201, and marked ST segment changes associated with angina during the test. The reported sensitivity and specificity of dobutamine-induced echocardiographic wall motion abnormalities in patients with peripheral vascular disease is similar to myocardial perfusion scintigraphy, but the confidence limits are wider due to the smaller sample size in these more recent studies. In conclusion, noninvasive cardiac testing should be used selectively in patients undergoing noncardiac surgery; the results provide useful estimates of short- and long-term risk of cardiac events, and the magnitude of abnormal response on noninvasive testing should be used to formulate decisions regarding the need for coronary angiography and subsequent revascularization.     

Pre-operative assessment of cardiac risk for non-cardiac surgery

We describe the cases of two patients who presented with granulocytic sarcoma with mediastinal involvement 15 and 21 months before development of acute myeloid leukemia. In both cases several bone marrow aspirates and trephine biopsy specimens, obtained at presentation and subsequently, revealed no evidence of leukemic infiltration. One case was originally misdiagnosed as large-cell non-Hodgkin's lymphoma, which resulted in inappropriate therapy. In both cases immunohistochemical staining revealed that tumor cells were positive for leucocyte common antigen but not for conventional B- or T-lymphoid-cell markers. Retrospective analysis revealed that tumor cells in both cases were positive for myeloid markers. Histopathologists should be aware that granulocytic sarcoma may occur in unusual extramedullary sites without evidence of bone marrow involvement. If inappropriate treatment is to be avoided, a diagnosis of granulocytic sarcoma should be considered when hemopoietic tumor cells do not stain with conventional antibodies against B- and T-lymphoid cells. Both histochemical and immunohistochemical staining should be performed in such cases to determine whether the cells are of myeloid lineage. A diagnosis of granulocytic sarcoma is not ruled out when bone marrow biopsy specimens show no evidence of leukemic infiltration.     

Cardiac tamponade secondary to chylopericardium following cardiac surgery: case report and review of the literature

Only four instances of isolated chylopericardium following cardiac operation have been reported previously. We encountered this complication in a young patient who was operated on for infundibular pulmonary stenosis. The etiology appears to be related to a combination of intraoperative lymphatic injury and catheter-related subclavian vein thrombosis, the latter potentially elevating pressure within the thoracic duct and thereby resulting in an accumulation of chyle within the pericardial space. Therapy for this problem usually includes partial pericardiectomy with or without ligation of the thoracic duct.     

The evaluation of a sexual assault risk reduction program: A multisite investigation.

This article summarizes the results of the Ohio University Sexual Assault Risk Reduction Project, which is a program designed to reduce college women's risk for sexual assault. The program was evaluated at 2 separate universities with 762 women. Participants were randomly assigned either to the program or to the no-treatment comparison group, and they completed measures that assessed sexual victimization, dating behaviors, sexual communication, and rape empathy at the pretest and at the 2-month and 6-month follow-ups. At the 2-month follow-up, there were no differences between the groups on any of the outcome measures. However, those women who were moderately victimized during the 2-month follow-up were significantly less likely to be revictimized during the 6-month follow-up period if they participated in the program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What is the marginal cost for marginal risk in cardiac surgery?

BACKGROUND: It has been shown that postoperative length of stay (LOS) correlates highly with mortality risk for cardiac surgical procedures. Similar correlations have been found for charges with LOS and costs with risk. METHODS: Postoperative LOS and risk scores were obtained, tabulated, and compiled into the five original Parsonnet risk groups for 2,589 patients who underwent cardiac operations from 1992 through 1996 at one hospital. The correlation of the group mean LOS with the group mean risk was tested. RESULTS: The correlation coefficient was 0.9827; 96.58% of the variance was removed using risk to predict LOS. A calculation of the difference in cost for difference in risk for cohorts of patients is developed. CONCLUSIONS: The high correlation of mean LOS with mean risk permits calculation of marginal cost for marginal risk based on clinical data. The marginal cost is equal to the difference in variable costs for cohorts.     

Behavioral risk reduction for HIV infection among gay and bisexual men: A review of results from the United States.

AIDS education and prevention campaigns have resulted in the most profound modifications of personal health-related behaviors ever recorded. The response of gay and bisexual men to the threat of AIDS can guide other prevention programs once the necessary motivations, impediments, and correlates of this change are better understood. We review and critique the research literature and suggest limitations of existing studies for making inferences about nongay, nonurban, and non-White populations. We recommend increased efforts to understand the role of alcohol and other drugs in AIDS risk behavior and suggest the importance of self-efficacy and social support for initiating and maintaining behavior change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sudden cardiac death in hypertrophic cardiomyopathy: risk evaluation

The pathophysiology of the lamb model of congenital diaphragmatic hernia (CDH) involves pulmonary hypoplasia, pulmonary hypertension, and surfactant deficiency. Inhaled nitric oxide (NO) is a highly selective pulmonary vasodilator. The aim of this study was to determine the effects of inhaled NO on pulmonary gas exchange, acid-base balance, and pulmonary pressures in a lamb model of CDH with or without exogenous surfactant therapy. At the gestational age of 78 days (full term, 145 days) 11 lamb fetuses had a diaphragmatic hernia created via a left thoracotomy and then were allowed to continue development in utero. After cesarean section, performed at term, six lambs received exogenous surfactant therapy (50 mg/kg, Infasurf) and five served as controls. All animals were pressure-ventilated for 30 minutes and then received 80 ppm of inhaled NO at an F1O2 of .9 for a 10-minute interval. Compared with the control lambs, the lambs with exogenous surfactant therapy had higher pH (7.17 +/- .06 v 6.96 +/- .07; P < .05), lower PCO2 (73 +/- 8 v 122 +/- 20, p < .05), and higher PO2 (153 +/- 38 v 50 +/- 23; P < .05). In control CDH lambs (without surfactant), inhaled NO did not improve pH, PCO2, or PO2, or decrease pulmonary artery pressure. In CDH lambs given exogenous surfactant, NO decreased pulmonary artery pressures (42 +/- 4 v 53 +/- 5; P < .005) and further improved PCO2 and PO2. NO also made the difference between pulmonary and systemic artery pressures more negative in the surfactant-treated lambs (-15 +/- 4 v -2.3 +/- 2.4; P < .005).(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac risk and peripheral vascular surgery: new approach based on a multifactorial risk index

To identify the morphological changes of urinary erythrocytes in hematuria objectively, flow cytometrical analysis of fluorescence-labeled erythrocytes was performed. Fifty-one fresh urine samples from 33 hematuric patients (16 with glomerulonephritis and 17 with urological disease) were obtained. Urine erythrocytes were stained with FITC-labeled antihemoglobin antibody, and distinguished from other particles with similar size. Forward scattered light intensity (FW-SC) was used as an indicator of red cell size and right orthogonally scattered light intensity (RT-SC) divided by forward scattering (RT-SC/FW-SC) was used as a marker of cell surface irregularity. The size of erythrocytes expressed by FW-SC was significantly smaller in glomerulonephritic hematuria (101.6 +/- 41.8) than that in urological hematuria (123.5 +/- 44.7). RT-SC/FW-SC was smaller in urological hematuria (1.22 +/- 0.18) in comparison with glomerulonephritic hematuria (1.33 +/- 0.12). These results suggest that erythrocytes in glomerulonephritic hematuria had smaller size and more complex surface structure in comparison with urological hematuria. When cutoff was set at 110 of FW-SC for the criteria of glomerulonephritic erythrocytes, a correct diagnosis was made in 73.3% (22/30) of glomerulonephritic hematuria and in 76.2% (16/21) of nonglomerular hematuria. We clarified more complex morphological changes of glomerulonephritic urinary erythrocytes objectively.     

Spirituality and religion in group counseling: A literature review with practice guidelines.

There has been increased discussion of the need to attend to clients' spirituality and religion as a part of the counseling process, but much of the literature to date has focused on individual counseling. How do the research and resulting practice implications apply to group counseling? This article provides a rationale for attending to spirituality and religion in counseling, explores the opportunities and barriers in attending to spirituality and religion in group counseling, and reviews the literature on the growing number of group interventions with a spiritual or religious focus. The article ends with specific guidelines for when and how to incorporate spirituality and religion into group counseling. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Involving parents in cancer risk reduction: A program for Hispanic American families.

The authors explored changes in dietary behavior, nutrition knowledge, and parental support among inner-city, low-income, Hispanic American families. Thirty-eight families were randomly assigned to receive a 12-week, culture-specific dietary intervention or be in a control group. Results showed that parental support was related to changes in diet, nutrition knowledge, and attendance for both mothers and children. Dietary behavior changes (e.g., reduction in dietary fat) were seen only in the treatment group. Distribution of health-related pamphlets to the control group may have promoted cognitive changes (e.g., increased nutrition knowledge) seen in this low-literacy sample. Further research is needed to document behavioral changes after ethnic-specific interventions and the maintenance of those changes over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A population-based prospective evaluation of risk of sudden cardiac death after operation for common congenital heart defects

1. Ischaemic cardiac preconditioning represents an important cardioprotective mechanism which limits myocardial ischaemic damage. The aim of this investigation was to assess the impact of dichloroacetate (DCA), a pyruvate dehydrogenase complex activator, on preconditioning. 2. Rat isolated hearts were perfused by use of the Langendorff technique, and were subjected to either preconditioning (3 x 4 or 3 x 6 min ischaemia) or continuous perfusion, followed by 30 min global ischaemia and 60 min reperfusion. DCA (3 mM) was either given throughout the protocol (pretreatment), during reperfusion only (post-treatment), or not at all. Throughout reperfusion mechanical performance was assessed as the rate-pressure product (RPP: left ventricular developed pressure x heart rate). 3. In non-preconditioned control hearts, mechanical performance was substantially (P < 0.001) depressed on reperfusion (the RPP after 60 min of reperfusion (RPP(t=60)) was 4,246+/-974 mmHg beats min(-1) compared to baseline value of 21,297+/-1,728 mmHg beats min(-1)). Preconditioning with either 3 x 4 min or 3 x 6 min cycles caused significant protection, as shown by enhanced recovery (RPP(t=60) = 7,818+/-1,138, P < 0.05, and 11,123+/-587 mmHg beats min(-1), P < 0.001, respectively). 4. Addition of DCA (3 mM) to hearts under baseline conditions significantly (P < 0.001) enhanced systolic function with an increased left ventricular developed pressure of 108+/-5 mmHg compared to 88.3+/-3.0 mmHg in the controls. 5. Pretreatment with 3 mM DCA had no effect on recovery of mechanical performance in the non-preconditioned hearts (RPP(t=60) = 3,640+/-1,235 mmHg beats min(-1)) while the beneficial effects of preconditioning were reduced in the preconditioned hearts (3 x 4 min: RPP(t=60) = 2,919+/-1,060 mmHg beats min(-1); 3 x 6 min: RPP(t=60) = 8,032+/-1,367 mmHg beats min(-1)). Therefore, DCA had increased the threshold for preconditioning. 6. By contrast, post-treatment of hearts with 3 mM DCA substantially improved recovery on reperfusion in all groups (RPP(t=60) = 5,827+/-1,328 (non-preconditioned), 14,022+/-3,743 (3 x 4 min; P < 0.01) and 23,219+/-1,374 (3 x 6 min; P < 0.001) mmHg beats min(-1)). 7. The results of the present investigation clearly show that pretreatment with DCA enhances baseline cardiac mechanical performance but increases the threshold for cardiac preconditioning. However, post-treatment with DCA substantially augments the beneficial effects of preconditioning.     

Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study

BACKGROUND: Although antibiotic prophylaxis against infective endocarditis is recommended, the true risk factors for infective endocarditis are unclear. OBJECTIVE: To quantitate the risk for endocarditis from dental treatment and cardiac abnormalities. DESIGN: Population-based, case-control study. SETTING: 54 hospitals in the Philadelphia area. PATIENTS: Persons with community-acquired infective endocarditis not associated with intravenous drug use were compared with community residents, matched by age, sex, and neighborhood of residence. MEASUREMENTS: Information on demographic characteristics, host risk factors, and dental treatment was obtained from structured telephone interviews, dental records, and medical records. RESULTS: During the preceding 3 months, dental treatment was no more frequent among case-patients than controls (adjusted odds ratio, 0.8 [95% CI, 0.4 to 1.5]). Of 273 case-patients, 104 (38%) knew of previous cardiac lesions compared with 17 controls (6%) (adjusted odds ratio, 16.7 [CI, 7.4 to 37.4]). Case-patients more often had a history of mitral valve prolapse (adjusted odds ratio, 19.4 [CI, 6.4 to 58.4]), congenital heart disease (adjusted odds ratio, 6.7 [CI, 2.3 to 19.4]), cardiac valvular surgery (adjusted odds ratio, 74.6 [CI, 12.5 to 447]), rheumatic fever (adjusted odds ratio, 13.4 [CI, 4.5 to 39.5]), and heart murmur without other known cardiac abnormalities (adjusted odds ratio, 4.2 [CI, 2.0 to 8.9]). Among case-patients with known cardiac lesions--the target of prophylaxis--dental therapy was significantly (P = 0.03) less common than among controls (adjusted odds ratio, 0.2 [CI, 0.04 to 0.7] over 3 months). Few participants received prophylactic antibiotics. CONCLUSIONS: Dental treatment does not seem to be a risk factor for infective endocarditis, even in patients with valvular abnormalities, but cardiac valvular abnormalities are strong risk factors. Few cases of infective endocarditis would be preventable with antibiotic prophylaxis, even with 100% effectiveness assumed. Current policies for prophylaxis should be reconsidered.     

Cholesterol reduction and the risk for stroke in men. A meta-analysis of randomized, controlled trials

OBJECTIVE: Reducing serum cholesterol lowers the risk for ischemic heart disease, but its effects on other vascular diseases are unknown. Published trials were reviewed to determine the effect of cholesterol-lowering interventions on fatal and nonfatal stroke. DESIGN: Meta-analysis of randomized, controlled trials. DATA IDENTIFICATION: A literature search of English-language studies examining the effect of modified diets or medications on cardiovascular end points from 1965 to 1992 using MEDLINE and a review of references of five quantitative overviews of cholesterol reduction and coronary disease. DATA ANALYSIS: Thirteen studies met three eligibility criteria: patients randomized to intervention or control; fatal or nonfatal stroke reported separately; and end points assessed without knowledge of treatment status. Heterogeneity among studies and overall effects of treatment on fatal and nonfatal stroke were estimated using the Mantel-Haenszel-Peto method to combine independent study results. The influence of various study designs and interventions was explored using subgroup comparisons. RESULTS: For fatal stroke, the overall odds ratio associated with cholesterol-lowering interventions in 13 trials was 1.32 (95% Cl, 0.94 to 1.86), and the odds ratio for the 10 single-intervention trials was 1.34 (Cl, 0.91 to 1.96). Among eight trials reporting nonfatal events, the summary odds ratio for nonfatal stroke for treated participants compared with controls was 0.88 (Cl, 0.70 to 1.11), and the odds ratio for total strokes was 0.98 (Cl, 0.80 to 1.19). Among three trials using clofibrate, treatment significantly increased the risk for fatal stroke (odds ratio, 2.64; Cl, 1.42 to 4.92) but not for nonfatal stroke (odds ratio, 0.87; Cl, 0.61 to 1.26). Regression analysis showed no statistical association between the magnitude of cholesterol reduction and the risk for fatal stroke. CONCLUSIONS: Lowering serum cholesterol through modified diets or medications does not reduce stroke mortality or morbidity in middle-aged men. Clofibrate appears to increase the risk for fatal strokes, but the mechanism for this effect is unknown.     

Heart reduction surgery: an analysis of the impact on cardiac function

OBJECTIVES: Reports of improved ejection fraction, coupled with decreased filling pressures, have prompted a number of centers to begin evaluating the efficacy of heart reduction surgery to ameliorate symptoms of heart failure. However, the impact of this operation on cardiac mechanics is unknown. We applied a multiple compartment elastance model to simulate the effects of excising cardiac mass on heart function. METHODS: The left ventricle was divided into two functional compartments to simulate excision of part of the wall. At multiple increments of mass reduction, the resulting end-systolic elastance, ejection fraction, stroke volume, end-diastolic pressure and volume, and diastolic stiffness were determined. RESULTS: Changes in systolic function were accompanied by offsetting changes in diastolic function; consequently, overall pump function (the Frank-Starling Relationship) was found to be depressed. The geometric rearrangement associated with this operation leads to a reduction in wall stress for a given level of pressure generation, thus implying an increase in the efficiency with which wall stress is transduced into intraventricular pressure. CONCLUSIONS: Overall pump function is depressed in the short run after heart reduction surgery. However, on the basis of theoretic arguments, heart reduction surgery may have long-term beneficial implications. Importantly, this analysis revealed that changes in parameters of ventricular function have different implications during heart reduction surgery than when such changes are observed with inotropism caused by acute pharmacologic therapy.     

A randomized trial of a brief HIV risk reduction counseling intervention for women.

There is an urgent need for the development and implementation of effective and feasible behavioral HIV and STD interventions. The purpose of the present randomized controlled trial was to evaluate the effectiveness of a single-session, skill-based sexual risk reduction intervention for women. Participants were assessed at baseline and at 1 month and 3 months following the intervention on measures of AIDS knowledge, behavioral intentions, self-efficacy, and sexual risk behavior. Compared with women in an AIDS-education-only condition, women receiving the skill-based intervention reported significantly higher rates of condom use at 3-month follow-up. Results suggest that brief sexual risk reduction programs are feasible and effective within a community setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Strategies for reduction of anthracycline cardiac toxicity

The term 'periventricular leukomalacia' (PVL) usually covers necrotic and/or gliotic lesions from perinatal origin occurring in the periventricular ring of telencephalic white matter. PVLs are found post-mortem in one third of brains from autopsies of premature infants; PVLs are diagnosed in 4 to 10% of infants born before 33 weeks of gestation and remaining alive more than 3 days after birth. PVL is very rare in at term infants. The proportion of PVLs from prenatal origin is estimated between one third and one half of cases. Recent progresses in neuroepidemiology, developmental neurobiology and imaging methods permit to revisit the pathophysiology of PVLs on a multifactorial basis. The final result of these multiple factors seem to be calcium influx due to glutamatergic overactivation triggered by cytokines, infection and inflammation, and deficit in neurotrophic factors. Periventricular topography can be explained by properties of intracerebral vascular wall at this stage of angiogenesis and by perfusion failure/hypoxia.     

The prevention of adhesions in surgery. A clinical review and experimental contribution

Induction of apoptosis in human monocytic THP.1 cells by etoposide or N-tosyl-L-phenylalanyl chloromethyl ketone resulted in release of mitochondrial cytochrome c, formation of ultracondensed mitochondria, development of outer mitochondrial membrane discontinuities and a reduction in mitochondrial membrane potential (delta psi m), as well as externalisation of phosphatidylserine, caspase-3 and -7 activation, proteolysis of poly(ADP-ribose) polymerase and lamin B1. The caspase inhibitor, benzyloxycarbonyl-Val-Ala-Asp (OMe) fluoromethyl ketone inhibited all these ultrastructural and biochemical characteristics of apoptosis except for the release of cytochrome c. Release of mitochondrial cytochrome c was a late event in non-apoptotic cell death occurring after commitment to cell death and without caspase activation. Thus apoptosis is characterised by release of mitochondrial cytochrome c prior to formation of ultracondensed mitochondria and a reduction in delta psi m and by a mechanism independent of rupture of the outer mitochondrial membrane.