Patient Size Research Articles

Pitfalls in the diagnosis of gallbladder disease in clinically severe obesity.

Cholelithiasis affects 10-20% of the USA population, with higher incidence in certain ethnic groups. Obesity is associated with an increase in gallstone formation, reported in up to 45% of morbidly obese patients. Ultrasound is the best diagnostic tool, although its accuracy is less in this particular population. This paper discusses false negative sonographic findings in morbid obesity. Retrospective review of 5257 patients submitted to bariatric surgery. Cholecystectomy had previously been performed in 16%. Gallbladder ultrasound was obtained in the remaining group, and cholecystectomy was done based on this information and/or intraoperative observations. Radiology results and surgical findings were correlated with pathology reports. Misread films were reviewed by a radiologist blind to these reports. The series consisted of 88% females. Mean age, weight and percentage overweight were 37 years, 125 kg and 105%, respectively. Cholecystectomy was performed in 3084 patients (59%). Discrepancies between radiological and pathological findings were found in 35 cases (1.1%). Five correct diagnosis of lithiasis also had gallbladder hydrops. Four 'inconclusive' and 20 'negative' studies showed definitive pathology. In six cases of 'non/poor visualization', lithiasis was encountered. Preoperative gallbladder ultrasound is mandatory in bariatric surgery. Results are accurate and false-negative reports rare if sonographers and radiologists are experienced. Non/poor visualization is usually due to technical problems or gallbladder pathology, not due to the patient's size. False-negative results are commonly caused by soft stones, microlithiasis or polypoid cholesterolosis. Single calculus impacted in the cystic duct can produce hydrops, resulting in a negative sonogram.

239 ハイレーション防止に効果的であった左心室造影(LVG)時における造影剤濃度の検討

239 ハイレーション防止に効果的であった左心室造影(LVG)時における造影剤濃度の検討

Late left ventricular function after surgery for children with chronic symptomatic mitral regurgitation.

The use of quantitative echocardiography has been emphasized in optimizing timing of surgery in adult patients with mitral regurgitation to avoid irreversible left ventricular dysfunction. In contrast, surgery for infants and children is often delayed until the appearance of severe symptoms because of the patient's size and anticoagulation requirements and the possible need for early reoperation. The purpose of this study was to determine long-term ventricular function after mitral valve surgery in symptomatic children and to analyze risk factors for adverse outcome. Thirty-three patients (0.5 to 19 years old) operated on for mitral regurgitation as a single hemodynamically significant lesion were studied. All but 3 had medically refractory symptoms. One patient died during surgery, and 32 were followed for 0.3 to 17.1 years (mean, 4.5 years). The mean preoperative left ventricular shortening fraction was 0.38+/-0.09. Successful mitral valvuloplasty or replacement was documented by long-term normalization of end-diastolic dimensions. Early postoperative shortening fraction was significantly reduced (0.28+/-0.1, P<.01), but it improved to 0.40+/-0.07 (P<.01) on late follow-up, at which time only 1 patient had ventricular dysfunction. Preoperative shortening fractions did not correlate well with early or late postoperative values (r=.18 and r=.31, respectively). Seven of 32 surviving patients had preoperative shortening fractions <0.33 (mean, 0.26+/-0.05) and 25 >0.33 (mean, 0.39+/-0.08). Analysis of these subgroups showed no significant differences between the groups in early or late postoperative function. Duration of mitral insufficiency appeared to be associated with the development of atrial arrhythmias. Late left ventricular function normalizes in children after surgical correction of mitral insufficiency. In contrast to adults, delay of surgery in children with significant mitral regurgitation until the onset of severe symptoms does not increase the risk for long-term ventricular dysfunction, although late atrial arrhythmias are more likely to be encountered.

F-18 FDG Uptake by Recurrent Hürthle Cell Carcinoma of the Thyroid Using High-Energy Planar Scintigraphy

F-18-2-deoxy-2-fluoro-D-glucose (FDG) has been reported to localize in various tumors. Localization or recurrent Hürthle cell cancer with FDG is described. An unsuccessful attempt was made to image this patient's tumor with I-131 and Tc-99m MIBI. Because of the patient's size, he could not be accommodated in the PET camera apperature. Use of a planar high energy gamma camera facilitated detection and ultimate treatment.

Laparoscopic Nissen fundoplication in disabled infants and children

During a 16-month period, 15 neurologically impaired infants and children for whom medical treatment failed underwent laparoscopic fundoplication. The indications for surgery included feeding difficulties, vomiting, and recurrent chest aspiration. The patients' weight range was 3.9 to 42 kg (6 weighed less than 12 kg). Access was modified according to each patient's size and shape. The average operating time was 2.2 hours (range, 1.4 to 3) for fundoplication and 3.1 hours (range, 2.3 to 4.1) for fundoplication with gastrostomy. Two patients had conversion to open surgery because of hypercarbia or perforated oesophagus. Use of postoperative analgesia was limited to the first 24 hours, and fluid intake and feeding were begun on days 1 and 2, respectively. Gas bloating was common postoperatively, and diarrhoea developed in three children. Twelve patients had clinical improvement, and a recurrent hiatus hernia developed in one. Laparoscopic fundoplication can be successful; however, awareness of the differences in technique for paediatric (disabled children in particular) and adult patients is essential. The technique deserves further investigation.

Value of body plethysmography in preoperative assessment of thoracotomy candidates.

The usefulness of body plethysmography in the assessment of thoracotomy candidates is not well documented. Reported thresholds for operability are generally expressed in absolute values, which do not take into account a patient's size, age or gender. Spirometric and plethysmographic data of 103 patients undergoing thoracotomy were examined for their ability to predict death due to cardiopulmonary insufficiency, pneumonia, and atelectasis during the first 30 postoperative days. Neither plethysmographic nor spirometric parameters could predict atelectasis. Patients who underwent lobectomy were susceptible to the development of atelectasis. A weak correlation between elevated functional residual capacity (FRC) and occurrence of postoperative pneumonia was found. Lung function testing was not able to separate survivors from non-survivors. Patients with pneumonia were at high risk of death in their postoperative course. Because of the non-linear relationship, a correlation coefficient between spirometric and plethysmographic variables was not calculated. The prevalence of cardiac risk factors was high, so the decision for invasive hemodynamic studies should rather be based upon a patient's history than restricted to patients with impaired lung function. Because of methodological differences, and probably insuitable reference values, body plethysmography cannot substitute for spirometry. For FRC and FRC to total lung capacity (FRC/ TLC) ratio, further investigations must be undertaken to establish a correct reference value.

MR IMAGING TECHNIQUES FOR SOFT-TISSUE LESIONS

MR imaging is the technique of choice for detection, characterization, and staging of soft-tissue neoplasms. MR examinations need to be tailored to each patient based upon the patient's size and anatomic region of interest so that optimal information is obtained. Technique is critical. Proper positioning to allow patient comfort and reduce motion artifacts is essential. Selection of the appropriate coils, image planes, and optimal pulse sequences to identify and determine the extent of lesions is critical for therapy planning.

The relationship between left mainstem bronchial diameter and patient size

Knowledge of a patient's left mainstem bronchial diameter would provide a useful guide to choosing the appropriate double-lumen tube (DLT) size for that patient. Therefore, the authors investigated the possibility that left bronchial diameter could be predictably estimated from a patient's size and sex. The routine preoperative chest X-rays of 100 adult male and female patients of known age, height, and weight were examined. The left bronchial diameter was measured on the posteroanterior (PA) chest x-ray, and a formula was used to correct for the magnification of intrathoracic structures encountered on the PA view. Multiple linear regression analysis was used to determine whether one or more of the variables (age, sex, height, weight, and body surface area) had a predictable relationship to the left bronchial diameter. The left mainstem bronchial diameter in men and women (mean +/- SD/range) was 12.4 +/- 1.5 mm/9.5 to 15.5 mm, and 10.7 +/- 1.0 mm/9.0 to 14.0 mm, respectively. In female patients, none of the variables was significantly correlated with bronchial diameter. In male patients, age (p = 0.013) and height (p = 0.008) individually produced a statistically significant prediction of endobronchial diameter. The following formula was best predictive of left bronchial diameter in men: diameter (mm) = 0.032 x age (year) + 0.072 x height (cm) -2.043. Applying this formula to mean age 50 who are 158, 172, and 185 cm in height, the predicted left bronchial diameters are 11.0, 12.0, and 13.0 mm, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Standardization in Reduction Mammaplasty

Reduction mammaplasty is enhanced by the use of more than one technique. By comparing the results of my reduction mammaplasties, over the past 20 years, aided by computer imaging and standardization. I set up some guidelines. The following parameters were selected: age, size of breast, weight, torso build, skin tone and texture, skin color, hereditary factors, degree of ptosis, and the patient's size request. The postoperative evaluations are based on volumetric reduction of size, appearance of scar, geometric appearance of the breasts in harmony with the torso build, nipple position, and patient satisfaction. These comparisons enabled me to provide recommendations for a variety of techniques to address the needs of different patients.

The role of bone scintigraphy in detecting child abuse

This review of diagnostic imaging in cases of suspected child abuse characterizes the significant differences between bone scintigraphy and x-ray evaluation, describes the advantages and disadvantages of each modality, postulates on the specific mechanisms of injury that produce the characteristic scintigraphic findings, and emphasizes the influences that scintigraphic studies have on the medical, social, and legal aspects of child abuse. The major advantages of bone scintigraphy are its increased sensitivity (25% to 50%) in detecting evidence of soft tissue as well as bone trauma in child abuse. Furthermore, it is postulated that the specific mechanisms of inflicting the trauma relate to the patient's size and are characterized by bone scintigraphy. During fits of anger or frustration, the perpetrator of child abuse grasps the small infant or child by the thorax during the shaking activity. This produces characteristic rib injuries. The older and heavier child is more likely to be grabbed by the extremities, which produces periosteal injuries manifested as characteristic abnormal localizations in the diaphyses of the extremities. The roentgenograms of these injuries are frequently normal. The importance of bone scintigraphy is its complementary nature in defining and characterizing the extent and severity of trauma from child abuse. Such findings have direct bearing on the medical, social, and legal outcomes for the abused child. The quality of scintigraphic imaging is important, requiring the use of magnification techniques in the infant. The interpretation of the scintigraphic images depends on an understanding of the mechanisms by which the radionuclide localizes in bone. The same traumatic incident can lead to decreased, normal, or increased localization at the trauma site. Radionuclide scintigraphy is a complementary rather than competitive imaging modality to X-ray evaluation in the diagnosis and management of physical child abuse.

The use of blood products in paediatrics

Transfusing children with blood and blood products requires special consideration of the patient's size, disease status and immunocompetence. Despite improved quality and safety of blood components the continuing risk of viral transmission dictates that every attempt should be made to reduce exposure to homologous blood. While many guidelines apply to all paediatric patients there are specific requirements for neonates, children with bone marrow failure and haemoglobinopathies, and children receiving large volume transfusions during surgery. These will therefore be discussed separately.

Transcatheter management of cyanotic congenital heart defects: a review.

In this review, the role of transcatheter methods in the management of cyanotic congenital heart defects is discussed. In patients with interventricular right-to-left shunting secondary to pulmonary outflow tract obstruction (most commonly tetralogy of Fallot), balloon dilatation may be an effective palliative procedure in a substantial proportion of patients, obviating the need for a palliative shunt. We would recommend this if the patient's size or cardiac anatomy makes that patient an unsuitable candidate for safe total surgical correction. Infundibular myectomy with atherectomy catheter in tetralogy of Fallot patients may become a useful adjunct in the management of these infants. Cyanotic children with interatrial right-to-left shunt secondary to severe valvar pulmonary stenosis respond to balloon pulmonary valvuloplasty in a manner similar to that seen with isolated pulmonary valve stenosis. In these patients, balloon valvuloplasty is the treatment of choice and may be corrective in most cases. In patients with a narrowed Blalock-Taussig shunt, balloon angioplasty may improve pulmonary oligemia and systemic arterial hypoxemia and may obviate the need for a second systemic-to-pulmonary artery shunt. Balloon angioplasty is recommended if the patient's cardiac defect is not amenable to surgical correction at a low risk either because of the size of the patient or because of the complexity of the cyanotic heart defect. In patients with pulmonary valve atresia, initial opening of the atretic pulmonary valve by either laser or surgery with subsequent balloon dilatation is potentially beneficial in reducing the total number of surgical procedures that these children are likely to require. However, further clinical trials are needed prior to their general use.

Immune globulin therapy

MMUNOGLOBULINS are protein components of the humoral part of the immune system. They are produced by the B lymphocytes and plasma cells. There are five major classes of immunoglobulins: IgG, IgM, IgA, IgD, and IgE. IgG constitutes the major immunoglobulin in the blood. In the late 1800s, Paul Ehrlich produced an antitoxin to diphtheria which became the first recognized ~/-globulin therapy, i The first available preparation for use of immune globulins was developed in the 1930s. 2 In 1946, a fractionation technique was developed by Cohn and associates to prepare serum immune globulin for commercial use. 3 The product was injected intramuscularly (IM), had relatively few side effects, and was used for prophylaxis against diseases such as measles and hepatitis A. The first clinical use in children was in patients with congenital immune deficiency characterized by absent ~/-globulins and recurrent pneumococcal sepsis. 4 Problems associated with the use of intramuscular ,/-globulins are well recognized and include pain following injection, limit on volume that can be administered in one injection site depending on the patient's size (usually no more than 5 to 10 mL per site), loss of IgG into extravascular tissue, a 4to 7-day lag before therapeutic levels are achieved, and degradation of antibody at the injection site. 5 These limitations led to the development of intravenous (IV) preparations by Swiss scientist Paul Imbach in the late 1970s. 6 In 1981, the first commercially available intravenous immune globulin (IVIG) product in the United States was approved by the Federal Drug

The relationship between oxygen demand, oxygen uptake, and oxygen supply

Results of the relationships between oxygen supply, demand, and uptake can be used to interpret cardiac output values, identify types of acute circulatory failure, guide attempts to improve cellular function, and thus prevent the development of multiple organ failure and death. Five steps in the interpretation of cardiac output values are recommended: (1) relate cardiac output to the patient's size; (2) determine the presence of anemia or hypoxemia; (3) measure mixed venous O2 saturation and (4) blood lactate levels; and (5) evaluate O2 uptake before and after a transient increase in cardiac output.

Obesity: A Risk Factor in the Burn Patient

Obesity is seldom recognized as a risk factor for the patient with burns. However, the overweight patient with burns presents major problems for the burn team, especially in the areas of wound care, pulmonary care, and general nursing care. One-hundred eighty adults (9.1% weighed more than 45 kg above ideal body weight or more than 100 kg in total weight. Mean weight was 110 kg, with 155 patients heavier than 100 kg. Mean age was 38 years with a mean burn size of 26% (11% full-thickness). The mortality rate was 21%, and respiratory and cardiovascular complications occurred in 33% of these patients. The obese patient presents problems disproportionate to burn size, burn location, and age. The obese patient's problems are related to weight. Care is often compromised by the physical constraints of a patient's size.

Failure of Pulse Oximetry to Detect Severe Hypoxia: Importance of Sensor Selection

Pulse oximetry is an effective method for non-invasive monitoring of arterial saturation. Clinically important overestimates of arterial saturation have not been previously reported. The magnitude of arterial desaturation in an infant with tetralogy of Fallot undergoing cardiac catheterization was not recorded correctly because of selection of an inappropriate probe for the patient's size.

Endoscopic sizing: An attempt at uniformity

The inside and outside diameters of all endoscopes and tracheotomy tubes in the endoscopy suite were systematically measured. These measurements were correlated with the manufacturer's stated size and comparisons noted. A lack of uniformity was noted often among and between all product lines. In addition, endoscopes and tracheotomy tubes were not uniformly labeled with inside and outside diameters. As a result, the proper choice of a tracheotomy tube or endoscope for a patient's size and age may be confusing. A chart was developed and included in order to allow quick and accurate recognition of tracheotomy tube and endoscope sizes across product lines to aid in the proper selection of tracheotomy tubes and endoscopic equipment.

The end of the crystalloid era?

Summary The metabolic response to surgery causes sodium and water retention. It does not seem logical to pour crystalloid solutions into patients in the peri-operative period, particularly when these solutions can cause deterioration in lung function. Plasma volume must be maintained to prevent a decreased blood flow to vital organs such as the kidneys. Blood or colloid solutions, not crystalloid solutions, should be used for this purpose, since the latter are distributed throughout the whole extracellular space and are less effective in maintaining plasma volume. Water given as 5% dextrose should be given in minimal quantities to maintain intracellular hydration. Patients undergoing minor to moderate surgery when they are likely to be drinking within 24 hours do not usually require any intravenous infusion. Moreover, to administer intravenous fluids to these patients may cause harm. No fluid regimens should be inflexible and the patient's size, age and fluid losses should be taken into account.

The end of the crystalloid era? A new approach to peri-operative fluid administration.

The metabolic response to surgery causes sodium and water retention. It does not seem logical to pour crystalloid solutions into patients in the peri-operative period, particularly when these solutions can cause deterioration in lung function. Plasma volume must be maintained to prevent a decreased blood flow to vital organs such as the kidneys. Blood or colloid solutions, not crystalloid solutions, should be used for this purpose, since the latter are distributed throughout the whole extracellular space and are less effective in maintaining plasma volume. Water given as 5% dextrose should be given in minimal quantities to maintain intracellular hydration. Patients undergoing minor to moderate surgery when they are likely to be drinking within 24 hours do not usually require any intravenous infusion. Moreover, to administer intravenous fluids to these patients may cause harm. No fluid regimens should be inflexible and the patient's size, age and fluid losses should be taken into account.

Permanent Cardiac Pacemakers in Children: Technical Considerations

Placement of permanent cardiac pacemakers in children presents technical problems that are not encountered in the adult. Problems unique to pacemaker implantation in children are related to the patient's size, the relative bulkiness of pulse generators, the lack of subcutaneous tissue, and the child's growth and long life expectancy. Based on our experience with implantation of 27 permanent cardiac pacemakers in 13 children, we have found that the use of small pulse generators, placement of epicardial leads, insertion of properitoneal pulse generators, and use of rechargeable pacemakers are satisfactory methods in children.