Role In Preoperative Evaluation Research Articles

Frequency of Readmission Among American Society of Anesthesia Classification after Total Hip and Total Knee Arthroplasty

Background: With the aging population and the increasing prevalence of degenerative joint diseases, the need for total joint arthroplasty (TJA) has surged. The American Society of Anesthesiologists (ASA) Physical Status Classification System plays a pivotal role in preoperative evaluation, predicting the risk of postoperative complications and mortality. Understanding the impact of ASA classification on surgical outcomes can guide improvements in patient care and surgical planning. Objective: This study aimed to investigate the relationship between ASA classification and the risk of postoperative readmission in patients undergoing total joint arthroplasty. Methods: Conducted at a single urban medical center, this descriptive, non-randomized study involved 352 patients who underwent primary TJA due to osteoarthritis, rheumatoid arthritis, or avascular necrosis. Participants were assigned an ASA classification preoperatively. The primary outcome measured was readmission within three months post-surgery, with secondary outcomes including the incidence of complications such as deep vein thrombosis (DVT), pulmonary embolism, and surgical site infections. Data were analyzed using SPSS version 21, with significance set at p<0.05. Results: Of the 352 participants, 165 (46.9%) were from rural areas, and 187 (53.1%) were from urban locations. The readmission rate was 6.8%, with ASA III and IV classifications showing significantly higher readmission rates (9.7% and 28.6%, respectively) compared to ASA I and II (1.8% and 4.4%). The most common reasons for readmission were chest infections (37.5%), followed by cardiac complications, pulmonary embolism, and neurological complications (20.8% each). The study found a significant correlation between higher ASA classification and increased readmission risk (p=0.021). Conclusion: Higher ASA classifications are associated with a greater risk of postoperative readmission in patients undergoing total joint arthroplasty. These findings underscore the importance of comprehensive preoperative assessments and tailored postoperative care strategies to mitigate the risk of readmission, particularly in patients with higher ASA scores.

High-Resolution Computed Tomography and Intraoperative Correlation in Cholesteatoma: Enhancing Preoperative Evaluation and Surgical Management.

Cholesteatoma, a hazardous non-neoplastic lesion of the temporal bone, is prevalent in socio-economically disadvantaged groups in developing nations like India. Timely detection and surgical intervention are essential for effective management. High-resolution computed tomography (HRCT) has revolutionized the assessment of temporal bone pathology, though its role in preoperative evaluation remains debated. This study aimed to validate HRCT's utility in diagnosing cholesteatoma, compare its findings with intraoperative observations, and assess sensitivity and specificity. This diagnostic accuracy study was conducted at a tertiary care center in Western India, from March 2021 to November 2022. HRCT findings of 54 cholesteatoma patients were evaluated and compared with intraoperative findings. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and Cohen's kappa coefficient were calculated. HRCT demonstrated a sensitivity exceeding 90% in identifying scutum erosion, mastoid sclerosis, and abnormalities in the tympanic membrane, along with a specificity surpassing 90% in detecting various conditions, including facial canal erosion, sinus plate erosion, lateral semicircular canal erosion, erosion of the posterior wall of the external auditory canal, and abnormalities in the tympanic membrane. Furthermore, HRCT exhibited an accuracy of over 90% in detecting most pathologies. There was a perfect or near-perfect agreement observed for abnormal tympanic membrane, sinus plate erosion, mastoid sclerosis, and erosion of the posterior wall of the external auditory canal (with kappa values > 0.8). Moderate to fair agreement was noted for other pathologies. HRCT offered precise detection of the majority of pathologies, thereby facilitating surgical planning. However, the presence of limitations in distinguishing specific abnormalities highlights the significance of utilizing HRCT in tandem with other diagnostic modalities to ensure meticulous diagnosis and effective treatment planning.

The value of enhanced multiparameteric MRI diagnostic model for preoperatively predicting surgical methods of inferior vena cava in patients with renal tumors and inferior vena cava tumor thrombus

BackgroundInferior vena cava tumor thrombus (IVCTT) invading the IVC wall majorly affects the surgical method choice and prognosis in renal tumors. Enhanced multiparameteric MRI plays an important role in preoperative evaluation. In this work, an MRI-based diagnostic model for IVCTT was established so as to guide the preoperative decisions.MethodsPreoperative MR images of 165 cases of renal tumors with IVCTT were retrospectively analyzed, and imaging indicators were analyzed, including IVCTT morphology and Mayo grade, IVCTT diameter measurements, bland thrombosis, primary MRI-based diagnosis of renal tumor, and involvement of contralateral renal vein. The indicators were analyzed based on intraoperative performance and resection scope of the IVC wall. Multivariate logistic regression analysis was used to establish the diagnostic model.ResultsThe morphological classification of the IVCTT, primary MRI-based diagnosis of renal tumors, maximum transverse diameter of IVCTT, and length of the bland thrombus were the main indexes predicting IVC wall invasion. The MRI-based diagnostic model established according to these indexes had good diagnostic efficiency. The prediction probability of 0.61 was set as the cutoff value. The area under the curve of the test set was 0.88, sensitivity was 0.79, specificity was 0.85, and prediction accuracy was 0.79 under the optimal cutoff value.ConclusionThe preoperative MRI-based diagnostic model could reliably predict IVC wall invasion, which is helpful for better prediction of IVC-associated surgical operations.

Pre-Operative Evaluation of Petrous Temporal Bone Pathologies by CT and MRI in Cochlear Implant Candidates

Aim: To evaluate pathologies of the petrous temporal bone in cochlear implant candidates on CT and MRI preoperatively. Methods: A cross-sectional study was conducted at Combined Military Hospital Lahore from Jan 2014 to April 2016. 163 candidates were evaluated on CT and 149 were evaluated on MRI. All patients belonged to pediatric age group. Pathologies were grouped using classification of Sennaroglu & Saatci and every pathology was sought in all the cases ensuring that the pathologiesare not missed. Results: High-resolution CT scan temporal bone revealed 69.9% normal studies. Chronic otitis media with mastoiditis was major abnormality observed in 16.6% of cases. Unilateral mastoiditis was seen in 6.1% of patients. Bilateral CSOM without mastoiditis was seen bilaterally in 1.8% of cases. While unilateral CSOM was observed 0.6 % of patients. Among inner ear malformations, Mondini malformation was seen in 4 cases (2.5%). A high jugular bulb was seen in 2 cases (1.2%).93.3% of cases were labeled as normal study on MRI. Four cases showed Mondini malformation. Infective process of middle ear showed a cumulative frequency of 2.7%. Inner ear aplasia was found in one patient. Sclerosing labyrinthitis was also found in one case. Conclusion: Both CT and MRI have substantial role in pre-operative evaluation of petrous temporal bone in cochlear implant candidates. Preoperative evaluation of petrous temporal bone by CT scan and MRI successfully identifies pathologies which can be absolute or relative contraindications of the cochlear implant as well as conditions in which surgical procedure needs to be modified. Keywords: Cochlear implants, HRCT temporal bone, MRI cochlea, Mastoiditis, Mondini malformation

Perioperative risk assessment - focus on functional capacity.

This review examines how functional capacity informs preoperative risk stratification, as well as strengths and limitations of options for estimating functional capacity. Functional capacity (or cardiopulmonary fitness) overlaps with other important characteristics, including muscular strength, balance, and frailty. Poor functional capacity is associated with postoperative morbidity, especially noncardiovascular complications. Both patient interviews and exercise tests are used to assess functional capacity. The usual approach of an unstructured patient interview does not predict outcomes. Structured interviews that incorporate validated questionnaires (Duke Activity Status Index) or standardized questions about physical activity (ability to climb stairs) do predict moderate-or-severe complications and cardiovascular complications. Among exercise tests, cardiopulmonary exercise testing (CPET) has shown the most consistent association with risks of complications. Other tests (6-min walk test, incremental shuttle walk test, stair climbing) might predict complications, but still require further high-quality evaluation. A straightforward way to better assess functional capacity is a structured interview with validated questionnaires or standardized questions about physical activities. Functional capacity can also be assessed by exercise tests, with the strongest evidence supporting CPET. Although some simpler exercise tests have shown promise, more research remains needed to better define their role in preoperative evaluation.

Fatal complication of infective endocarditis: Radiological diagnosis of aortomitral curtain pseudoaneurysm

Infective endocarditis is the infection of the endocardium. The pathologic hallmarks of infective endocarditis are vegetations. They appear as irregular, mobile or fixed masses that usually attach to the endocardium on the low-pressure side of a valve, chordae tendinae or ascending aorta. Duke criteria are clinically relevant for the diagnosis of infective endocarditis. In addition to clinical and laboratory findings with these criteria, the diagnosis can be made with high accuracy with imaging findings. Imaging also plays a decisive role in pre-operative evaluation, during heart valve operations and in the evaluation of often severe complications to the disease. We present a 75-year-old male patient who was diagnosed with aortomitral curtain pseudoaneurysm due to infective endocarditis after clinical, laboratory and radiological evaluation in the light of literature review.

Comparison of High Resolution Computed Tomography with Intraoperative Findings in Patient with Chronic Suppurative Otitis Media, NAMS, Bir Hospital, Kathmandu, Nepal

Introduction: Chronic suppurative otitis media (CSOM) is an important cause of middle ear disease and its complications challenge both otologist and radiologist. The major benefit of HRCT is an excellent visualization of the osseous structure by means of special algorithms. This study compares the HRCT with intraoperative findings in patients with CSOM.
 Methods: This is an observational descriptive study conducted at NAMS Bir Hospital. Total of 30 patients, referred for HRCT from the department of ENT were studied. Comparison of HRCT findings was done with intraoperative findings regarding the status of EAC, ossicular chain, bony plate, inner ear structure and facing nerve canal was done, considering intraoperative findings as the gold standard.
 Results: Out of 30 patients, 16 patients had CSOM with cholesteatoma and 14 patients had CSOM without cholesteatoma. HRCT presented sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 87.5%, 85.7%, 87.5%, 85.7% and 86.7% respectively in diagnosing CSOM with cholesteatoma. HRCT presented sensitivity and specificity of 85.7% and 87.5% in identification of malleus erosion, sensitivity and specificity of 86.7% and 80%, in the identification of incus erosion. HRCT showed the specificity of 85% with relatively low sensitivity of 70% in identification of erosion of stapes. HRCT showed a sensitivity of 100% and specificity of 85.7%. HRCT presented sensitivity and specificity of 83.3% and 95.8% in diagnosing tegmen tympanum erosion. HRCT showed the highest sensitivity (100%) and specificity (100%) in diagnosing erosion of sigmoid sinus plate and mastoid cortex. HRCT showed relatively low sensitivity of 66.7% and 75% in diagnosing erosion of LSCC and facial canal respectively. HRCT detected soft tissue mass in the middle ear/mastoid in all 30 patients of CSOM. Hence, the sensitivity, specificity, positive predictive value and negative predictive value of HRCT for soft tissue mass in the middle ear and mastoid, all were 100%.
 Conclusion: The HRCT has a valuable role in preoperative evaluation of a case of CSOM. It has high sensitivity in diagnosing CSOM with cholesteatoma. However, HRCT has relatively low sensitivity for LSCC and facial nerve canal erosion.

The Role of Malnutrition in Ninety-Day Outcomes After Total Joint Arthroplasty

BackgroundResearch has linked malnutrition to more complications in total joint arthroplasty (TJA) patients. The role of preoperative albumin in predicting length of stay (LOS) and 90-day outcomes remains understudied. Often, an albumin cut-off ≤3.5 g/dL is used as proxy for malnutrition, although this value remains understudied. This preoperative level may be missing some patients at risk for adverse events post TJA. MethodsTJA patients at a single institution from 2013 to 2018 were reviewed for preoperative albumin level. In total, 4047 cases (total knee arthroplasty: 2058; total hip arthroplasty: 1989) had available data, including 90-day readmissions, 90-day emergency department (ED) visits, and postoperative LOS. ResultsAbout 5.6% experienced a readmission and 9.6% had at least one ED visit within 90 days. Overall prevalence of malnutrition was 3.6%, and this cohort experienced a longer average LOS (3.5 vs 2.2 days, P < .0001) and was more likely to experience a readmission (16% vs 5%, P < .0001) or ED visit (18% vs 9%, P = .0005). Additionally, albumin ≤3.5 g/dL was correlated with more frequent discharge to skilled nursing facility/rehab (30.8% vs 14.7%, P < .0001), increased risk for 90-day readmission with univariable (odds ratio [OR] 1.79, P < .0001) and multivariable logistic regression (OR 1.55, P < .0001), and increased risk for 90-day ED visits with univariable (OR 1.62, P < .0001) and multivariable regression (OR 1.35, P < .0001). The optimal albumin cut-off was 3.94 g/dL in a univariable model for 90-day readmission. ConclusionScreening for malnutrition may serve a role in preoperative evaluation. An albumin cutoff value of 3.5 g/dL may miss some at-risk patients.

Neonatal Jaundice.

Hyperbilirubinemia is a common occurrence in neonates; it may be physiological or pathological. Conjugated hyperbilirubinemia may result from medical or surgical causes, and can result in irreversible liver damage if untreated. The aim of imaging is the timely diagnosis of surgical conditions like biliary atresia and choledochal cysts. Abdominal ultrasound is the first line imaging modality, and Magnetic resonance cholangiopancreatography (MRCP) also has a role, especially in pre-operative assessment of choledochal cysts (CDCs). For biliary atresia, the triangular cord sign and gallbladder abnormalities are the two most useful ultrasound features, with a combined sensitivity of 95%. Liver biopsy has an important role in pre-operative evaluation; however, the gold standard for diagnosis of biliary atresia remains an intra-operative cholangiogram. Choledochal cysts are classified into types according to the number, location, extent and morphology of the areas of cystic dilatation. They are often associated with an abnormal pancreaticobiliary junction, which is best assessed on MRCP. Caroli's disease or type 5 CDC comprises of multiple intrahepatic cysts. CDCs, though benign, require surgery as they may be associated with complications like cholelithiasis, cholangitis and development of malignancy. Severe unconjugated hyperbilirubinemia puts neonates at high risk of developing bilirubin induced brain injury, which may be acute or chronic. Magnetic resonance imaging of the brain is the preferred modality for evaluation, and shows characteristic involvement of the globus pallidi, subthalamic nuclei and cerebellum - in acute cases, these areas show T1 hyperintensity, while chronic cases typically show hyperintensity on T2 weighted images.

Role of 3D reconstruction in the evaluation of patients with lower segment oesophageal cancer.

Three-dimensional (3D) reconstruction has been used in evaluating the lungs and liver, but there is only little research on the application of 3D reconstruction for the oesophagus. This research aims to study the application of 3D reconstruction in patients with lower segment oesophageal tumours to improve the diagnosis and treatment of oesophageal cancer and to provide a better method of preoperative assessment. All the patients were treated at the First Hospital of Jilin University between January 2014 and August 2015 for oesophageal cancer. We collected the patients' imaging data and used surface reconstruction technology to reconstruct their oesophageal tumours and adjacent structures. Tumour shape and other specific parameters were analysed and calculated, and comparisons of the results from different conditions of 3D reconstruction were made. IBM SPSS 19.0 was used to analyse all the data. All the data were averaged over three measurements. The t-test was used to compare the mean of the two groups, and variance analysis was used among the groups, where P<0.05 indicated a significant difference. Of the 72 patients, there were 48 cases in which a gastroscope was able to pass through the oesophageal lesion and 24 cases where this was not possible. The location of the lesion ranged from 30 to 42 cm among those 48 cases. The endoscopic measurement length and the 3D length were both longer than the pathological length (P<0.05), but there was no significant difference between the endoscopic measurement length and the 3D length. In the reconstructed data of positive lymph nodes, the length, diameter, volume, CT value and reconstruction of the lymph nodes in the negative group were significantly different compared with the positive group. The application of 3D reconstruction in oesophageal cancer is safe and effective. 3D reconstruction plays an important role in preoperative evaluation of tumours and the surrounding lymph nodes and may be useful for evaluation of the long-term efficacy of radiotherapy and chemotherapy for oesophageal cancer.

Obstructive Sleep Apnea and the Impact on Surgical Outcomes in Gynecology.

Obstructive sleep apnea syndrome (OSAS) is a common medical condition in the United States and affects gynecologic surgical outcomes. The aim of this review was to improve perioperative diagnosis and management of OSAS in patients presenting for gynecologic surgery and ultimately improve perioperative outcomes. The role of preoperative evaluation and screening is also addressed. Medical databases were queried for publications pertaining to OSAS complications, risk factors, screening, and perioperative management. Pertinent articles were reviewed by the study authors. Obstructive sleep apnea syndrome is underdiagnosed in the preoperative surgical population. Obesity and other risk factors for OSAS are prevalent in patients with gynecologic issues but are not fully assessed with screening prior to surgery. Effective treatment modalities, such as continuous positive airway pressure, and perioperative management strategies are available to improve patient outcomes. Increased diagnosis and treatment for OSAS in the perioperative period can improve perioperative outcomes, surgical outcomes, and long-term patient outcomes. Strategies to increase effective management in patients presenting for gynecologic surgery are needed.

Neural Matrix and Its Role in Preoperative Evaluation of Partial Epilepsy

The network characteristic of the central neural system has been widely accepted as a basic fabric form. However, the matrix characteristics of neural network are still not fully understood. If we ignore the matrix characteristics of the neural networks and just pay close attention to its connection mode, we are likely to fall into the theory of mechanical reductionism. This can lead to a problem in representing consciousness in a disadvantageous situation. It can also be a barrier to further improving the global workspace theory. Incomplete elucidation of the mechanisms of consciousness representation can also affect the assessment of the surgical outcome of partial epilepsy with conscious injury. Therefore, this paper reviews the epistemological development of neuroscience. We will initially describe the matrix characteristics of the neural system and their significance to the information processing mechanism, and further explore the role of neural matrix in identifying cases of partial epilepsy with little effect on the resection of the lesion.

MRI in the evaluation of obstructive reproductive tract anomalies in paediatric patients

To outline the anatomical variations of obstructive reproductive tract anomalies (ORTA) using magnetic resonance imaging (MRI) and its role in preoperative evaluation. MRI and treatment of 21 paediatric patients with ORTA were reviewed and analysed. MRI findings were correlated with ultrasound and surgical findings. Patients presented in two distinct ways: primary amenorrhoea with cyclic pelvic pain, or progressive dysmenorrhoea. MRI showed haematocolpos, haematocervix, haematometra, and/or haematosalpinx; it also provided detailed information regarding uterine morphology, ipsilateral kidney absence, and endometriosis. Diagnosis at MRI of the obstruction sites correlated completely (100%) with the surgical diagnosis. Obstruction occurred at different levels of the genital tract, and surgical treatment was given based on the obstruction sites. One patient underwent excision of the hymen tissue for imperforate hymen. Four cases of lower vaginal atresia were treated with vaginoplasty. Three patients with typical Herlyn-Werner-Wunderlich (HWW) syndrome underwent resection of the vaginal septum, and one patient with concurrent post-partum placenta increta was treated accordingly; one patient with atypical HWW syndrome had the left uterus resected. There were 11 cases of cervical agenesis or cervicovaginal dysgenesis, eight of which were complicated with uterine anomalies, and in all cases the uterus was removed. Among the 10 obstructive cervical anomalies, there were three cases of cervical agenesis and seven cases of cervical dysgenesis, including five obliterated cervical os (cervical obstruction), one cervical fibrous cord, and one cervical fragmentation. ORTA can occur from the hymen to the lower segment of the uterus and requires surgical intervention. The preoperative evaluation is vital to guide proper surgery. MRI, with its imaging advantages, is the imaging technique of choice to assess the obstructed sites and complicated anomalies of ORTA.

Neural matrix and its role in preoperative evaluation of partial epilepsy

The network characteristic of the central neural system has been widely accepted as a basic fabric form. However, the matrix characteristics of neural network are still not fully understood. If we ignore the matrix characteristics of the neural networks and just pay close attention to its connection mode, we are likely to fall into the theory of mechanical reductionism. This can lead to a problem in representing consciousness in a disadvantageous situation. It can also be a barrier to further improving the global workspace theory. Incomplete elucidation of the mechanisms of consciousness representation can also affect the assessment of the surgical outcome of partial epilepsy with conscious injury. Therefore, this paper reviews the epistemological development of neuroscience. We will initially describe the matrix characteristics of the neural system and their significance to the information processing mechanism, and further explore the role of neural matrix in identifying cases of partial epilepsy with little effect on the resection of the lesion.

Nasal endoscopy: an adjunct to patient selection for preoperative low-dose CT examination in chronic rhinosinusitis.

The growing awareness of increased X-ray exposure to the public has led to the propagation of several methods for reducing the radiation dose during CT examination. Low-dose CT protocols do not, however, have an established role in pre-operative evaluation. The aim of this article was to assess the usefulness of nasal endoscopy in the selection of patients under pre-operative care for low-dose CT examination. A cadaver head was used to discover institutional minimum acceptable CT image quality and scanning settings. Then, 134 adult patients with chronic rhinosinusitis (CRS) were enrolled into the study and divided randomly into standard dose (120 kVp, 100 mAs) or low-dose CT groups (120 kVp, 45 mAs). Subjective assessment of the diagnostic image quality of the surgically relevant anatomical structures was compared using a five-point scale (from excellent to unacceptable) by a radiologist and sinus surgeon independently. Pathologic states of the nose were quantified according to the Lund-Kennedy endoscopic system (LKES) and Lildholdt's scale. Image quality was similar in low-dose and standard dose groups in patients without polyps. The quality of 13% of scans from patients with polyps from the low-dose group and 4% from the standard dose group was in the range from moderate to poor. The quality of scans obtained with low milliamperes second (mAs) values worsened in patients with polyps in the middle meatus, but the difference was particularly pronounced compared with standard dose among subjects with Lildholdt's score above 2 (p < 0.001). Correlation with LKES revealed that changes other than polyps (i.e. discharge, oedema, scaring or crusting) in the nasal cavity alone do not affect the image quality. Interobserver agreement in both groups was very high. Low-dose scanning should be promoted as the screening imaging method of choice in patients with suspected CRS. Furthermore, low mAs value examination can be performed pre-operatively without fear of significant image quality deterioration in uncomplicated CRS patients without polyps, or with minor changes in nasal endoscopy. Standard dose CT, which provides a better identification of bony landmarks, minimizes diagnostic errors and risk to patients, so it might be considered in those with polyps below the middle turbinate.

Paraganglioma—Role of preoperative evaluation and endovascular embolization

An understanding of the vascular architecture of paragangliomas can aid in both diagnosis and treatment. There is a growing role for vascular evaluation and intervention of these highly vascular tumors. This article addresses the specifics of the vasculature of paragangliomas, with focus on preoperative imaging, preoperative balloon test occlusion and endovascular embolization. The authors present both common and improvised techniques.

Building a bridge to save a failing ventricle: radiologic evaluation of short- and long-term cardiac assist devices.

Heart failure is recognized with increasing frequency worldwide and often progresses to an advanced refractory state. Although the reference standard for treatment of advanced heart failure remains cardiac transplantation, the increasing shortage of donor organs and the unsuitability of many patients for transplantation surgery has led to a search for alternative therapies. One such therapy is mechanical circulatory support, which helps relieve the load on the ventricle and thereby allows it to recover function. In addition, there is increasing evidence supporting the use of mechanical devices as a bridge to recovery in patients with acute refractory heart failure. In this article, the imaging evaluation of various commonly used short- and long-term cardiac assist devices is discussed, and their relevant mechanisms of action and physiology are described. Imaging, particularly computed tomography (CT), plays a crucial role in preoperative evaluation for assessment of candidacy for implantation of a left ventricular assist device (LVAD) or total artificial heart (TAH). Also, echocardiography and CT are indispensable in assessment of complications associated with cardiac devices. Complications commonly associated with short-term assist devices include bleeding and malpositioning, whereas long-term devices such as LVADs may be associated with infection, pump thrombosis, and cannula malfunction, as well as bleeding. CT is also commonly performed for preoperative planning before LVAD or TAH explantation, replacement of a device or one of its components, and cardiac transplantation. Online supplemental material is available for this article.

Anaesthetic management for laparoscopic cholecystectomy in patient with situs inversus totalis.

Sir, Situs inversus totalis is an autosomal recessive congenital condition in which major thoracic and abdominal visceral organs are reversed from their normal position. We report anaesthetic management of a patient with situs inversus totalis who underwent laparoscopic cholecystectomy. A 61-year-old lady, a known hypertensive on medications, diagnosed to have situs inversus totalis presented for a laparoscopic cholecystectomy. On preanaesthetic evaluation, patient's vital parameters and biochemical investigations were within normal limits. Her chest X-ray revealed situs inversus with dextrocardia [Figure 1]. Electrocardiograph (ECG) showed T wave inversion in lead I, aVL, V2 to V6 with deep Q waves in lead I and aVL which was consistent with dextrocardia [Figure 2]. Echocardiography revealed dextrocardia with mild aortic regurgitation and normal left ventricular ejection fraction. Pulmonary function tests showed a peak expiratory flow rate of 200 L/min. In the operation theatre, ECG monitor was connected with left sided ECG leads on the right side and vice versa. After premedication, general anaesthesia (GA) was induced with intravenous induction agent thiopentone and muscle relaxation obtained with vecuronium. Intubation was performed with 8.0 mm internal diameter endotracheal tube and position checked by auscultation. Anaesthesia was maintained with 1% isoflurane in oxygen and nitrous oxide mixture. Regular tracheal and oral suctioning were done which revealed minimal secretions and peak airway pressures were closely monitored. The procedure was uneventful and patient made satisfactory recovery. Figure 1 Chest radiograph showing dextrocardia with clear lung fields Figure 2 Electrocardiograph showing T wave inversion in anterolateral leads Anaesthetic management of a patient of situs inversus includes workup for Kartagener's syndrome and other multisystem anomalies. Kartagener's syndrome is a condition with immotile cilia and a triad of bronchiectasis, sinusitis and situs inversus which affects 20% of patients with situs inversus.[1] Congenital heart diseases are present in more than 90% of cases with situs inversus with levocardia and in 3–5% of cases in situs inversus with dextrocardia.[2] Complete heart block is found to occur in over 20% of patients with situs inversus. Airway abnormalities may manifest as aglossia, hypoglossia or Goldenhar syndrome.[3] Electrocardiograph electrodes if normally placed in these patients will show inverted T waves in lateral leads resembling a lateral wall myocardial ischemia. In the preanaesthetic evaluation, this may prompt unnecessary workup for suspected myocardial ischemia. Electrodes are to be placed in the mirror position for correct tracing during the surgery. During intubation left endobronchial placement of the endotracheal tube may occur, since the left bronchus is more in line with the trachea. Central venous catheter must be placed cautiously under ultrasound guidance because of the likelihood of associated vascular anomalies. During defibrillation, paddles should be placed in reverse position on the upper left and lower right of the chest. There are case reports of prolonged paralysis after administration of succinylcholine in patients with situs inversus totalis and hence it is prudent to avoid depolarising muscle relaxants.[4] Pulmonary function tests play an important role in preoperative evaluation of the patients with Kartagener's syndrome. Physiotherapy, incentive spirometry, antibiotics and bronchodilators have a beneficial role in the preoperative preparation of the patient. It is prudent to avoid nasal intubation due to the associated sinusitis. Furthermore, inspired gases should be humidified to avoid viscid secretions. It is beneficial to induce and maintain GA with volatile anaesthetic due to the resultant bronchodilatation and reduced ventilatory depression in the early postoperative period. To conclude, apart from keeping in mind the various anomalies associated with situs inversus, appropriate modifications in anaesthesia technique is essential for smooth conduct of anaesthesia.

Magnetic resonance imaging and histology correlation in the neocortex in temporal lobe epilepsy.

To investigate the histopathological correlates of quantitative relaxometry and diffusion tensor imaging (DTI) and to determine their efficacy in epileptogenic lesion detection for preoperative evaluation of focal epilepsy. We correlated quantitative relaxometry and DTI with histological features of neuronal density and morphology in 55 regions of the temporal lobe neocortex, selected from 13 patients who underwent epilepsy surgery. We made use of a validated nonrigid image registration protocol to obtain accurate correspondences between in vivo magnetic resonance imaging and histology images. We found T1 to be a predictor of neuronal density in the neocortical gray matter (GM) using linear mixed effects models with random effects for subjects. Fractional anisotropy (FA) was a predictor of neuronal density of large-caliber neurons only (pyramidal cells, layers 3 and 5). Comparing multivariate to univariate mixed effects models with nested variables demonstrated that employing T1 and FA together provided a significantly better fit than T1 or FA alone in predicting density of large-caliber neurons. Correlations with clinical variables revealed significant positive correlations between neuronal density and age (rs = 0.726, pfwe = 0.021). This study is the first to relate in vivo T1 and FA values to the proportion of neurons in GM. Our results suggest that quantitative T1 mapping and DTI may have a role in preoperative evaluation of focal epilepsy and can be extended to identify GM pathology in a variety of neurological disorders.

Cardiac magnetic resonance in patients with pectus excavatum: impact of thoracic surgery on cardiac function - a follow- up-study

Background Pectus excavatum (PE) as the most common anterior chest deformity is characterized by sternal depression with corresponding leftward displacement and rotation of the heart which is troublesome for assessment by ultrasound. Therefore CMR plays a growing role in preoperative evaluation. Indication for surgical correction is based on a diameter-based assessment of the thorax (Haller-Index, HI) and symptoms. Imaging data describing cardiac performance after surgery are rare. The aim of the study was to assess cardiac function during follow-up (FU). Methods 37 patients with PE (30 male, age 12-43 years) underwent CMR using 1.5T MRI-scanner (Avanto, Siemens Healthcare, Germany) prior to surgery and repeatedly postoperative (10 days, 3 months and 1 year). The highly experiences surgeons (more than 130 procedures/year) implanted a titan-bar (Nuss procedure) based on the usual clinical indication. CMR protocol included state of the art cine SSFP covering the left ventricle (LV) as short axis (TR 33.6 ms, TE 1.18 ms, FOV 292 × 360 mm, matrix 256 × 208, sth 7 mm without gap) and the right ventricle (RV) axial orientation (TR 34.56 ms, TE 1.21 ms, FOV 332 × 269 mm, matrix 256 × 208, sth 6 mm without gap). HI was measured on survey images (Figure 1). We quantified the enddiastolic and endsystolic volumes of LV and RV: calculated the ejection fractions (EF) and stroke volumes (SV) using CMR42 (circle cvi, Canada). Results CMR images were evaluable despite implanted titanium bars. All patients completed one year FU. HI was significantly reduced after surgery (pre: 9.9 ± 5.7 vs. post: 2.8 ± 0.5, p < 0.001) indicating a successful procedure. Pleural effusions were detectable at day 10 in almost all (24 from 25 patients) pericardial effusion in 3 and it was resolved in all completely after 1 year. There were variable findings at different FU-time-points. The most positive change in RVEF was observed at 10 days FU followed by slight reduction on 3 months and further decrease at 1 year. Despite these findings the RVEF remained significantly improved at 1 year. Interestingly, RVEF was found to change significantly from baseline to 1 year FU (p < .0001), whereas LVEF did not (p = 0.0539). RVSV and LVSV were found to change significantly from baseline to 1 year follow-up (p = 0.0018 and 0.0008, respectively). Weak correlation was found between the delta (baseline/1 year) HI compared to RVEF.