Appropriate Timing Of Surgical Intervention Research Articles

Effect of Delayed Surgery for Ventricular Septal Rupture on Postoperative Outcomes.

The prognosis of ventricular septal rupture (VSR) after acute myocardial infarction remains poor; hence, surgical repair is essential. However, the appropriate timing for surgical intervention remains unclear. We aimed to compare the prognosis between early (<96 hours) and delayed (≥96 hours) surgery for VSR. This single-center, retrospective cohort study used data from 49 patients who underwent VSR repair after acute myocardial infarction (AMI) between 2007 and 2022 at our institution. In-hospital and one-, three-, and 10-year mortality and major adverse cardiac and cerebrovascular events were compared between the early (group A) and delayed (group B) surgery after AMI. No significant differences were found between the patients' backgrounds of the two groups. The in-hospital mortality rates were 37.5 and 16.0% for groups A and B, respectively (P = 0.114). The overall survival rates estimated using Kaplan-Meier analysis were 66.5 ± 6.9, 58.2 ± 7.5, and 28.8 ± 10.6% after one, three, and 10 years, respectively. The mortality rates in group B at three (hazard risk ratio: 2.691; 95% confidence interval: 1.02-7.097) and 10 (hazard risk ratio: 2.575; 95% confidence interval: 1.125-5.891) years were significantly better than those in group A. Major adverse cardiac and cerebrovascular events were significantly different between the two groups at all time points. These results showed that patients who underwent surgery for VSR 96 hours afterAMI had better long-term survival than those who underwent surgery within 96 hours.

Thyroid cancer and pregnancy: a systematic ten-year-review.

Thyroid cancer is the second most common malignancy during pregnancy, especially the well-differentiated thyroid cancer (well-DTC). Therefore, complex medical and social dilemmas arise, dealing with which requires deep knowledge of the nature and characteristics of the disease and pregnancy as a whole. The purpose of this review is to present the diagnostic and therapeutic strategies of thyroid cancer during pregnancy and the postpartum period. Extended review of the literature [2011-2023] was performed. Two hundred ninety-six articles were found, from which 225 were excluded due to irrelevant subjects. Seventy-one articles were assessed for eligibility, from which 33 articles were cohort studies and case reports and were included in the review. From the 33 included studies, 18 were retrospective cohort studies, 1 was cohort study, 2 were case control studies, 1 was meta-analysis and 11 were case reports. The primary endpoints of these studies refer to the progression and recurrence of DTC during pregnancy, the prevalence of thyroid cancer in pregnancy and the most appropriate time for surgical intervention. The majority of the studies agree that well-differentiated tumors with mild clinical and imaging characteristics do not require immediate surgical treatment, but mere monitoring. Surgery can be delayed after childbirth. In contrast, tumors with aggressive behavior as well as non-differentiated ones, require immediate surgery because delay under these circumstances can dramatically reduce survival rates. Finally, a history of thyroid cancer does not seem to affect future deliveries, on condition that no residual disease exists at the onset of pregnancy.

Descending necrotizing mediastinitis with esophageal perforation and tracheal ulcer: a case report and literature review

BackgroundDescending necrotizing mediastinitis (DNM) is a rare and life-threatening condition, with high morbidity and mortality. Consequently, appropriate and prompt diagnosis and treatment are necessary. Herein, we report a case of esophageal perforation and bronchial ulcer secondary to DNM, for which thoracoscopic esophagectomy was performed after the failure of conservative treatment.Case presentationA 63-year-old man was diagnosed with mediastinitis affecting the posterior mediastinum after presenting with a sore throat, back pain, and dyspnea. He also had type 2 diabetes mellitus and renal failure. The patient developed septic shock the following day, and intensive treatment was initiated. The condition of the patient gradually improved; however, the laboratory data revealed that levels of C-reactive protein remained high. On day 22, the esophageal perforation was demonstrated on esophagogastroduodenoscopy. Bronchoscopy was remarkable for the ulcer on the membranous tracheal wall, though he did not go into respiratory failure. The emergency thoracoscopic esophagectomy was performed on day 27. The reconstruction surgery was performed on day 100.ConclusionsDespite the fact that the general condition is stable with conservative treatment, DNM can develop esophageal perforation. Thus, it is essential to determine the appropriate timing of surgical intervention if levels of inflammation markers continue to be high.

Correlations between Sagittal Parameters and Functional Scores in 65-Year-Old Osteoporotic Females with Vertebral Body Fracture under Low-Energy Mechanism

Background: Vertebral compression fractures (VCFs) are the most common fragility fractures associated with low-energy injury mechanisms in postmenopausal women with osteoporosis. No clear consensus is currently available on the optimal timing for surgical intervention in specific cases. Methods: This study examined the correlations between sagittal parameters, functional scores, and the appropriate timing for surgical intervention during the recovery stage in patients with osteoporosis with thoracolumbar (TL) vertebral body fractures. A total of 161 women aged ≥ 65 years with osteoporosis were included in the study. Spinal sagittal parameters from standing plain films and functional outcomes as the Oswestry disability index (ODI) and the visual analogue scale (VAS) were collected. Results: We found that TL junction Cobb angle was significantly correlated with ODI &gt; 30 (p &lt; 0.001) and VAS &gt; 6 (p &lt; 0.001) and the discriminative values for predicting ODI &gt; 30 and VAS &gt; 6 were a TL kyphotic angle of 14.5° and 13.5°, respectively. Among women aged ≥ 65 years with osteoporosis, the back pain and functional impairment observed within 6 months following a compression fracture are associated with a greater TL kyphosis angle. Conclusions: This suggests that a more proactive approach may be necessary when addressing the conditions of these patients.

Does a time threshold exist for bladder repair after which outcomes worsen? A Trauma Quality Improvement Program study

BackgroundThe appropriate timing of surgical intervention for bladder injuries is not well-defined. The effect of time to surgery on the outcomes of patients with a bladder injury was assessed using data from the Trauma Quality Improvement Program. MethodsPatients with dominant or isolated bladder injuries who underwent surgical repair from 2017 to 2019 were studied. Mortality, infection (surgical site infection or sepsis), acute kidney injury, overall length of stay, and length of stay after surgery were compared between patients who underwent bladder repair within and after 24 hours of arrival at the emergency department. The role of time to surgical repair in the outcomes of patients with a bladder injury was evaluated. ResultsA total of 1,507 patients with a mean time to bladder repair of 14.0 hours were studied. In total, 233 (15.5%) patients with a bladder injury underwent bladder repair more than 1 day after emergency department arrival. These patients had significantly more infections (5.6% vs 2.5%, P = .011), more acute kidney injuries (7.8% vs 1.8%, P < .001), and a longer length of stay after surgery (16.0 vs 12.3 days, P = .001) than patients who underwent bladder repair within 1 day. A time to bladder repair longer than 24 hours after emergency department arrival did not significantly affect mortality (P = .075) but significantly increased the risk of infection/acute kidney injury (odds = 1.823, P = .040). However, the infection/acute kidney injury risk did not increase with increasing time to surgery in patients who underwent bladder repair within 24 hours (P = .120). ConclusionPatients with dominant or isolated bladder injuries may have a poor outcome (ie, increased infection rate, acute kidney injury, longer overall length of stay, and longer length of stay after bladder repair) if they undergo surgical repair more than 24 hours after arrival at the emergency department.

Quality of life during the wait for ruptured anterior cruciate ligament reconstruction: a randomized controlled trial.

Background:There is a lack of prospective evidence to guide surgeons when making recommendations about the appropriate timing of surgical intervention for ruptured anterior cruciate ligament (ACL), activity modifications to reduce the risk of secondary injury before surgery, and the short- and long-term risks associated with delayed ACL reconstruction. This study aimed to determine whether longer wait times are associated with a prolonged decrease in quality of life and an increased incidence of secondary joint injury after ACL rupture.Methods:We recruited 53 patients who presented between 2013 and 2017 at a single sports medicine minor injury clinic with a suspected acute ACL rupture, based on clinical examination; ACL rupture was confirmed on magnetic resonance imaging. Patients were randomly allocated to undergo early reconstruction (< 12 wk after injury) or reconstruction after a regular wait time (≥ 12 wk). We compared scores on the ACL quality of life measure (ACL-QOL) and the incidence of secondary knee injury at baseline and at surgery between the 2 groups. Participants also completed the Tegner scale (level of activity) at the time of consent and within 7 days before surgery.Results:Twenty-eight patients were randomly assigned to the early surgery group and 25 patients to the regular wait time group. There was no difference in mean age between the 2 groups. There were no between-group differences in mean ACL-QOL score at the time of injury (28.5 [standard deviation (SD) 12.5] v. 28.5 [SD 12.6]) or at surgery (34.9 [SD 17.5] v. 38.0 [SD 17.5]). The mean wait time was significantly longer in the regular wait time group than in the early surgery group (29.6 wk [SD 13.2 wk] v. 10.6 wk [SD 5.1 wk], p = 0.001). In both groups, Tegner scale scores were significantly lower after than before ACL rupture (p < 0.001) and remained low while patients waited for surgery. There were no between-group differences in the incidence of chondral or meniscal injury at surgery, although the study was not adequately powered to draw any statistical conclusions.Conclusion:Wait time for ACL reconstruction may affect patients’ quality of life, as it remained diminished for a longer period when surgery was delayed. A low activity level during the waiting period was observed in both groups; this low activity level may be one reason why no between-group differences in the incidence of secondary injury were observed. The findings suggest that patients with a limited activity level during the waiting period have a low risk of secondary injuries.

AB117. SOH21AS062. Surgical intervention in epistaxis—a retrospective review from a tertiary referral centre

Background: Approximately 60% of individuals will experience an episode of spontaneous epistaxis. Management strategies vary as do recurrence rates. Surgical intervention is reserved for those cases who have failed conservative measures and the main focus is arterial ligation. The appropriate timing for surgical intervention in the stepwise management of refractory epistaxis has not been well characterised. The aim of our study was to assess practice in a tertiary referral centre and the outcomes of those patients who undergo surgical intervention.

Surgical outcomes of percutaneous transhepatic gallbladder drainage in acute cholecystitis grade II patients according to time of surgery

The objective of this study was to determine the appropriate timing for surgical intervention for Grade II acute cholecystitis patients. The study compares the clinical outcomes of patients in Group A, who were treated with early laparoscopic cholecystectomy (ELC) within the first two weeks of hospitalization, and Group B, treated with delayed laparoscopic cholecystectomy (DLC) after recovering from symptoms and that received conservative treatment and were discharged for more than two weeks. From November 2011 to June 2019, from a total of 196 acute cholecystitis patients that received percutaneous transhepatic gallbladder drainage (PTGBD) insertion, we conducted a retrospective review of the group that received early laparoscopic cholecystectomy within 2 weeks and the group that received delayed laparoscopic cholecystectomy. The clinical characteristics and post-treatment outcomes were evaluated. In all patients treated with PTGBD insertion, Group A, the patients who were treated with ELC, showed a significantly longer mean operative time than Group B, the patients who were treated with DLC (72.46±46.396 vs. 54.08±27.12, P=0.001). Similarly, Group A showed a significantly longer postoperative hospital stay compared to Group B (5.71±5.062 vs. 4.27±2.931, P=0.014). In patients with Grade II acute cholecystitis with PTGBD insertion, DLC produces better outcomes with shorter hospital stay and operative time than ELC. These results suggest that DLC may lead to a better outcome than ELC, specifically when deciding the timing for laparoscopic cholecystectomy in patients diagnosed with acute Grade II cholecystitis.

Laparoscopy to Assist Surgical Decisions Related to Necrotizing Enterocolitis in Preterm Neonates.

Aim of the Study: Necrotizing enterocolitis (NEC) is a devastating intestinal disease that mainly affects preterm infants. Despite advancements in neonatal care, mortality of NEC remains high and controversies exist regarding the most appropriate time for surgical intervention and challenging of diagnosing NEC. Using a pig model of NEC, we aimed to examine if laparoscopy is feasible for diagnosis of NEC. Methods: Preterm caesarean-delivered piglets (n = 42) were fed with increasing amounts of infant formula up to 5 days to induce NEC. On days 3-5, we examined the intestine by laparoscopy under general anesthesia. The bowel was examined by tilting the pigs from supine position to the left and right side. Macroscopic NEC lesions were identified and graded according to a macroscopic scoring system, then a laparotomy was performed to rule out any organ injury and missed NEC lesions. Results: Visible NEC lesions (scores 4-6) were found in 26% (11/42) of the piglets. A positive predictive value of 100% was found for laparoscopy as a diagnostic marker of NEC in both colon and the small intestine. One piglet had a higher NEC score in the small intestine found at laparotomy, than at laparoscopy, resulting in a sensitivity of 67%, and a specificity of 100% for the small intestine. Conversely, both the sensitivity and specificity for colon was 100%. Acceptable levels of agreement was found, with minimal proportional bias in both colon and the small intestine for laparoscopy and laparotomy. Ultrasound examination had a lower sensitivity of 67% and specificity of 63%. All piglets were respiratory and circulatory stable during the procedure. Conclusions: In preterm piglets, laparoscopy is a feasible tool to diagnose NEC with a high positive predictive value and a high specificity.

Outcomes After Open Reduction With Internal Fixation of Mandible Fractures.

Mandible fractures contribute substantially to morbidity after blunt trauma. Controversy exists surrounding the appropriate timing of surgical intervention and benefit from routine postreduction imaging. The authors retrospectively reviewed 146 patients who sustained traumatic mandible fractures at a level 2 trauma center over a 5-year period, between January 2012 and December 2016. The authors excluded all patients who did not undergo surgery, underwent operative closed reduction only, sustained other significant maxillofacial injuries, penetrating mechanisms, and other major injuries based on injury severity scores (ISS) over 15. There were 51 patients meeting inclusion criteria. The authors reviewed admission face computed tomography (CT) scans and Panorex x-rays. Patients were divided into early (<72 hours) and late (>72 hours) open reduction with internal fixation (ORIF) groups. The authors reviewed demographics, mechanism of injury, postreduction imaging, and ISS. All statistical analyses were performed using Stata 15. There were 39 males (76%) and 12 females (24%) in the authors' study, with a mean age of 32 years. Twenty-eight patients (55%) underwent early ORIF and 23 patients (45%) underwent late ORIF, with no mortalities. There was no statistically significant difference in ISS between the 2 groups (P = 0.081). Preoperative face CT scans were performed in 49 patients (96%) and Panorex in 2 patients (4%). Eight patients (16%) had both modalities, with CT face identifying fractures in 5 patients not seen on Panorex, resulting in a change in operative approach. Postreduction imaging was obtained in 33 patients (65%), of whom 26 were Panorex X-rays. These demonstrated adequate reduction in 31 patients (94%) and did not change management in any instance. Complications occurred in 19 patients (37%), of whom there were 11 with uncontrolled pain after 1 week, 6 abscesses, 5 nonunions/malunions, 2 hardware extrusions, and 1 incisional dehiscence. A positive urine drug screen predicted uncontrolled pain (P < 0.05). There was no statistically significant difference in complications between the 2 groups. The authors' data suggest that CT scans of the face are superior to panoramic radiographs in traumatic mandible fracture evaluation, with no apparent benefit from routine postreduction imaging in detecting complications. Open reduction with internal fixation remains an effective treatment with favorable outcomes, and operative delays > 72 hours do not appear to increase complication rates.

The Role of Stereopsis and Binocular Fusion in Surgical Treatment of Intermittent Exotropia

Background/Aims: The purpose of this study is to identify the appropriate timing for surgical treatment of intermittent exotropia (XT) in the pediatric population by examining several parameters that may contribute to surgical planning. Methods: A retrospective chart review was conducted on patients between the ages of 3 and 17 years undergoing surgical management for intermittent XT. Preoperative and postoperative data regarding age, past medical history, visual acuity, stereopsis, magnitude of deviation and control was recorded. Medical records were reviewed and analyzed to determine if preoperative control of near misalignment, stereopsis, or presence of amblyopia may play a role in surgical outcome. Results: Ninety-five patients met inclusion criteria. Mean age was 6.71 years. Mean follow up period was 10.79 months. At least 140 sec arc of stereopsis using Titmus testing was present in 39.5% of patients preoperatively, while 55.8% of patients had less than 140 sec arc preoperatively, indicative of poor fusion at near. 47.2% of patients had good control of the near misalignment preoperatively, while 52.7% of patients had fair to poor control preoperatively. There was no statistically significant difference in surgical outcomes when comparing preoperative level of control of misalignment at near (P=0.2284) and stereopsis (P=0.2537). Presence of amblyopia preoperatively also had no association with surgical outcome (P=1.00). Conclusion: The use of worsening stereopsis and/or alignment control at near as parameters to determine the appropriate time for surgical intervention does not predict improved outcomes in patients with intermittent XT.

Cervical spine instability in the course of rheumatoid arthritis - imaging methods.

Cervical spine is affected in more than a half of patients with rheumatoid arthritis (RA). Depending on the degree of damage to the individual joints and ligaments RA-related cervical spine instability takes the form of atlanto-axial subluxation, subaxial subluxation or cranial settling. In the advanced cases spinal stenosis can occur as well as spinal cord injuries with typical neurological symptoms. The identification of patients with cervical spine instability before the occurrence of neurological complications still constitutes a diagnostic challenge.The article presents the methods of cervical spine imaging with the use of plain radiographs, magnetic resonance imaging (MRI) and computed tomography (CT). We discuss the advantages and disadvantages associated with each method and the possibility of its application in the diagnosis of cervical spine instability in RA. The knowledge of the above mentioned issues is indispensable to select an appropriate time for surgical intervention.

Atendimento inicial às queimaduras de mão: revisão da literatura

Aims: To address, through a literature review, the management of hand burns, with emphasis on the initial care. Methods: Between February and July 2015, 30 articles selected in the databases Medline/PubMed, LILACS, SciELO and Google Scholar were reviewed. Both the English and Portuguese languages were included in the search. Selected articles were published in the last 10 years and matched the following descriptors: hand burn; hand injury; acute treatment; primary treatment; and their counterparts in Portuguese. Results: Classification of burns is displayed, including depth, extent and aggravating factors. The initial management that avoid complications such as claw hand, compartment syndrome and infection is addressed. Early procedures include occlusive dressings, escharotomy, fasciotomy, and carpal tunnel opening, followed by dressings with topical antimicrobial agents, debridement and grafting. Controversial aspects are discussed on the most appropriate time for surgical intervention, if it is necessary. Conclusions: The correct early approach to hand burns can prevent irreversible consequences. The appropriate management on hand burns includes since the initial clinical evaluation of the burned area by a general practitioner, to the realization of early procedures in order to prevent limb function loss and unnecessary future reconstructions. The high incidence of this type of burn also stresses the importance of a proper conduct.

Appropriate timing of surgical intervention for the proximal type of cervical spondylotic amyotrophy.

The purposes of this study were to evaluate the clinical outcome after surgical treatment of patients with the proximal type of cervical spondylotic amyotrophy (CSA) and to explore the appropriate timing for surgical intervention. A retrospective review was performed on a consecutive cohort of 41 patients who underwent surgical treatment for the proximal type of CSA between 1995 and 2011 at the Nagoya Spine Group Hospitals. We collected information regarding age, type of muscle atrophy, preoperative and final manual muscle test, duration of symptoms, high-intensity areas on T2-weighted MRI images, low-intensity areas on T1-weighted MRI images, levels of spinal canal stenosis, the compression lesion site, cervical kyphosis and surgical procedures (laminoplasty, anterior spinal fusion and posterior spinal fusion). Univariate analyses and multivariate logistic regression analysis were performed to identify correlates of a poor outcome. To explore the appropriate timing for performing surgery, we analyzed the data using receiver operating characteristic (ROC) analysis. The duration of CSA symptoms was 11.6 months on average. The surgical results were excellent for 25 patients, good for six, fair for nine and poor for one. On multivariate logistic regression analysis, the duration of symptoms was statistically associated with a poor surgical outcome (OR 1.393, p = 0.011). ROC analysis demonstrated that 4.3 months from the onset of CSA symptoms was the appropriate time to undergo surgery. Our results indicate that we should recommend surgical intervention to patients with the proximal type of CSA within about 4 months after the onset of symptoms if conservative treatment has not been successful.

Visual outcomes in treated bacterial keratitis: four years of prospective follow-up.

We described the change in visual acuity experienced by eyes successfully treated for bacterial keratitis. This was a prospective cohort study of a subset of study participants who had previously enrolled in the Steroids for Corneal Ulcers Trial (SCUT). All study participants had been diagnosed with culture-proven bacterial keratitis before enrollment in SCUT and subsequently were randomized to adjunctive topical corticosteroids or placebo. During SCUT, we monitored study participants at enrollment, 3 weeks, 3 months, and 12 months. We invited a subset to complete a comprehensive eye examination approximately 4 years after enrollment in SCUT. Certified refractionists assessed best spectacle-corrected visual acuity (BSCVA) using the same protocol at each study visit. We examined 50 SCUT participants at 4 years after enrollment. Among those in this cohort, mean logMAR BSCVA at enrollment was 0.85 (Snellen equivalent, 20/160; 95% confidence interval [CI], 0.71-0.99). On average, visual acuity improved by 2.9 logMAR lines from enrollment to 3 weeks (P < 0.001), 1.2 lines from 3 weeks to 3 months (P = 0.002), and 0.8 lines from 3 to 12 months (P = 0.01). The BSCVA did not change significantly between 12 months and 4 years (0.04-line improvement, P = 0.88). After controlling for visual acuity at enrollment, BSCVA was not significantly different between the corticosteroid and placebo groups at 4 years (P = 0.53). Cases of bacterial keratitis may continue to demonstrate improvements in visual acuity up to 12 months following diagnosis, but further improvements are unlikely. These findings may guide the appropriate timing of surgical intervention in these patients. (ClinicalTrials.gov number, NCT00324168.).

On a definition of the appropriate timing for surgical intervention in orthognathic surgery

Together with the introduction of new orthodontic techniques and minimally invasive surgery protocols, the emergence of modern patient prototypes has given way to novel timing schemes for the handling of dento-maxillofacial deformities. The aim of this study was to define, justify, and systematize the appropriate timing for orthognathic surgery. A retrospective analysis of orthognathic surgery procedures carried out over a 3-year period was performed. Six timing schemes were defined: ‘surgery first’, ‘surgery early’, ‘surgery late’, ‘surgery last’, ‘surgery only’, and ‘surgery never’. Gender, age at surgery, main motivation for treatment, orthodontic treatment length, and number of orthodontic appointments were evaluated. A total of 362 orthognathic procedures were evaluated. The most common approach was ‘surgery late’. While aesthetic improvement was the leading treatment motivation in ‘surgery first’, ‘surgery early’, and ‘surgery last’ cases, occlusal optimization was the chief aim of ‘surgery late’. Sleep-disordered breathing was the main indication for treatment in ‘surgery only’. Compared to ‘surgery late’, orthodontic treatment was substantially shorter in ‘surgery early’ and ‘surgery first’ cases, but the number of orthodontic appointments was similar. In conclusion, the skilful management of dento-maxillofacial deformities requires a comprehensive analysis of patient-, orthodontist-, and surgeon-specific variables. Each timing approach has well-defined indications, treatment planning considerations, and orthodontic and surgical peculiarities.

The role of internal fixation for long bone metastasis prior to impending fracture: an experimental model

BackgroundPatients with long bone metastasis have many therapeutic options, including surgery. However, the appropriate time for surgical intervention and the use of internal fixation prior to impending fracture remains controversial. The purpose of this study was to establish a long bone metastatic model with internal fixation, and to determine whether prophylactic internal fixation for long bone metastasis prior to impending fracture would affect bone destruction, tumor progression, and mortality. Materials and methodsWe implanted VX2 tumor cells into the tibiae of 45 rabbits divided equally into three groups: internal fixation, control, and sham groups. Rabbits were monitored by X-ray and computed tomography, and blood serum levels were examined every 2weeks. ResultsComputed tomography data revealed significantly higher bone destruction in rabbit tibiae in the sham and control groups compared with those in the fixation group; there were volumetric bone losses of 0.2, 0.4, and 2.3% in the fixation, sham, and control groups, respectively, at 3weeks, which increased to 1.2, 2.5, and 6.1% at 5weeks. Rabbits in the fixation group showed significantly prolonged survival (64.5±13.5days) in comparison with rabbits in the sham group (50.3±11.6days) and control group (38.2±4.9days). ConclusionOur results suggest that prophylactic internal fixation may hinder bone destruction and tumor progression, thus extending the survival period for patients with long bone metastasis.

English

Congenital facial paralysis or facial paralysis at birth may be partial or complete. It may be idiopathic in nature or secondary to either birth trauma, tumors or other intrauterine environmental anomalies. Prompt diagnosis and appropriate timing of surgical intervention would improve quality of life if not complete functional restoration. Present article reports one such 60 years old male still waiting for treatment.

The patient pathway for mitral valve surgery

Mitral valve disease can present as mitral regurgitation or mitral stenosis, causing the valve to leak or to narrow. In extreme cases the papillary muscle can rupture and the patient presents as an acute emergency. Patients with mitral disease will develop congestive heart failure and associated arrhythmias. The condition requires pharmacological intervention for symptom control and careful monitoring to assess when surgical intervention is indicated. Decisions regarding appropriate timing of surgical intervention should be made following discussion among the whole multidisciplinary team and patients should have the opportunity to learn about all their surgical options. Once a decision to operate (whether repair or replacement) has been made, the patient embarks on a process of preoperative screening and assessment, which is outlined in this article together with postoperative care.

OEvaluation of Ultrasonography as a Diagnostic Tool in Maxillofacial Space Infections

ABSTRACTObjectivesThe purpose of the study was to establish the role of ultrasonography in determining the involvement of specific fascial spaces in maxillofacial region and the stage of infection, in indicating the appropriate time for surgical intervention and to compare clinical and ultrasonographic findings.Material and MethodsTwenty five patients with fascial space infection in maxillofacial region were subjected to ultrasonographic examination following a detailed clinical and radiological examination. Ultrasonography guided needle aspiration was performed. Based on the findings, patients diagnosed with abscess were subjected to incision and drainage and those with cellulitis were subjected to medical line of treatment.ResultsMore than one fascial space was involved in all patients. On clinical examination 64 spaces were involved, of them 34 spaces had abscess formation and 30 spaces were in the stage of cellulitis. On ultrasonography examination, 28 spaces were reported to have abscess formation and 36 spaces were diagnosed to be in the stage of cellulitis. On comparative analysis of both clinical and ultrasonographic findings, ultrasonography was found to be sensitive in 65% of the cases and having specificity of 80%. It was registered statistically significant (P < 0.001) agreement between these two methods of assessment (kappa index = 0.814). ConclusionsUltrasonography is a quick, widely available, relatively inexpensive, and painless procedure and can be repeated as often as necessary without risk to the patient. Thus ultrasonography is a valuable diagnostic aid to the oral and maxillofacial surgeon for early and accurate diagnosis of fascial space infection, their appropriate treatment and to limit their further spread.