Referral For Surgical Intervention Research Articles

Gender inequality and cardiovascular diseases

Despite generally accepted recognition of the difference in characteristics and outcomes of cardiovascular diseases between men and women, implementation of a gender and sex-specific approach for the treatment of women in clinical practice has been extremely slow or non-existent. Women continue to be hospitalized at later stages of the disease, receive less aggressive medical care, often experience recurrent symptoms of the disease, and have a lower quality of life. Furthermore, sex biased research and significant knowledge gaps still persist. Meanwhile, women's cardiovascular health requires not only sex-specific research, but also an acknowledgement of the complex interaction of gender and sociocultural aspects that influence women's lives and cardiovascular outcomes. Developing sex and gender-specific algorithms for timely diagnosis, risk stratification, follow-up, and referral for surgical intervention, incorporating sex and gender into research, and studying the mechanisms of differences may help reduce the gap in outcomes between women and men. The aim of the article is to provide a framework of current barriers for cardiac female patients and to equip physicians with information about potential solutions. This article covers terminology and relevant aspects of the subject of cardiovascular inequalities, history of inclusion of women in clinical trials, women's mortality rates for cardiac surgery, and tips on managing the problem.

A Detailed Review of Surgical Management of Uncommon Cutaneous Disorders.

A varietyof cutaneous disorders can present to the general surgeon either directly or by referral for surgical intervention. Some conditions are commonly seen and operated on by general surgeons which include lipoma, epidermoid cyst, etc.On the other hand, some areuncommon conditions like dermatofibrosarcoma protuberans and chondroid syringoma which require a high index of suspicion to diagnose. Most general surgeons are not familiar with the latest guidelines to treat such uncommon conditions. In this article, we provide a review of uncommon cutaneous disordersrequiring surgical intervention that were encountered at our high-volume tertiary care centerand a discussion about their etiology, presentation, diagnosis, management and follow-up with one case report of each condition. The objective of this article is to familiarize the general surgeon with thesecutaneous disorders which though uncommon, will present in their practice at some point.

Prognostic implications of staging right heart failure in patients with significant tricuspid regurgitation undergoing tricuspid valve surgery

Abstract Introduction Mortality of tricuspid valve (TV) surgery for severe secondary tricuspid regurgitation (TR) remains relatively high. Current guidelines advise surgery in patients with symptomatic severe TR as a concomitant procedure to left-sided valve surgery. Right ventricular (RV) dysfunction is an important prognostic marker and may appear late in the natural history of TR. How a staging algorithm of right heart failure (RHF) may impact on TV surgery outcomes has not been evaluated. Purpose To evaluate the impact of staging RHF on survival of patients with significant TR undergoing TV surgery. Methods Patients diagnosed with significant (moderate and severe) TR who subsequently underwent TV surgery, were staged into 4 groups of progressive disease according to the diagnosis of RV dysfunction and the presence of RHF: stage 1, at risk for RHF; stage 2, RV dysfunction without clinical symptoms of RHF; stage 3, RV dysfunction with symptoms of RHF, and stage 4, RV dysfunction with refractory symptoms of RHF (Figure 1). The study endpoint was all-cause mortality. Results A total of 279 patients (mean age 64±12 years, 49% male), were included in the analysis, of which 20 patients (7%) were in stage 1, 14 patients (5%) were in stage 2, 141 patients (51%) were in stage 3 and 104 patients (37%) were in stage 4. The majority of the patients (266 patients, 95%) underwent TV annuloplasty. Most patients had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting (254 patients, 91%). In per-group analysis, patients in stage 4 had significantly larger left ventricular (LV) and RV dimensions, lower LV ejection fraction and more severe diastolic dysfunction than patients in other RHF stages. During a median follow-up of 65 [15 - 106] months after TV surgery, 145 deaths (52%) occurred. The cumulative survival rates were 88%, 77% and 60% at 1 month, 1 year and 5 years, respectively. The Kaplan-Meier curves for overall survival according to RHF stage are shown in Figure 2. Survival rates at 5 years were significantly worse in more advanced stages of RHF: 71% (stage 1 and 2), 66% (stage 3) and 49% (stage 4); log-rank chi-square: 11.302; p=0.004. Right heart failure stage was independently associated with all-cause mortality following adjustment for age, gender, LV ejection fraction, kidney function, TV annulus diameter, concomitant mitral valve surgery and time delay from diagnosis until surgery (p=0.021). Conclusion Patients diagnosed with significant TR may benefit from earlier referral for surgical intervention, before presenting with RV dysfunction and before the onset of symptoms of RHF. Funding Acknowledgement Type of funding sources: None. Figure 1. Stages of right heart failureFigure 2. Kaplan-Meier curves for overall survival

Examining the forgotten valve: outcomes of tricuspid valve surgery, a 15-year experience.

We have entered an era of renewed interest in novel approaches to surgical intervention and minimally invasive and transcatheter technique. With an aging population, isolated tricuspid valve regurgitation incidence is rising; however, referral for surgical intervention remains low. We undertook this retrospective review to assess outcomes and challenges associated with tricuspid valve intervention. A comprehensive retrospective review of all patients undergoing tricuspid valve intervention in our institution between 2004 and 2018 was carried out. A total of 259 patients who underwent a tricuspid intervention between 2004 and 2018 were identified. Of those, 229 underwent a repair and 30 underwent a replacement. Median survival for repair was 3124days, and replacement was 2294days. In-patient mortality was 12% for those undergoing repair and 7% for the replacement patients. Of those undergoing redo tricuspid valve intervention, eight patients (61.5%) were alive at most recent follow-up. Eight patients required intraoperative pacemakers, 2 required postoperative pacemakers. Of those who had intraoperative epicardial pacing systems placed, 5 of the 8 remained pacing dependent on most recent follow up. Beyond technical challenges, decision making regarding pacemaker requirement requires further exploration. Redo tricuspid valve surgery carries a significant mortality risk and consideration should be given to earlier intervention in this context.

Steroids have no place in the management of cervical myelopathy

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in adults in Western society. Very little has been written about it in Nigeria. This would give the impression that it is rare in Nigeria. Unfortunately, this is not the case and having seen a few patients now in Abuja, we can appreciate some of the real issues. Patients with cervical spondylotic myelopathy are not being properly diagnosed and managed. It is often thought to be a disease of old age and part of life. Others feel that old age and infirmity preclude management and so patients are not referred to hospital. Families also at times prefer local management with traditional healers. Finally, patients are often treated only by general practitioners, general medicine physicians and neurologists. We have now seen a few patients who have been treated long term for CSM by neurologists without referral for surgical intervention. Patients having been seen are placed on long term steroid therapy, vitamin C and analgesics and neuropathic pain medicines such as Carbamazepine, Gabapentin and Pregabalin. Our perspective is that such treatment especially for moderate or severe CSM is of little benefit to address the fundamental and underlying problem in CSM. In our opinion, steroid use is not necessary and predisposes patients to diabetes, osteoporosis and avascular necrosis of the head of femur. The other two key problems in the past were poor availability of MRI scans and spine trained neurosurgeons.

Analysis of chronic obstructive pulmonary disease referrals for lung volume reduction surgery. The University of California San Diego Emphysema Treatment Group.

Preliminary results of lung volume reduction surgery (LVRS) for patients with severe emphysema are promising, although many issues regarding the selection process for LVRS are still unaddressed. For example, it is unclear which patients should be referred for pulmonary rehabilitation, lung transplantation, or LVRS, and whether health-care providers are optimizing conservative treatment options before referral for surgical intervention. The purpose of this analysis is to describe preliminary results of the evaluation process for LVRS implemented as part of an integrated, programmatic approach to the evaluation, treatment, and rehabilitation of patients with advanced emphysema. The records of 105 consecutive patients with chronic obstructive pulmonary disease (COPD) referred for consideration for LVRS at the University of California San Diego Medical Center were reviewed. Results of prospective data collection pertaining to patient demographic, baseline dyspnea scores, and history of prior treatment, including pulmonary rehabilitation, were extracted. Patient disposition after the evaluation was noted. One hundred five patients (mean age 65 years, range 40 to 84 years) completed evaluation. Fifty-eight had never before participated in pulmonary rehabilitation, and 47 of these patients were eventually referred to a rehabilitation program. Fourteen patients were referred for consideration of lung transplantation, 25 were considered eligible for LVRS, 13 were still undergoing rehabilitation and surgical eligibility had not yet been determined, and 53 were ineligible for LVRS because patients had other illnesses (n = 34), did not meet radiological or physiologic criteria (n = 5), were considered too ill (n = 5), or were too healthy (n = 9) after rehabilitation to warrant surgical intervention. Lung volume reduction surgery is a surgical option to be considered within the framework of an integrated medical evaluation program that includes pulmonary rehabilitation. Pulmonary rehabilitation remains an often underused therapeutic alternative in patients with severe COPD. It has become the central component of our comprehensive management program for patients with severe dyspnea and deteriorating quality of life.

Understanding and Assessing Communicative Disorders in Children

The pediatrician is frequently confronted with the problem of diagnosis and treatment of preschool-aged children suspected of having middle ear disease and speech / language impairments. Guidelines for referral of these children (otolaryngologist, audiologist, speech therapist) have not been clearly defined. The use of tympanometry and acoustic reflex testing was described to assist in the diagnosis of middle ear pathology, to provide an objective way to monitor spontaneous or antibiotic-induced remissions and to determine more accurately when a referral for surgical intervention is needed. A 35-item screening test is described, permitting speech and language assessments in the office and quantifying and comparing with age peers: vocabulary, articulation, receptive language and expressive language abilities. These office interventions enhance the physician's ability to judiciously recommend consultations.