Value of routine pre-operative chest X-ray in patients over the age of 40 years

The overall usefulness of routine chest X-ray, its cost benefit ratio and effect on anaesthetic management in patients over the age of 40 years was assessed. Four hundred and seventy-seven consecutive patients undergoing elective non-cardiopulmonary surgery with no cardiopulmonary diseases, having a routine preoperative chest x-ray were selected at the Aga Khan University Hospital, Karachi. Twenty five (5.2%) were excluded from the study as their chest x-ray were not available at the time of surgery. Twenty eight (8.3%) below and 33 (28.7%) above 60 years of age had abnormalities in chest x-ray but the difference in cardiac abnormalities in two age groups was insignificant. The frequency of lung field abnormalities increased with age from 3.2% in less than 60 to 15.6% in patients above 60 years of age. The difference in frequency of occurrence of lung field abnormalities was statistically significant in case of lung abnormalities. Only one case required change in anaesthetic management based on routine preoperative chest x-ray. Our study showed that the incidence of significant lung field abnormalities increased in patients aged 60 years and above with no history of chronic obstructive airway disease. We recommend routine preoperative chest x-ray be carried out only in patients over the age of 60 years.     

Evaluation of routine postoperative chest X-rays in the management of the cardiac surgical patient

OBJECTIVES: To evaluate the role of routine chest X-rays in the management of patients post cardiac surgery. METHODS: 340 adult patients undergoing cardiac surgery were studied in three consecutive groups (A, B, C) of 100 patients each. Forty patients were excluded due to the intensive care stay greater than 36 h (n = 35), or early mortality within 36 h (n = 5). Routine chest X-rays were performed according to different protocols in Groups A and B. In group C there were no routine chest X-rays during the entire postoperative period [corrected]. In all three groups chest X-rays were performed where clinically indicated. Group A had three routine chest X-rays post-operation. Group B had one routine chest X-ray on day 4 post-operation. Group C had chest X-rays only when indicated. The X-rays were evaluated in terms of their assistance value and the resultant number of interventions. RESULTS: The three groups were similar preoperatively for age, sex, preoperative left ventricular function, presence of chronic obstructive airway disease and type of operation performed. The total number of chest X-rays in groups A, B and C were 304, 133 and 36, respectively. The number of chest X-rays leading to interventions were five, four and four in groups A, B and C, respectively. Chest X-rays that helped in management were 36, 28, and 28, respectively, in the same groups. There was no mortality or morbidity attributable to non-performance of routine chest X-ray. CONCLUSIONS: Routine chest X-rays post-cardiac surgery are of very little value and patients are adequately managed by performing chest X-rays only when clinically indicated. There was no increased mortality or morbidity attributed to lack of routine chest X-rays in any of these groups. We recommend performing chest X-rays only when clinically indicated in satisfactorily recovering adult cardiac surgical patients.     

Interobserver variability in the interpretation of chest roentgenograms of patients with possible pneumonia

BACKGROUND: Previous studies have found considerable interobserver variability in the roentgenographic diagnosis of pneumonia. In this study we determined the impact of experience on interobserver variability in the interpretation of chest roentgenograms of patients with pneumonia and defined the characteristics of chest roentgenograms interpreted as pneumonia by all groups. METHODS: The chest roentgenograms of 15 consecutive patients with a clinical and roentgenographic diagnosis of pneumonia were read by a convenience sample of 10 first-year and 20 fourth-year medical students, 21 medical residents, and 21 staff physicians from the department of medicine. Three board-certified radiologists served as the gold standard. The majority rule decision and logistic regression analysis were used to analyze agreement among the various groups of observers. RESULTS: Agreement with the majority decisions of the gold-standard radiologists on the presence or absence of pneumonia for all observations of the various groups were as follows: original radiologist, 87%; first-year medical students, 59%; fourth-year medical students, 54%; medical residents, 66%; and attending staff, 72%. Chest roentgenograms with dense lobar or segmental opacities were generally interpreted as pneumonia by all observers. Patchy opacities caused major disagreements and were usually read as not being due to pneumonia. Bronchopneumonia was not diagnosed by any of the observers. Air bronchograms, atelectasis, and chronic obstructive lung disease were usually not recognized by the nonradiologists. CONCLUSIONS: There is considerable interobserver variability in the roentgenographic diagnosis of pneumonia. This variability does not improve with increasing experience. Dense lobar or segmental opacities are uniformly recognized as pneumonia while patchy opacities result in a variety of interpretations.     

Improving in-training evaluation programs

OBJECTIVES: Radical vulvar surgery is associated with significant morbidity. DESIGN: The aim of the study was to assess retrospectively the feasibility of less extensive surgery in vulvar cancer patients operated in our institution with radical intent. The feasibility of less extensive surgical procedures was investigated, based on the retrospective analysis of preoperative assessment of tumour location and extent in a group of 162 patients. RESULTS: In the next step, the pathology reports of actually performed extensive operations were carefully reviewed in a search of microscopic evidence of tumour outside the limits of proposed conservative procedures. Conservative surgery was regarded technically possible in 127 patients (85.8%). Macro- or microscopic multifocality was detected in 22 patients (14.9%), of whom in 15 cases conservative surgery was regarded possible on the basis of clinical assessment. However, only in 11 cases tumour was found outside the limits of planned excision, in 9 of those cases--due to multifocal lesions. CONCLUSIONS: Less extensive surgery is technically feasible in a vast majority of vulvar cancer patients, however the selection for conservative procedures based only on clinical assessment of tumour extent is not sensitive enough to assure radical treatment in all patients and better methods of preoperative evaluation, such as vulvoscopy or random vulvar biopsies need to be investigated before the decision on routine use of conservative surgery is made.     

Role of lung perfusion scintigraphy in relation to chest computed tomography and pulmonary function in the evaluation of candidates for lung volume reduction surgery

Lung perfusion scintigraphy is employed to evaluate patients with severe emphysema who are candidates for lung volume reduction surgery (LVRS). Our purpose was to investigate the role of scintigraphy in relation to chest computed tomography (CT) and lung function in this setting. Six observers blinded to clinical data retrospectively scored preoperative scintigrams of 70 patients undergoing bilateral video-assisted LVRS according to the distribution of lung perfusion as homogeneous, intermediately heterogeneous, or markedly heterogeneous. Heterogeneity of emphysema distribution was also assessed by chest CT. Dyspnea and pulmonary function were measured preoperatively and 3 mo postoperatively. In 42 patients with markedly heterogeneous, in 18 with intermediately heterogeneous, and in 10 with homogeneous perfusion, mean (+/- SE) FEV1 increased by 57 +/- 8% (p < 0.0001), 38 +/- 9% (p < 0.001), and 23 +/- 9% (p = NS) (p = NS for intergroup comparisons). In a multiple regression analysis, functional improvement after LVRS was more closely correlated with preoperative hyperinflation and the degree of emphysema heterogeneity estimated by chest CT than with the degree of perfusion heterogeneity assessed by scintigraphy. In 16 of 22 patients with homogeneous emphysema distribution in the chest CT scintigraphy revealed intermediately or markedly heterogeneous perfusion. We conclude that lung perfusion scintigraphy has a limited role in prediction of outcome, but it may help to identify target areas for resection in LVRS candidates with homogeneous CT morphology.     

Evaluation of current practices in routine preoperative crossmatching for transurethral resection of the prostate

Increasing demand for blood during elective surgery has led to attempts to rationalize routine preoperative crossmatching to those operations when there is a reasonable (greater than 30%) chance of it being required. Results of a questionnaire returned by 86% of the urology units in Great Britain show that 41% continue to crossmatch 2 units of blood before transurethral prostatectomy. A review of 301 transurethral prostatectomies performed with preoperative grouping and saving of blood showed that only 11% of the patients required transfusion. The need for transfusion was significantly associated with presentation in chronic or acute on chronic retention (p < 0.01), and the operative factors of weight of resection (p < 0.0001) and degree of hemostasis (p < 0.001). Therefore, a policy of routine preoperative blood grouping and saving is safe, and could be widely adopted, leading to financial saving and a decrease in wastage of blood that becomes too old to use.     

Role of kinins in basal and furosemide-stimulated renin secretion

OBJECTIVE: To determine risk factors predictive of outcomes to aid in the cost-effective preoperative evaluation and postoperative management of patients who are undergoing tonsillectomy and adenoidectomy for obstructed breathing during sleep. DESIGN: A historical cohort study with a nested case-control analysis that examined risk factors associated with postoperative respiratory complications. SETTING: Children's Medical Center of Dallas, Dallas, Tex, which is a pediatric referral hospital for secondary and tertiary pediatric care with both private and university-appointed physicians. PATIENTS: A convenience sample of 355 patients who were undergoing tonsillectomy and adenoidectomy for obstructed breathing during sleep throughout a 1-year period. INTERVENTION: None. MAIN OUTCOME MEASURE: The occurrence of postoperative complications, including airway obstruction, apneas with oxygen desaturations, airway interventions (e.g., endotracheal intubation), or administration of supplemental oxygen, as they related to associated medical conditions (e.g., cerebral palsy or prematurity) and diagnostic tests (e.g., chest x-ray film and electrocardiogram). RESULTS: Five associated medical conditions (cerebral palsy; seizures; age, < or = 3 years; congenital heart disease; and prematurity) were identified as important predictors of a complicated postoperative course using stepwise logistic regression analysis. Those children with an abnormal chest x-ray film or electrocardiogram were also identified as having an associated medical condition that was predictive of postoperative complications. CONCLUSIONS: Children with 1 or more of the associated risk factors identified should be considered candidates for postoperative inpatient observation. A preoperative chest x-ray film and electrocardiogram were found to be of little predictive value, and they are probably not cost-effective screening tests for postoperative respiratory complications.     

Granulosa and theca cell tumors in children: a report of 17 cases and literature review

OBJECTIVE: To identify preoperative and perioperative features that may lead to a risk of surgical-site infection (SSI) after coronary artery bypass surgery. DESIGN: 884 patients who underwent coronary artery bypass grafting in 1992 and 1993 were studied. The associations between 23 preoperative and perioperative features and the presence of SSI at the donor site or in the chest area were evaluated by univariate analysis followed by multivariate logistic regression analysis. SETTING: A university hospital. RESULTS: 172 patients (19.5%) either had an SSI recorded before discharge or had received antibiotics prescribed for a suspected SSI during the 1-month surveillance period after discharge. Multivariate logistic regression analysis showed an extreme body mass index (BMI; P=.015), female gender (P=.023), and chronic obstructive pulmonary disease (COPD; P=.030) to be independent risk features for SSI. The donor site was infected in 136 patients (15.4%), an event for which female gender (P=.003) was the only independent risk feature. Forty-seven patients (5.3%) had an SSI of the chest area, with diabetes (P=.003) and extreme BMI (P=.010) as independent risk features. CONCLUSION: Extreme BMI, female gender, and COPD are highly significant independent predictors of the development of SSI. Female gender is a risk feature specifically for SSI at the donor site, whereas diabetes and extreme BMI predict it in the chest area.     

Reactive derivatives of phosphorothioate oligonucleotide analogues. II. Properties of phosphorothioate oligodeoxyribonucleotide derivatives containing an aromatic residue of nitrogen mustard gas

STUDY OBJECTIVE: To evaluate current practice in preoperative testing of healthy children undergoing elective surgery that is not expected to result in significant blood loss. DESIGN: Survey of members of the Society for Pediatric Anesthesia. SETTING: Anesthesiologists practicing in North America. POPULATION: A total of 1,200 questionnaires were mailed. INTERVENTIONS: Questionnaires were mailed to all members of the Society for Pediatric Anesthesia. All members were asked to specify which tests were routinely performed and to state why. Specific questions were asked about performing complete blood count (CBC), hemoglobin (Hb), hematocrit (Hct), and urine analysis (UA) in all patients, pregnancy test in adolescents, prothrombin time (PT) and activated partial thrombin time (PTT) prior to tonsillectomy, and sickle cell testing in black and/or Mediterranean children. MEASUREMENTS AND MAIN RESULTS: 685 of 1,200 (57%) questionnaires were returned. No attempt was made to identify and follow-up with nonresponders. Hb testing is routinely performed in 27% to 48% of the children depending on the age of the patient. UA is ordered preoperatively in less than 15% of the children. Pregnancy test was ordered by 43% of the respondents. Hemostatic tests prior to tonsillectomy were conducted by 45% of the anesthesiologists. CONCLUSION: The results indicate the present practice of routine preoperative laboratory testing for children undergoing elective outpatient surgery. In spite of the many studies that indicate no specific benefits of performing routine preoperative testing in healthy children undergoing scheduled surgery, many physicians continue to order these tests in all such children.     

Cost-effectiveness of preoperative localization studies in primary hyperparathyroid disease

OBJECTIVE: To evaluate the effect of preoperative localization studies on the surgical management of patients with primary hyperparathyroid disease (PHPT). SUMMARY BACKGROUND DATA: Reported cure rates of initial surgical exploration for PHPT are close to 95%. Preoperative localization studies are frequently obtained to improve surgical success and decrease operative time. METHODS: Initial cervical exploration was performed in 113 patients with PHPT from 1981 to 1993. Twenty-four patients (21%) had surgery without preoperative localization studies. The remaining 89 patients (79%) had 132 noninvasive preoperative localization studies. Success of the localization studies in tumor localization, pathologic findings, postoperative serum calcium levels, and operative times were compared. Patient costs of the studies were calculated. RESULTS: Disease was identified during operation in 23 of 24 patients (96%) having cervical exploration without preoperative localization studies, and they had normal calcium levels after surgery. Eighty-seven of 89 patients (98%) having preoperative localization studies were surgically cured. The highest sensitivity rate (60%) and highest positive predictive value (79%) of the localization studies were found with thallium-technetium scintiscanning. Average cost of the localization studies was $901 per patient. Combination studies were obtained in 32 patients at an average cost of $1,314 per patient without improving sensitivity. Mean operating time did not differ for localized and nonlocalized patients. CONCLUSIONS: Preoperative localization studies did not improve parathyroid localization or cure rate and did not substantially shorten operating time in initial cervical exploration for PHPT. The economic burden of routine preoperative localization studies in these patients is not justified.     

A prospective evaluation of the value of preoperative laboratory testing for office anesthesia and sedation

PURPOSE: The purpose of this investigation was to determine whether routine laboratory testing affected the clinician's preoperative evaluation and decision-making process for patients undergoing general anesthesia or intravenous sedation in the oral and maxillofacial surgery office. PATIENTS AND METHODS: This was a prospective evaluation of the records of 458 who required an office general anesthetic or intravenous sedation for routine dentoalveolar surgery. The patients ranged in age from 15 to 54 years and were categorized as American Society of Anesthesiologists Classification I or II. Fifty-two percent were female. All patients underwent a history and physical examination, complete blood cell count, and urine analysis. Female patients were tested for pregnancy by measuring the serum beta human chorionic gonadotropin level. All patients older than 40 years of age were further evaluated by posterior-anterior and lateral chest radiographs, as well as electrocardiography. On the day of surgery, the data were reviewed and analyzed, and specific components of the history were reassessed. The results of the decision-making process were evaluated by one investigator. RESULTS: From the 458 patients initially enrolled, 78 failed to return on the appointed day. Of the 235 patients requiring general anesthesia who did return on the appointed day, five had aberrant laboratory values (2%). These consisted of one patient with a low hematocrit, one with a low red blood cell count, one with a low white blood cell count, and two with a urine analysis positive for blood. No procedure was canceled based on the aberrant data. Of the 145 patients requiring intravenous sedation who did return on the appointed day, six had aberrant laboratory values (4%). Two patients exhibited elevated white blood cell counts, two possessed low red blood cell counts, one known to have diabetes had an elevated urine glucose, and one patient with an elevated human chorionic gonadotropin level realized that her menstrual cycle was delayed. The latter two patients had their procedures deferred. CONCLUSIONS: Based on the results of this study, a good history and physical examination and then reassessment of key portions of the history were the major factors in the development of the anesthetic treatment plan. Laboratory data had little if any effect on the decision-making process.     

Radiotherapy in Ewing's sarcoma and PNET of the chest wall: results of the trials CESS 81, CESS 86 and EICESS 92

PURPOSE: Treatment results and the pattern of relapse were evaluated in the multimodal treatment of Ewing's sarcomas of the chest wall. METHODS AND MATERIALS: In a retrospective analysis, 114 patients with non-metastatic Ewing's sarcoma of the chest wall were evaluated. They were treated in the CESS 81, CESS 86, or EICESS 92 studies between January 1981 and December 1993. The treatment consisted of polychemotherapy (VACA, VAIA, or EVAIA) and local therapy, either surgery alone (14 patients), radiotherapy alone (28 patients) or a combination of both (71 patients). The median follow-up was 46.6 months (range 5-170). A relapse analysis for all patients with local or combined relapses was performed. RESULTS: Overall survival was 60% after 5 years, event-free survival was 50%. Thirty-seven patients had a systemic relapse (32.4%), 11 patients had a local relapse alone (9.6%), and 3 patients had a combined local and systemic relapse (2.6%). The risk to relapse locally after 5 years was 0% after surgery alone, 19% after radiation alone, and 19% after postoperative irradiation. None of the 8 patients with preoperative irradiation have failed locally so far. With the introduction of central radiotherapy planning in CESS 86, local control of irradiated patients improved. Ten of 14 patients with local failure could be evaluated in the relapse analysis: 3 patients had an in-field relapse, 4 patients had a marginal relapse, 2 patients had a relapse outside the radiation fields, and 1 patient failed with pleural dissemination. Six treatment deviations were observed. CONCLUSION: Local control was best after surgery alone in a positively selected group of patients. Local control after radiation or combined radiation and surgery was good. With diligent performance of radiotherapy, it will be possible to further improve the results in the radiotherapy group.     

Anterior discectomy and fusion for painful cervical disc disease. A report of 50 patients with an average follow-up of 21 years

STUDY DESIGN: This is a retrospective long-term clinical and roentgenographic review of 50 patients who underwent anterior discectomy and fusion for painful cervical disc disease. The patients were reviewed by the senior author. OBJECTIVE: To evaluate the long-term effectiveness of anterior cervical discectomy and fusion and identify clinical and roentgenographic factors that may increase the chances of recurrent problems. SUMMARY OF BACKGROUND DATA: Many studies have demonstrated the initial effectiveness of this procedure; however, there are no previously published reports that include the results of a 21-year follow-up period. METHODS: Office charts and hospital records were used to obtain information about diagnosis, surgery, and complications. On follow-up examination, all patients were interviewed and examined, and roentgenograms were obtained. RESULTS: Forty-eight patients had initial pain relief, and of these, 32 remained pain-free an average of 21 years after surgery. Sixteen had recurrent pain an average of 7.2 years after surgery. Eight of these required surgery for disc disease at an adjacent level. The abrupt onset of pain was the only clinical or roentgenographic factor that correlated with recurrent pain. CONCLUSION: Anterior cervical discectomy and fusion yield excellent initial results. However, patients must be cautioned that recurrent symptoms can occur, and, in a small percentage of patients, the symptoms may be severe enough to require additional surgery.     

Comparison of routine and selective endoscopic retrograde cholangiography before laparoscopic cholecystectomy

To evaluate the role of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy, we compared the frequency of concomitant common bile duct stones, their clinical outcome, and the frequency of bile duct injury between a group of 128 patients with routine preoperative ERC (group A) and 1010 patients with selective ERC (group B). Overall, 48 patients (4.2%) had duct stones, but the predictive signs were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 37 patients in group B, 22 were diagnosed by selective ERC and underwent endoscopic removal. Of four patients whose stones were found by operative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphincterotomy, which failed in one. The stones were not recognized until pain recurred in the remaining 11 patients. Sphincterotomy was successful in nine patients but failed in the other two. Thus postoperative sphincterotomy failed in 3 of 13 patients (23%), necessitating open surgery. Forty-two patients overall (3.7%) had aberrant biliary tract anatomy, which did not lead to bile duct injury in any of the patients. Morbidity of routine ERC (3.1%) was lower than that of selective ERC (7.4%) (p < 0.05). It should be noted that a certain proportion of duct stones may be missed by selective ERC, necessitating laparotomy when sphincterotomy fails. The routine use of preoperative ERC may be justified at institutions where the expertise is available, at least until laparoscopic lithotomy becomes easy.     

Impaired mobility: Guillain-Barré syndrome

Blood endotoxin concentrations measured in 57 patients with digestive disorders pre- and postoperatively, were found to peak one day after surgery, then gradually return to the preoperative level. The plasma endotoxin concentration was not significantly different in patients with and without liver cirrhosis before surgery, but was significantly higher in the cirrhosis group one day after surgery. The preoperative endotoxin concentration did not correlate with the white blood count (WBC), platelet count, or routine biochemical liver function tests, however, a significant negative correlation was observed between the plasma endotoxin and fibronectin concentrations. The ability of plasma to inactivate endotoxin was quantified by serial measurements of the endotoxin concentration following the addition of a known quantity to each patient's plasma. The plasma from normal subjects quickly inactivated endotoxin, but inactivation was decreased in the plasma from patients with liver failure.     

Mask physiotherapy for prevention of pulmonary complications after heart surgery. A controlled study

The objective of this prospective, consecutive, randomized, controlled study was to investigate the effects of mask physiotherapy on postoperative complications after heart surgery. Sixty-six low-risk male patients undergoing coronary artery by-pass graft surgery were evaluated. The patients were treated with routine chest physiotherapy alone or supplied with either positive expiratory pressure (PEP), or inspiratory resistance-positive expiratory pressure (IR-PEP). Postoperative pulmonary complications were assessed by forced vital capacity (FVC), arterial oxygen tension (PaO2), and chest X-ray examination. There was an almost equal decrease and subsequent rise in spirometric and blood gas values in all three groups, but patients treated with the PEP mask had a borderline significantly higher increase in PaO2 from day three to day six compared with patients treated with no mask. There was an almost equal frequency of atelectasis in the three treatment groups. It is concluded that no significant differences in outcome were found between the three groups.     

Thromboembolism after foot and ankle surgery. A multicenter study

Thromboembolic disease presents a potentially fatal complication to patients undergoing orthopaedic surgery. Although the incidence after hip and knee surgery has been studied and documented, its incidence after surgery of the foot and ankle is unknown. For this reason, a prospective multicenter study was undertaken to identify patients with clinically evident thromboembolic disease to evaluate potential risk factors. Two thousand seven hundred thirty-three patients were evaluated for preoperative risk factors and postoperative thromboembolic events. There were six clinically significant thromboembolic events, including four nonfatal pulmonary emboli, after foot and ankle surgery. The incidence of deep vein thrombosis was six of 2733 (0.22%) and that of nonfatal pulmonary emboli was four of 2733 (0.15%). Factors found to correlate with an increased incidence of deep vein thrombosis were nonweightbearing status and immobilization after surgery. On the basis of these results, routine prophylaxis for thromboembolic disease after foot and ankle surgery probably is not warranted.     

Natural history of uncorrected flexion contractures following total knee arthroplasty

Over a 2-year period, 29 patients were identified that had preoperative flexion contractures less than 30 degrees and were not fully corrected to neutral following total knee arthroplasty. They were followed after surgery at 3, 6, and 12 months, and yearly thereafter with complete clinical and roentgenographic examinations to determine the natural history of the flexion contracture and its effect on the clinical outcome. The mean age of the 10 women and 19 men was 66 years (range, 47-80 years). The mean preoperative flexion contracture was 11 degrees (range, 5 degrees-30 degrees). The mean follow-up period was 33 months (range, 24-60 months). The mean values of the flexion contractures at each follow-up period were; immediately after surgery, 10.5 degrees; at 3 months, 5 degrees; at 6 months, 2 degrees; at 12 months, 1 degree; and at 24 months, 1 degree (P < .0001). Resolution of the flexion contracture did not vary between patients under and over the age of 65 years. There was no statistically significant difference in the residual flexion contracture when knees with preoperative contractures from 0 degrees to 14 degrees and 15 degrees to 30 degrees were compared. The clinical outcome was not affected by the residual flexion contracture after 6 months of follow-up evaluations. Significant improvements can occur after surgery with rehabilitation, and it appears that complete intraoperative correction is not necessary. There appears to be no difference in the natural history of flexion contractures with regard to age or severity up to 30 degrees.     

Functional neuroanatomy of the basal ganglia as studied by dual-probe microdialysis

This is a report of two cases of mature mediastinal teratoma associated with elevated serum SCC levels. The first patient was a 17-year-old female admitted to our hospital for severe left chest pain. Chest x-ray film and CT scan showed a mediastinal tumor. The preoperative serum SCC level was elevated. Resection was performed and the pathological diagnosis was mature teratoma. The second patient was a 32-year-old male admitted to our hospital for severe anterior chest pain. A chest CT scan showed a mediastinal tumor. The preoperative serum SCC level was high. Surgery was performed and the pathological diagnosis was mature teratoma. The cause of the high serum SCC levels was unclear, but we suspect that the pulmonary atelectasis may have caused it.     

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.