Recommendations for the National Institute for Neurologic Disorders and Stroke spinal cord injury common data elements for children and youth with SCI.

STUDY DESIGN: In 2014, the adult spinal cord injury (SCI) common data element (CDE) recommendations were made available. This project was a review of the adult SCI CDE for relevance to children and youth with SCI. OBJECTIVES: The objective of this study was to review the National Institute of Neurologic Disorders and Stroke (NINDS) adult SCI CDEs for relevance to children and youth with SCI. SETTING: International. METHODS: The pediatric working group consisted of international members with varied fields of expertise related to pediatric SCI. The group convened biweekly meetings for 6 months in 2015. All of the adult SCI CDEs were reviewed, evaluated and modified/created for four age groups: 0-5 years, 6-12 years, 13-15 years and 16-18 years. Whenever possible, results of published research studies were used to guide recommendations. In the absence of empirical support, grey literature and international content expert consensus were garnered. Existing pediatric NINDS CDEs and new CDEs were developed in areas where adult recommendations were not appropriate. After internal working group review of domain recommendations, these pediatric CDEs were vetted during a public review from November through December 2015. RESULTS: Version 1.0 of the pediatric SCI CDEs was posted in February 2016. CONCLUSION: The pediatric SCI CDEs are incorporated directly into the NINDS SCI CDE sets and can be found at https://commondataelements.ninds.nih.gov.

Unprotected left main coronary artery disease. Surgical therapy.

Coronary artery bypass grafting (CABG) has been established as a safe concept in the treatment of unprotected left main coronary artery (ULMCA) disease and is considered the first-line treatment in current interdisciplinary guidelines. Regardless of the complexity of the lesion and the concomitant diseases, CABG is associated with excellent long-term results. Randomized controlled trials investigating the role of percutaneous coronary intervention in the setting of ULMCA lesions are frequently underpowered and suggest that, when restricted to less complex lesions, percutaneous coronary intervention is associated with results comparable to surgery. Thus, there is an urgent need for further randomized controlled trials RCTs with all-comers design to supply precise data under real-life conditions representative of the left main stem anatomy. Until then, an interdisciplinary approach to patients with ULMCA lesions is mandatory in view of the existing guidelines.

A comparison of the Nexfin® and transcardiopulmonary thermodilution to estimate cardiac output during coronary artery surgery.

The newly introduced Nexfin(®) device allows analysis of the blood pressure trace produced by a non-invasive finger cuff. We compared the cardiac output derived from the Nexfin and PiCCO, using transcardiopulmonary thermodilution, during cardiac surgery. Forty patients with preserved left ventricular function undergoing elective coronary artery bypass graft surgery were studied after induction of general anaesthesia and until discharge to the intensive care unit. There was a significant correlation between Nexfin and PiCCO before (r(2) = 0.81, p < 0.001) and after (r(2) = 0.56, p < 0.001) cardiopulmonary bypass. Bland-Altman analysis demonstrated the mean bias of Nexfin to be -0.1 (95% limits of agreement -0.6 to +0.5, percentage error 23%) and -0.1 (-0.8 to +0.6, 26%) l.min(-1).m(-2), before and after cardiopulmonary bypass, respectively. After a passive leg-raise was performed, there was also good correlation between the two methods, both before (r(2) = 0.72, p < 0.001) and after (r(2) = 0.76, p < 0.001) cardiopulmonary bypass. We conclude that the Nexfin is a reliable method of measuring cardiac output during and after cardiac surgery.

Stented bioprostheses in aortic position.

INTRODUCTION: Biological stented prostheses are currently the main type of prosthetic valve used for aortic valve replacement. The ratio of bioprotheses to mechanical prostheses has switched in the last 15 years; the percentage of biological  prostheses implanted has risen from 30 % to 85 %. Moreover the total number of implanted stented bioprostheses remained stable over the last years despite competing procedures like stentless prostheses or transcatheter aortic valve implantation. METHODS: A literature search of all published aortic valve replacement studies was performed from January 2000 through May 2012. RESULTS: The recommendations guiding the type of heart valve replacement have been revised in recent years. Of particular interest are the new generation of biological prostheses with extended durability, a decrease in mortality of reoperation and an increase in life expectancy. Comorbidities such as chronic renal insufficiency or chronic atrial fibrillation are no longer contraindications to bioprostheses. CONCLUSION: Overall, even in face of more innovative biological alternatives the implantation of stented bioprostheses is still a very interesting option and represents actually the most frequent valve implantation technique for aortic stenosis.

[Mid-term outcome of cardiac surgery patients with prolonged postoperative intensive care treatment]. / Mittelfristiges Outcome kardiochirurgischer Patienten mit einer verlängerten postoperativen Intensivtherapie.

BACKGROUND: The number of patients of advanced age and with severe comorbidities undergoing cardiac surgery is rising. Therefore, in addition to the cardiac surgery procedure itself, postoperative intensive care treatment plays an increasingly important role. The mid-term outcome of patients with postoperative long-term stays in intensive care and perioperative risk factors for an adverse outcome have not been sufficiently evaluated. MATERIAL AND METHODS: All patients who underwent cardiac surgery in our institution between 2000 and 2004 and who required intensive care treatment on our cardiac surgery intensive care unit for at least 1 week were analyzed. Patients who received heart or lung transplantation or surgery for congenital heart failure were excluded. A total of 31 perioperative variables were evaluated for 230 patients. Follow-up was performed 1 year postoperatively. RESULTS: In all, 4.3% of our patients required a prolonged stay in intensive care following cardiac surgery. Overall 1-year mortality among patients with a long-term stay in intensive care was 26.9%. The logistic regression identified postoperative renal failure requiring dialysis (OR 4.98) as the strongest predictor for mortality within the first year after surgery, followed by postoperative tracheotomy and preoperatively known atrial fibrillation. CONCLUSION: Mid-term survival among patients who underwent cardiac surgery followed by a complicated postoperative course is encouragingly high. The risk factors identified for an adverse prognosis may be helpful in improving therapy strategies and general therapy decision-making.

Accuracy of the pleth variability index to predict fluid responsiveness depends on the perfusion index.

BACKGROUND: Respiratory variations in plethysmographic waveform amplitudes derived from pulse oximetry are believed to predict fluid responsiveness. The non-invasive pleth variability index (PVI) is a variable based on the calculation of changes in the perfusion index (PI). The aim of the following study was to examine whether the predictive power of PVI depends on different values of PI. METHODS: Eighty-one patients undergoing elective coronary artery surgery were studied before operation: at baseline after induction of anaesthesia and during passive leg raising (PLR). Each patient was monitored with central venous pressure (CVP), the PiCCO monitor and the non-invasive Masimo monitoring system. Stroke volume index by transpulmonary thermodilution (SVI(TPTD)), pulse pressure variation (PPV), stroke volume variation (SVV) and systemic vascular resistance index (SVRI) were measured using the PiCCO monitoring system. PI and PVI were obtained by pulse oximetry. RESULTS: Responders were defined to increase their SVI(TPTD) >15% after PLR. The highest area under the curve (AUC) was found for PPV (AUC: 0.83, P<0.0001) and SVV (AUC: 0.72, P=0.002), in contrast to PVI (AUC: 0.60, P=0.11) and CVP (AUC: 0.60, P=0.13). The accuracy of PVI to predict fluid responsiveness was improved on analysing patients with higher PI values. PI of about 4% (n=45) achieved statistical significance (AUC: 0.72, P=0.01). CONCLUSION: The PVI was not able to predict fluid responsiveness with sufficient accuracy. In patients with higher perfusion states, the PVI improved its ability to predict haemodynamic changes, strongly suggesting a relevant influence of the PI on the PVI.

Patient and caregiver knowledge of severity of injury among youth with spinal cord injury.

DESIGN: Multicenter cross sectional study. OBJECTIVES: Describe patient and caregiver knowledge of severity of injury and examine the relationship between AIS status and patient/caregiver report. SETTING: United States METHODS: Participants were between 1 and 21 years of age with a stable spinal cord injury (SCI). Participants underwent ISCSCI exams and were interviewed with the following questions: 1. Did the patient/caregiver know the difference between complete and incomplete spinal cord injury before participation? 2. What level of injury does the patient/caregiver report? 3. What severity of injury does the patient/caregiver report? 4. If a severity is given, who told them and how was it tested? RESULTS: Overall, 16% of patients and 20% of caregivers knew the difference between complete and incomplete SCI. Older patients were more likely to know the difference and caregivers of patients with shorter durations of injury were more likely to know the difference. Those who reported a severity of injury different from their actual severity were more likely to have a complete spinal cord injury and a higher injury severity as measured by the AIS impairment scale. Only 18% of people who were able to report a severity of injury stated that an ISCSCI exam was how the doctor gave them the diagnosis. CONCLUSION: Many patients and caregivers do not understand the difference between complete and incomplete SCI. It is vital that an AIS diagnosis only be given following the ISCSCI exam based on agreed standards.

[Quality standards in intensive care of cardiac surgery]. / Qualitätsstandards in der herzchirurgischen Intensivmedizin.

The quality of ICU treatment is very important with regard to the outcome of patients requiring prolonged ICU stay following cardiac surgery. We conducted an internal quality survey and observed a one-year survival rate of almost 75 % after protracted ICU stay. In order to optimize the quality we identified pulmonary hypertension and prolonged mechanical ventilation as predictors for an adverse outcome. According to our findings the risk for a prolonged postoperative course is higher in patients with impaired renal function and in patients undergoing complex procedures. In these patients preoperative right heart catheterization should be performed without exception. If treatment of high pulmonary resistance leads to a benefit in terms of survival should be a matter of future investigations. There are several causes which may lead to prolonged mechanical ventilation and most of them can hardly be affected. It is known that the application of CPB impairs the respiratory function. Own studies demonstrated that the utilization of a minimized CPB does not lead to shorter ventilation times. Since there is no promising approach to reduce ventilation time by standardized means, early extubation remains the main measure. It is a long and stony way to implement quality standards on the basis of quality surveys. Finding an effective approach to optimize quality is often difficult. However, discouragement has to be avoided at al costs, since the continuous endeavor after quality and improvement of quality are basic requirements of medical progress.

Patient and caregiver knowledge of autonomic dysreflexia among youth with spinal cord injury.

OBJECTIVES: To describe the prevalence and knowledge of autonomic dysreflexia (AD) from patient and caregiver perspectives, and its relationship to the American Spinal Injury Association (ASIA) Impairment Scale (AIS) classification, level of injury, severity of injury, injury etiology, gender and race. METHODS: Participants were between 1 and 21 years old. Demographic information was collected from the medical records, and patients and caregivers were interviewed with the following questions: (1) Does the patient experience AD? (2) Does the patient/caregiver know what AD is? (3) Can the patient/caregiver name three signs/symptoms of an AD episode? (4) Does the patient/caregiver know how to treat AD? RESULTS: Overall, 40% of patients and 44% of caregivers said that the patient was symptomatic for AD. AD was more common in those with traumatic etiologies, in patients with injuries at or above T6 and those with greater injury severity as measured by the AIS. For patients and caregivers, AD was less common in the youngest age group (0-5 years old). Patients with greater knowledge of AD were more likely to have traumatic etiologies, have T6 or higher injuries, be in the oldest age at injury group, be older at time of examination and have had a shorter duration of injury. CONCLUSIONS: AD seems to be more common in patients with traumatic injuries, older ages at injury, greater injury severity on the AIS and level of injury at or above T6.

Is there really a clinical benefit of using minimized extracorporeal circulation for coronary artery bypass grafting?

BACKGROUND: Minimized extracorporeal circulation is intended to reduce the negative effects associated with cardiopulmonary bypass. This prospective study was performed to evaluate whether minimized extracorporeal circulation has a clinical benefit for coronary artery surgery patients compared to standard extracorporeal circulation. METHODS: Sixty patients were randomized into two study groups: 30 patients underwent coronary artery bypass grafting using minimized extracorporeal circulation and 30 patients were operated using standard extracorporeal circulation. Baseline characteristics, intraoperative details, postoperative data, perioperative blood chemistry determinations of hematocrit, platelets, muscle-brain fraction of the creatine kinase, cardiac troponin T and colloid osmotic pressure as measurements of intrathoracic blood volume index and extravascular lung water index were compared. RESULTS: Baseline characteristics and intraoperative details of both groups were similar. Patients who underwent minimized extracorporeal circulation showed more short-term dependency on norepinephrine ( P < 0.01). Their maximal postoperative muscle-brain fraction of the creatine kinase was lower ( P < 0.05) and their hematocrit on arrival in the intensive care unit was higher ( P < 0.01). No other significant differences were found. In both collectives, values for hematocrit ( P < 0.001), platelets ( P < 0.001), colloid osmotic pressure ( P < 0.001) and intrathoracic blood volume index ( P < 0.05) decreased, while the extravascular lung water index did not change significantly during cardiopulmonary bypass. CONCLUSIONS: A clinical advantage of minimized over standard extracorporeal circulation was not found. Furthermore, a higher number of patients in the minimized extracorporeal circulation group required postoperative norepinephrine infusions for hemodynamic stabilization. In summary, the presumed superiority of minimized extracorporeal circulation for coronary artery bypass grafting in standard patients could not be confirmed.

Severe obesity does not adversely affect perioperative mortality and morbidity in coronary artery bypass surgery.

OBJECTIVE: Obese patients are usually thought to have an increased risk for complications in coronary artery bypass surgery. METHODS: Therefore, the data of 500 consecutive patients undergoing coronary artery bypass grafting at our department in 1998 by use of cardiopulmonary bypass were analyzed. Severe obesity was defined as body mass index (BMI) > or = 30.0 kg/m(2). Obese patients (n=100; group O) were compared to the remaining 400 patients (group C). Both groups were comparable with respect to sex, history of prior myocardial infarction, chronic obstructive pulmonary disease, previous stroke, duration of cardiopulmonary bypass, aortic cross-clamp time and number of distal anastomoses performed. Obese patients were slightly younger and diabetes and hypertension were more common in these patients. RESULTS: Survival and potential complications including perioperative myocardial infarction, sternal wound infection, wound infection at the leg, renal failure, stroke, prolonged mechanical ventilation, pneumonia, reexploration for bleeding, and atrial arrhythmias were analyzed. No significant differences between obese and non-obese patients were detected. CONCLUSION: Severe obesity does not necessarily adversely affect perioperative mortality and morbidity in patients undergoing coronary artery bypass grafting in this study.

Recurrence following stapled coloproctostomy for carcinomas of the mid portion of the rectum.

A retrospective analysis of 90 patients who underwent a curative surgical resection for a carcinoma of the middle third of the rectum was carried out to determine the preliminary recurrence rates associated with stapled coloproctostomy. Acknowledging the obvious limitations of this preliminary report, the liberal use of restorative resections for these lesions does not appear to be resulting in an obvious increase in tumor recurrence, and the use of the circular intraliminal staplers has significantly decreased the number of abdominoperineal resections required to treat these lesions. We will continue to use stapled coloproctostomy for the majority of these lesions; however, definitive statements regarding the over-all effect of this approach upon survival time await further studies incorporating larger numbers and longer follow-up studies.

Colocolostomy and coloproctostomy utilizing the circular intraluminal stapling devices.

Coloproctostomy or colocolostomy by peranal insertion of a circular stapling device was performed on 265 patients between January 1978, and June 1981. A low anterior resection was performed in 174 patients. Stapler-related technical complications occurred in 52 patients (20 per cent). Complementary transverse colostomies were performed in 11 patients, of which seven were performed on the first 30 patients. Intraoperative complications occurred in 18 patients (7 per cent). Twenty-six major postoperative complications occurred (10 per cent), and clinical anastomotic leaks occurred in eight patients (3 per cent). Four postoperative deaths occurred (1.5 per cent). This study concludes that (1) coloproctostomy or colocolostomy can be safely performed by transanal insertion of a circular stapling device, (2) these instruments allow a sphincter-preserving procedure to be performed for lesions in the low and midrectum (5 to 10 cm from the anal verge) with an acceptable early morbidity and mortality, and (3) the majority of stapler-related technical complications can be managed without protecting colostomy.

Restorative proctocolectomy with ileal reservoir and ileoanal anastomosis.

An initial experience with a technique of restorative proctocolectomy utilizing a rectal mucosectomy, total colectomy, and ileal reservoir (Parks S-pouch) with ileoanal anastomosis for patients with ulcerative colitis and familial polyposis is presented. Although there were no deaths, significant morbidity did occur and was attributed to the use of a temporary loop ileostomy which may not be necessary. Early functional results are promising and to date, patient satisfaction is very high.

Endorectal advancement flap for treatment of simple rectovaginal fistula.

An endorectal advancement flap technique has been utilized in 35 women for repair of "simple" rectovaginal fistulas, i.e., those of low or midseptal location, less than 2.5 cm in diameter, and of traumatic or infectious etiology. Colostomy is unnecessary. Concomitant sphincteroplasty for correction of associated anal incontinence is readily accomplished. Results are excellent with healing ultimately achieved in 32 of 35 women (91 per cent).

Abdominoperineal resection for recurrent cancer following anterior resection.

Cases are reviewed of 12 patients who had abdominoperineal resections for cancer recurrence subsequent to anterior resection. Although this procedure is technically more difficult, we experienced no mortality or significant morbidity, and the postoperative hospital stay was similar to that of patients who received an abdominoperineal resection as a primary procedure. Although we have no long-term cures, at least significant palliation can be achieved in selected patients who have no evidence of distant metastases.

Villous adenomas of the rectum: the accuracy of clinical assessment.

To avoid an unnecessary radical operation, it is important for surgeons to identify a clinically benign villous tumor of the rectum, especially in the middle third area, where a transanal approach may not be feasible. If the high accuracy of this clinical impression can be achieved, alternative methods such as piecemeal snare excision, or electrocoagulation, or both are justified. To evaluate the diagnostic accuracy of a benign rectal villous tumor, 151 patients with totally excised rectal tumors were reviewed. All of these patients had soft and nonulcerated lesions and were judged to be benign. Induration and ulceration of the lesions signified malignancy and were excluded. One hundred and fourteen patients (76%) had benign villous adenomas, 23 patients (15%) had superficial carcinomas, and 14 patients (9%) had invasive carcinomas. Hence the accuracy of detecting a clinically benign villous tumor of the rectum was 91%. This is high enough to avoid a more radical procedure when the clinical impression is that of a benign villous tumor of the rectum.

Perianal endometrioma: report of five cases.

One of the gynecologists' commonest findings at pelvic laparotomy is endometriosis. Despite the fact that the presence of endometrial tissue in ectopic locations is commonplace, the finding of a perianal endometrioma is no more than a surgical curiosity. Very few cases have been reported. The present report describes five such verified cases. Interestingly enough, only two of the five cases were diagnosed preoperatively. The pathogenesis of endometriosis has been, and continues to be, controversial. The prevailing theories include 1) transtubal regurgitation of menstrual blood, 2) the coelomic metaplasia doctrine, 3) lymphatic dissemination, and 4) hematogenous spread. Pathologically the lesions may vary grossly from red-blue to yellowish-brown implants, ranging in size from microscopic to 1-2 cm in diameter. The definitive histologic diagnosis requires two of the following three features-glands, stroma, and hemosiderin pigment. The clinical manifestations depend upon the functional activity of the involved tissue and may range from an asymptomatic mass to the classic presentation of a mass increasing in size and becoming acutely painful during menstruation but subsiding in size and decreasing in tenderness between menstrual periods. These protean manifestations are readily illustrated by the cases presented. Anatomically the lesions are usually found in old episiotomy scars. Because these lesions are usually readily accessible, and because their exact nature is frequently not known preoperatively, the treatment of choice is local excision. Complementary hormonal therapy has been suggested, but the value of such treatment is not yet proven. Ovarian ablative therapy is also considered.