The role of echocardiography in the diagnosis of infectious endocarditis

Echocardiography is irreplaceable in the diagnosis of infectious endocarditis. If in easily examined patients transthoracic examination suffices, in all other cases transoesophageal echocardiography is essential. It is important to emphasize the importance of searching carefully for complications, of assessment of the patient's risk and whether it is suitable to repeat the examination during treatment.     

The current course and treatment of infectious endocarditis

Clinical study of 172 patients treated in the Burdenko Military Hospital for subacute infectious endocarditis in 1980-1996 compared with 192 cases in 1950-1979. Contemporary course of the disease is attended by a few symptoms, primordiality and single-valve affection. On the grounds of antibiotics sensitivity of the most prevalent infection agents discovered in 1996, the article develops some schemes of antibacterial therapy for Streptococcus, Enterococcus and staphylococcal etiology of disease. Rational antibiotic therapy together with surgery measures reduced lethality to 14.3% for Streptococcus endocarditis, to 16.7%--for Enterococcus and to 34.4%--for Staphylococcus.     

The role of echocardiography in preoperative diagnosis of cardiac risk in patients before non-cardiac surgical interventions

Echocardiography is a noninvasive method for cardiac evaluation. A review of the current literature shows that the routine use of echocardiography for assessing perioperative cardiac risk in patients undergoing noncardiac surgery can not be supported. Only patients with suspected relevant heart valve diseases, acute heart failure, cardiomyopathy or condition after heart or heart-lung transplantation may benefit from preoperative echocardiography. In patients with suspected or proven coronary artery disease stress echocardiography offers the most relevant additional information for the anaesthesiologist. However, because of the high financial and personal implications it should be reserved to those patients who are not able to perform a normal stress test. Besides in patients in whom transthoracic echocardiography doesn't offer sufficient information or is not possible transesophageal echocardiography plays only a minor role in preoperative cardiac evaluation.     

Transesophageal echocardiography diagnosis of perforation of the mitral valve secondary to infective endocarditis

We report on a patient with infective endocarditis and severe mitral regurgitation secondary to perforation in the base of the posterior mitral leaflet. Transthoracic echocardiography was inconclusive. Only transesophageal echocardiography could confirm the presence of vegetations, their characteristics and the existence of valvular perforation. We also review the literature on the contribution of transesophageal echocardiography to the diagnosis of infective endocarditis and its complications.     

The Epstein-Barr virus in patients with infectious endocarditis

Serological markers of Epstein-Barr virus (EBV) infection has been investigated in 28 patients with infectious endocarditis. In 75% of patients IgM antibodies to "early" antigen of the virus which are the marker of active viral infection occurred vs 6.2% among healthy blood donors. Specific for infectious endocarditis reaction profile (anti-EBV combination in one person) indicates reactivation of latent viral infection. The conclusion is made on the necessity of further investigation of both the role of EBV in pathogenesis of pyoseptic diseases and immunologic mechanisms for reactivation of latent viral infections.     

The current surgical treatment of primary malignant melanoma of the skin

In our Department, between 1991 and 1996, 132 patients, there of 87 male-45 female, average age of 48.2 years underwent surgery because of stage 1 (T2) to stage 3 melanoma that was located on the skin. None of patients suffered from early or in situ melanoma. Our retrospective study was based on those 94 patients who had been followed up by Department or dermatology-oncology in our medical centre. Surgery is still the primary treatment for cutaneous malignant melanoma. Thin melanomas (up to 2 mm in thickness) can be excised with 2 cm margins. Whether this is also true for thicker melanomas is not known and the only way to obtain more knowledge is to participate in prospective randomised studies. Elective lymph node dissection is associated with significant morbidity which includes lymphedema, wound complications and paresthesias of the extremity. For this reason we use an alternative operative approach uses selective lymphadenectomy with identification of the sentinel node.     

The clinical significance of disorders in the hemostatic system in infectious endocarditis

AIM: Study of blood clotting to evaluate hemostatic disorders in infectious endocarditis (IE). MATERIALS AND METHODS: The trial included 124 patients with IE (61 males and 63 females aged 15-70 years). Primary and secondary IE was in 38 and 62% of patients, respectively. RESULTS: Clinically evident hemostatic disorders were observed in 93(74.2%) cases. They manifested as intravascular platelet activation with development of hypercoagulatory status and chronic DIC-syndrome. CONCLUSION: A differentiated approach is advisable to correction of thrombotic disorders in IE basing on the severity of blood coagulation impairment.     

The specifics of diagnosis and surgical treatment of traumatic pneumocephalus

Traumatic pneumocefalus (TPC)--complication of severe craniocerebral injury--occurs, as a rule, in fractures, line of which is coming across the air-containing sinuses of the skull base. Depending on the air localization subarachnoidal, subdural, epidural, ventricular, clinically asymptomatic and strained forms of TPC are discerned. TPC diagnosis is based on taking into account the clinico-neurological and radiological examination peculiarities. In the acute craniocerebral injury period surgical treatment for parabasal injuries is directed on the skull cavity hermetization and for TPC--the valve mechanism abolition, liquorous fistula closure, the air tumor emptying and intracranial space hermetization. Presence of strained progressing TPC constitutes the life perilous indication for surgical intervention.     

The current role of radiotherapy in the treatment of invasive bladder cancer

Invasive bladder cancer remains a therapeutic challenge. Approximately 50% of patients treated with radical cystectomy die of metastatic disease. External beam radiation therapy when given alone has results inferior to that of surgery, and although it has shown some benefit when given in the preoperative setting, this was not verified by randomized trials. Altered fractionation radiation schemes and combined modality using a cisplatin-based combination chemotherapy with radiation have resulted in up to 60% bladder preservation.     

Rare and atypical manifestations of infectious endocarditis

Along with typical clinical symptoms in present-day infectious endocarditis atypical picture may arise: impairment of CNS and cardiac muscle with psychosis, arrhythmia, defective cerebral circulation, heart failure. In the absence of typical manifestations diagnosis of infectious endocarditis presents difficulties.     

Perivalvular abscess complicating infective endocarditis: complementary role of echocardiography and indium-111-labeled leukocytes

A 49-year-old black man with hypertension-induced chronic renal failure requiring hemodialysis and a history of arteriovenous access graft infection was admitted with Staphylococcus aureus sepsis, dyspnea, and peri-incisional erythema over his arteriovenous graft fistula. Results of a transthoracic echo demonstrated aortic sclerosis and concentric left ventricular hypertrophy. Results of a whole-body In-111 white cell (WBC) scan were negative over the arteriovenous graft site; however, an intense abnormal focus of labeled WBCs was evident to the left of the sternum. A subsequent transesophageal echocardiogram showed a mixed cystic-solid calcified mass adjacent the left aortic cusp. Surgery confirmed a perivalvular abscess. As a whole-body imaging modality, the In-111 WBC scintigram indicated the true location of the infectious process responsible for the patient's sepsis. The combination of echocardiography and radiolabeled WBC imaging increases sensitivity for detection of endocarditis/perivalvular abscess. Radiolabeled WBC imaging is more efficacious for monitoring therapy because the echocardiogram often does not change with treatment of endocarditis/perivalvular abscess.     

Value and limitations of transesophageal echocardiography in infective endocarditis

Echocardiography has contributed considerably to the evolution in the management of patients with infective endocarditis. There is a clear hierarchy with respect to sensitivity of the different methods is superior when compared to 2-D and M-mode echocardiography in identifying both vegetations and perivalvular complications e.g. abscess formation, aneurysms, mural endocardial lesions. For patients with suspected endocarditis, in whom vegetations can not be clearly identified or in whom abscess formation is suspected with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) with mono- or multiplane scans has become the standard diagnostic procedure. For the examination of prosthetic valves it is the method of choice. It has even been suggested that it is employed as routine measure in all patients with suspected infective endocarditis. TEE is a safe semi-invasive technique with an extremely low complication rate and high sensitivity. Its specificity depends largely on the patient group which is examined. In patients with indicative clinical symptoms the specificity and the predictive value of vegetations are high. When used as screening method to assess echodense formations at cardiac valves particularly in the elderly, in whom degenerative changes prevail, its specificity and positive predictive value of vegetation-like structures are much lower. The negative predictive value of a negative transesophageal echocardiogram remains high, however. Valve abscesses are detected rarely by transthoracic echocardiography. It is the domain of TEE to assess them particularly in the aortic and mitral valve area. For them the specificity and positive predictive value of TEE in the diagnosis of infective endocarditis is high again. Of further importance was the observation that patients with vegetations of > 10 mm were more likely to suffer embolic complications. It should be noted, however, that infective endocarditis remains a clinical diagnosis: neither is the demonstration of a vegetation already the equivalent of endocarditis, nor does missing vegetations completely rule out the possibility of it. But without doubt, the presence of vegetations, of abscess formation or a concomitant pericardial effusion add valuable information to clinical diagnosis of infective endocarditis, which still needs a "high index of suspicion".     

The role of powered instrumentation in the surgical treatment of allergic fungal sinusitis

Allergic fungal sinusitis is a chronic disorder that is being more frequently recognized by otolaryngologists. It is a recurrent illness characterized by frequent exacerbations, and requires aggressive medical and surgical treatment. When surgical therapy is employed, it is necessary to ensure adequate debridement and removal of edematous tissue. We have been using powered dissection as our primary method in sinus surgery over the past three year. We have treated 11 patients with allergic fungal sinusitis, and find powered instrumentation to be very effective in removing the polypoid tissue from the nose and sinuses, and in providing a clear surgical field. The procedure can be performed safely with minimal trauma to normal tissue. We believe that the use of powered dissection greatly enhances the comprehensive treatment of allergic fungal sinusitis.     

The role of laparoscopy in the diagnosis and treatment of abdominal pain syndromes

BACKGROUND: Diagnostic laparoscopy plays a significant role in the evaluation of acute and chronic abdominal pain in the era of therapeutic laparoscopic surgery. METHODS: We referred to our personal series of laparoscopy for both acute and chronic abdominal pain. This is a retrospective review of data accumulated prospectively between 1979 and the present. RESULTS: In our series, 387 consecutive patients underwent laparoscopy because of abdominal pain. In a group of 121 patients with acute abdominal pain, a definitive diagnosis was made in 119 cases (98%). Two patients needed laparotomy to confirm the diagnosis; both had a disease process that did not require laparotomy to treat. A definitive therapeutic laparoscopic procedure was performed in 53 cases 944%). In 45 patients (38%), a diagnosis was made that did not require therapeutic laparoscopy or laparotomy to treat. In the remaining 21 patients (17.5%), exploratory laparotomy was needed to treat the condition. In a chronic abdominal pain group of 265 patients, the etiology was established laparoscopically in 201 cases (76%). A definitive therapeutic laparoscopic procedure was performed in 128 patients (48%). There was a normal laparoscopic examination in 64 patients (24%). There was one false negative laparoscopy that required laparotomy to treat 1 month later. CONCLUSIONS: Laparoscopy is an accurate modality for the diagnosis of both acute and chronic abdominal pain syndromes. These data support the use of laparoscopy as the primary invasive intervention in patients with acute and chronic abdominal pain.     

Viral croup: current diagnosis and treatment

Viral croup, a common illness in children, manifests with noisy, labored breathing. Parainfluenza viruses are the most common cause of croup; however, other causes including epiglottitis and bacterial tracheitis should be considered in the differential diagnosis. The diagnosis is primarily based on clinical findings; imaging studies may be useful in selected cases. Although most children recover from this self-limited illness with only minimal medical intervention, some are severely affected by laryngeal swelling and require respiratory support with analgesics, cool mist, corticosteroids, nebulized epinephrine, heliox, and, rarely, intubation. In this article, the current diagnostic and management strategies for viral croup are summarized.     

The strategy and current potentials of parenteral feeding in surgery

Based on the literature data the author analyzes the potentials, indications and principles of the parenteral alimentation of surgical patients. Possible complications and measures for their prevention are discussed.