Laparoscopy as the primary modality for the treatment of women with endometrial carcinoma.

BACKGROUND: The current study was conducted to assess the feasibility of laparoscopy in the treatment of women with early stage endometrial carcinoma and to compare the surgical outcome, cost, and quality of life among these patients with those treated with laparotomy. METHODS: A prospective study was conducted over 2 years in which all women with early stage endometrial carcinoma who could tolerate laparoscopic surgery were treated with laparoscopically assisted vaginal hysterectomy (LAVH), bilateral salpingo-oophorectomy (BSO), and lymphadenectomy. Women with a similar disease stage who underwent similar surgical procedures through laparotomy in the previous 2 years were used as the control group. Both groups were compared with regard to their characteristics, surgical outcome, and cost and were interviewed regarding their quality of life. RESULTS: Eighty-six of 90 women with endometrial carcinoma underwent LAVH. The procedure was converted to laparotomy in 5 patients (5.8%). Laparoscopic surgery thus was successful in 90% of the women. There were no significant differences noted between those women who underwent LAVH and those who underwent total abdominal hysterectomy (TAH) (n = 57) with regard to patient characteristics, type of surgical procedure, preoperative and postoperative hematocrit, complications, patient recall of postoperative pain, and tumor recurrence. LAVH patients had significantly smaller body mass indices, a longer surgical time, more pelvic lymph nodes, a smaller decrease in postoperative hematocrit, received less pain medication, had a shorter hospital stay, an earlier return to full activity and work, and a higher level of satisfaction with their treatment, although their procedures had a higher cost compared with TAH patients. CONCLUSIONS: The majority of women with early stage endometrial carcinoma can be treated with laparoscopy with an excellent surgical outcome, shorter hospitalization, earlier recovery, and improved quality of life, but with a higher financial cost.

Bedside cardiac examination: constancy in a sea of change.

The general trend in the recent literature has been to highlight the difficulties and shortcomings of the physical examination and to attribute these difficulties to deficiencies in training rather than to intrinsic weaknesses in auscultation itself. The call is for better training. Given the advice of the authors mentioned above, individual training may be warranted at the postgraduate level and in the large community of practicing internists and cardiologists. Although not proven, it is likely that individual training with computer technology, audiotape instruction, or simulator technology such as described in the following paragraphs would be effective at improving bedside clinical diagnosis and cost-effective patient care in the postgraduate, continuing medical education setting. The advances in auscultation during the last few years have been more incremental than fundamental. There is ongoing research into the mechanism of production of S3 and S4, and mathematical modeling techniques have recently been used with some success in evaluating the vibrations of S3 and S4 as forced, damped oscillations of a viscoelastic system. Analysis of sound energy with the technique of spectral waveform analysis, which investigates the frequency content of sound signals, has been used for many years in the study of cardiovascular sound. By the use of various methods of mathematical analysis, investigators have found potentially useful information in spectral sound patterns of prosthetic valves, murmur characteristics, and even potentially hemodynamic information from heart sounds. Despite the mathematical advances, there are still disturbing drawbacks to some of the analytic techniques, such as the production of mathematical terms containing "negative energy." Although the potential of obtaining significant clinical information from spectral analysis of heart sound recordings is attractive, the clinical usefulness of such techniques remains virtually nonexistent. Similar to the recent advances in auscultation, the technical advances in the design of the stethoscope have also been more incremental than fundamental. There are at least 3 recently introduced electronic stethoscopes that have the capability of amplification and filtration and that claim noise reduction. Because their introduction is recent, no information is available in the peer-review literature regarding their clinical performance; therefore their place in the clinical arena remains to be elucidated--perhaps a boon for patient care providers with specific hearing defects and perhaps useful in noisy clinical environments. Peer-review literature has not shown clear superiority of one type of acoustic stethoscope over another. The teaching of auscultation has been an area of recognized importance in patient care since the inception of auscultation as a medical art. Attempts to facilitate practitioner learning in the performance and interpretation of auscultation have advanced through the decades limited only by the technical infrastructure of the day. The availability of recorded heart sounds and murmurs appeared shortly after the availability of recording and playback devices, with first vinyl and later tape recordings. In 1974, technology was employed to create a virtual patient named "Harvey," an engineered cardiology patient simulator that reproduces many of the physical findings of the cardiology examination. Later, with the advent of commercially available CD-ROM devices, newer, better-integrated teaching devices have been developed, some of them outstanding in their clarity and quality. Despite the obvious value of such instructional aids that are best used in the individual setting, there is evidence that the classroom is still of significant value in teaching auscultation. However, nowhere else in the practice of medicine is a mentor approach more valuable than in learning auscultation. (ABSTRACT TRUNCATED)

Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy?

OBJECTIVE: The aim of this study was to investigate the feasibility and safety of laparoscopic management of obese women with early stage endometrial cancer and to compare the surgical outcome, cost, hospital stay, recall of postoperative pain control, time to return to full activity and to work, and overall satisfaction among these women and those managed by laparotomy. METHODS: We conducted a prospective study over 2 years applying laparoscopic surgery to all women with clinical stage I endometrial cancer and body mass indices (BMIs) between 28.0 and 60.0 who can tolerate such surgery. As a control, we used women with clinical stage I endometrial cancer and similar BMIs who underwent laparotomy in the previous 2 years. Both groups were compared in their characteristics, surgical outcome, cost, and hospital stay, and interviewed regarding time to recovery, recall of postoperative pain control, and overall satisfaction with their management. RESULTS: Forty of 42 obese women who presented with clinical stage I endometrial cancer during the study period were offered laparoscopic surgery. The procedure was converted to laparotomy in 3 (7.5%) patients. Laparoscopic surgery was thus successful in 88.1% of all obese women. There was no significant difference between women who underwent laparoscopy and those who underwent laparotomy in patient characteristics, proportion of women who underwent lymphadenectomy, complications, total cost, patients' recall of postoperative pain, and patients' satisfaction with management. Women who underwent laparoscopy had a significantly longer operative time, more pelvic lymph nodes removed, a smaller drop in postoperative hematocrit, less pain medication, and a shorter hospital stay (194.8 versus 137.7 min, P <0.001; 11.3 versus 5.3, P < 0.001; 3.9 versus 5.4, P = 0.029; 32.3 versus 124.1 mg, P < 0.001; and 2.5 versus 5.6 days, P < 0.001, respectively). There was a trend toward earlier resumption of full activity and return to work among women who underwent laparoscopy (23.2 versus 45.0 days, P = 0.073, and 35.3 versus 67.0 days, P = 0.055, respectively). CONCLUSIONS: Most obese women with early stage endometrial cancer can be safely managed through laparoscopy with excellent surgical outcome, shorter hospitalization, and less postoperative pain than those managed through laparotomy.

Management of orthotopic heart transplant recipients at Brooke Army Medical Center.

Advances in heart transplantation and post-operative rejection therapy have given new hope to patients with end-stage congestive heart failure and cardiomyopathies. The growing numbers of pre- and post-transplant patients and the complexity of their care underscore the need for a multispecialty approach to patient management. This study examines the success of a multi-service program at Brooke Army Medical Center which offers pre- and post-transplant care to active duty, dependent, and retired military personnel.

Changing presentation of coronary heart disease in an inpatient population within the U.S. military health care system.

This study examines the changing presentation of coronary heart disease (CHD) in an inpatient population at Brooke Army Medical Center. The specific objectives of the study were to examine the presentation of CHD in a population unbiased by diagnosis-related group (DRG) reimbursements and to assess the importance of unstable angina and prior history of disease in the presentation of CHD. One thousand fifteen discharges in 1985 and 1,304 discharges in 1990 with the diagnosis of CHD were reviewed by cardiologists for evidence of symptomatic heart disease at the time of hospitalization. Forty percent of these charts were accepted into this study. The presentation rates of CHD were 1% with sudden death, 26% with myocardial infarction, 64% with angina, and 9% with congestive heart failure (CHF). During the study period, stable angina, Q-wave infarctions, and the myocardial infarction case fatality rate decreased (p < 0.05) and CHF and non-Q wave infarcts increased (p < 0.001). However, unstable angina was the most common presentation of CHD, and differences (p < 0.05) were noted in the presentation of CHD in patients with and without a prior history of disease. This study demonstrates the significance of unstable angina and prior history of CHD in an environment free of bias from DRG reimbursements.

Tetralogy of Fallot in a 71-year-old patient with new onset hypoxemia.

This study reports the evaluation and successful surgical management of a 71 year-old female with known Tetralogy of Fallot and symptomatic hypoxemia. A hybrid (fluid-micromanometer) catheter system was employed to examine right heart pressure gradients. This case presents unique hemodynamics along with angiography and palliative surgical management.

Subtle features of the hemodynamic response to amyl nitrite inhalation: new aspects of an old tool.

Although amyl nitrite inhalation (ANI) antedates all current short acting vasodilators as a clinically useful pharmacologic stressor, few clinicians are aware of the subtle hemodynamic actions of this agent. This study examined transients in left and right heart hemodynamics after ANI in seven men (ages 44 +/- 7 years) undergoing elective cardiac catheterization. High-fidelity central aortic (AoP), left ventricular (LVP), pulmonary artery (PAP), right ventricular (RVP), and right atrial (RAP) pressures were simultaneously recorded from left and right heart multisensor catheters. As expected, ANI caused an acute fall in Ao pressure (27%; p < 0.01) and reflex tachycardia (p < 0.001). Little change was noted in PAP, RVP, RAP, or LV end-diastolic pressures or the time constant of LV isovolumetric relaxation (tau). LV ejection time decreased 23 +/- 10 ms (p < 0.05) and RV ejection time did not change. Baroreflex sensitivity was similar during pressure fall and recovery (6.4 +/- 4.5 vs. 6.1 +/- 3.6 ms/mmHg), however hysteresis (p < 0.05) was noted. Aortic pressure waveforms also changed following ANI. Changes were determined to be in part a consequence of the attenuation and delay in arterial wave reflections. This study extends the understanding of the complex nature of the hemodynamic response associated with ANI.

Comparison of short-time Fourier, wavelet and time-domain analyses of intracardiac sounds.

Heart sounds provide clinicians with valuable diagnostic and prognostic information. They are repetitive in nature, but reflect complex mechano-acoustical events which have been inadequately described by traditional digital signal processing methods. In this study, left ventricular and aortic intravascular phonocardiograms were obtained from six patients by catheter-mounted piezoelectric transducers. Phonocardiograms (PCGs) were bandpass filtered (50-500 Hz), digitized at 4kHz and analyzed by three separate techniques: (1) Short-Time Fourier Transform (STFT), (2) Fast Wavelet Transform (FWT), and (3) a pulse-counting time-domain method based on an Order Statistic (OS) filter. The resulting time-frequency distributions were employed to examine intra-patient and inter-patient acoustic variability. Results suggest that STFT and FWT provide comparable temporal and frequency resolution of cardiac acoustical events. However, the time-varying and multicomponent nature of heart sounds was poorly characterized by the OS technique employed in this study. This study suggests that improved localization of acoustic events during the cardiac cycle may prove useful in the development of automated auscultation devices.

Effect of exercise on indices of valvular aortic stenosis.

Changes in the physiologic state of the patient may affect indices of valvular aortic stenosis. We determined the effects of supine exercise on the Gorlin valve area, Cannon valve area, aortic valve resistance, and a modified stroke work loss index in 80 patients with aortic stenosis. Exercise caused a significant increase in the Gorlin and Cannon valve area, while work loss and valve resistance decreased significantly. The average percent change in work loss, 12.2%, was lower than the other indices (P less than 0.02), i.e., 15.3% for valve resistance, 18.6% for the Gorlin area, and 19.3% for the Cannon area. The correlation between the rest and exercise measurements was highest for work loss (r = 0.94), compared to 0.93, 0.88, and 0.89 for the other 3 indices, respectively. In patients with a Gorlin area below 1 cm2, exercise caused a significant decrease in work loss, but not Cannon area or valve resistance. However, the percent change was significantly lower and the correlation was better with the work loss index. We conclude that the work loss index is less affected by supine exercise than other indices of aortic stenosis.

Effects of respiration on size and function of the athletic heart.

This study compares the effects of quiet breathing on the heart structure and function of pentathlon athletes (n = 11) and a less-conditioned control group (n = 12). Two-dimensional echocardiography was employed to direct an M-mode beam through the heart to minimize measurement errors due to respiratory motion of the heart. Respiration was simultaneously recorded with M-mode echocardiograms from a minimum of five respiratory and an average of 25 cardiac cycles. Athletes had greater (p less than 0.01) end-diastolic transverse dimensions (10%), and interventricular septal and left ventricular posterior wall thicknesses (25%). During inspiration right ventricular internal end-diastolic dimensions increased (8 vs 12%) and left ventricular end-diastolic dimension (LVIDd) decreased (7 vs 8%) in athletes and controls, respectively. Although significant reciprocal changes in LVIDd (p less than 0.01) occurred during respiration, no respiratory change was noted in the transverse diameter of the heart, interventricular septal, posterior wall thickness, LV end-systolic volume or ejection fraction. Inspiration caused a 21% fall (p less than 0.01) in LV stroke volume in both groups. Eighty-four to 92% of the inspiratory decrease in LV stroke volume in the subjects studied could be attributed to ventricular interdependence; no significant interaction was found between level of conditioning and respiration.

Recently diagnosed idiopathic dilated cardiomyopathy: incidence of myocarditis and efficacy of prednisone therapy.

Fifty-two patients with recently diagnosed idiopathic dilated cardiomyopathy were studied to determine the incidence of myocarditis; patients were randomly assigned to receive either conventional therapy alone or conventional therapy plus prednisone to assess possible therapeutic efficacy with regard to survival. Inflammatory criteria were present in 23% of the population studied with 13% having overt myocarditis according to the Dallas criteria. The addition of prednisone to conventional therapy did not improve survival in a homogeneous population with new-onset dilated cardiomyopathy. Furthermore, the diagnosis of myocarditis by endomyocardial biopsy did not influence 2-year survival once dilated cardiomyopathy had developed. Biopsy-documented myocarditis resolved in all patients, according to results of 3-month follow-up endomyocardial biopsies, regardless of treatment group. There was a trend for patients with a left ventricular ejection fraction less than 20% to show reduced survival at 2 years compared to the group with a higher ejection fraction (p = 0.07). Right ventricular dysfunction determined at catheterization was present in 20 of 52 patients and was the most significant predictor of survival. Patients with preserved right ventricular function had a 95% 24-month survival rate compared to 47% for patients with right ventricular diastolic dysfunction (right ventricular end-diastolic pressure greater than or equal to 11 mm Hg) (p = 0.005).

Heart size and function of soldiers, athletes, and sedentary men.

This study compares the heart sizes and left ventricular masses of soldiers (n = 11) with age- and body size-matched groups of sedentary men (n = 10) and accomplished athletes (n = 11). Echocardiography revealed that active duty soldiers (A) who met minimal fitness standards and pentathletes (P) had greater average left ventricular (LV) end-diastolic volumes (A = 10%, NS; P = 28%, p less than 0.05), stroke volumes (A = 29%, NS; P = 44%, p less than 0.01), and LV masses (A = 22%, NS; P = 76%, p less than 0.01) than sedentary subjects. Athletes had an average LV wall thickness which was 23% (p less than 0.05) greater than that of soldiers and 32% (p less than 0.01) greater than that of sedentary men. The LV wall thickness to radius ratio (h/r) was similar between soldiers and sedentary men, but in athletes the h/r was greater (p less than 0.01) than in the less conditioned subjects. These data suggest that soldiers who meet minimal standards of fitness exhibit cardiac morphometric features consistent with endurance conditioning. However, the soldiers studied were significantly less (p less than 0.001) conditioned than the competitive athletes. These data suggest that improvements in aerobic and cardiac conditioning could be achieved through a greater emphasis on physical training.

Left ventricular performance of the athletic heart during upright exercise: a heart rate-controlled study.

This study compares the left ventricular performance of chronically conditioned pentathletes (N = 10) with less-conditioned subjects (N = 10) during dynamic upright exercise. The pentathletes were found to have a superior treadmill performance [24 +/- 4 vs 17 +/- 2 min (SD), P less than 0.01], reduced resting heart rate (41 +/- 13 vs 62 +/- 6 bpm, P less than 0.01), and increased left ventricular mass (254 +/- 85 vs 179 +/- 35 g, P less than 0.05) compared to the control group. Radionuclide ventriculography and heart rate controlled-bicycle ergometry were employed to examine changes in left ventricular ejection fraction, end-diastolic volume, end-systolic volume, and stroke volume. Heart rate was controlled by adjusting the resistance of the ergometer until stable heart rates of 90, 110, 130, and 150 bpm were achieved. Following heart rate stabilization, 99mTc images were acquired during 3-min stages at each target heart rate level. In the pentathletes, left ventricular ejection fraction, end-diastolic volume, and stroke volume increased (P less than 0.01) during exercise, and end-systolic volume tended to decrease. No difference was noted in left ventricular ejection fraction between groups when heart rates were matched. However, the exercise-induced changes in end-diastolic volume and stroke volume were greater (P less than 0.01) in the pentathletes. In conclusion, the athletes studied relied on the same mechanism as the less-conditioned subjects for improving pump performance during exercise stress, but the athletes' ability to mobilize a greater end-diastolic volume accounts for their larger stroke output during each stage of heart rate-matched exercise.

Evaluation of ECG changes in dentists treating awake patients.

Twenty-eight male dentists were evaluated with 24 hour ambulatory ECG while working on awake patients. Only one of the participants showed any sign of stress induced arrhythmias after a patient fainted. The remainder of the subjects were indistinguishable from previously studied normal populations.

Limitations of the cardiokymograph for assessing left ventricular wall motion.

In order to evaluate the reliability and reproducibility of the CKG we studied four groups of patients. In 27 patients with a prior myocardial infarction the CKG recordings were compared to simultaneous wall motion videotracking. Identical wall motion was recorded in 75% of left ventricular sites and most of the discordant sites were false abnormal posterior wall motion recorded by the CKG. The second group consisted of 21 normal subjects studied by CKG only and 35% displayed anterior dyskinesis during expiration. The third group consisted of nine stable patients who were studied on two separate days by CKG and identical wall motion was recorded in only 55% of the sites on the two recordings. The final group consisted of seven patients with mitral regurgitation and all had late systolic outward movement posteriorly. Systolic wall motion was normal postoperatively in the three patients who underwent valve replacement. We conclude that: (1) the usefulness of the CKG is limited by the frequent recording of false wall motion abnormalities in normal subjects, (2) false anterior wall motion abnormalities can be reduced by recording during inspiration, (3) false posterior wall motion abnormalities may be due to systolic left atrial expansion, and (4) cardioxymography recordings are often not reproducible.