Routine Preoperative Evaluation Research Articles

MDCT Evaluation of the Prevalence of Tracheomalacia in Children With Mediastinal Aortic Vascular Anomalies

The purpose of this study is to determine the prevalence of tracheomalacia (TM) associated with different types of mediastinal aortic vascular anomalies in symptomatic children using paired inspiratory-expiratory multidetector computed tomography (MDCT). The study group consisted of 15 consecutive symptomatic pediatric patients (12 males/3 females; mean age of 4.4 y; age range of 2 wk to 16 y) with mediastinal aortic vascular anomalies, who were referred for paired inspiratory-expiratory MDCT during a 35-month time period. Computed tomography (CT) angiography was also concurrently performed during the end-inspiration phase of the study. Two radiologists in consensus reviewed all CT images in a randomized and blinded fashion. End-inspiration and end-expiration CT images were reviewed for the presence and severity of tracheal narrowing and the type of mediastinal aortic vascular anomaly involved. TM was defined as > or =50% reduction in tracheal cross-sectional luminal area between end-inspiration and end-expiration. The presence of TM was correlated with the type of mediastinal aortic vascular anomaly and compared with the bronchoscopy results when available (n=9). Mediastinal aortic vascular anomalies included innominate artery compression (IAC) (n=6), a right aortic arch with an aberrant left subclavian artery (n=5), double aortic arch (n=3), and a left aortic arch with an aberrant right subclavian artery (n=1). Eight of 15 (53.3%) patients demonstrated TM. TM was seen in all 6 patients (100%) with IAC, 1 of 3 (33.3%) patients with double aortic arch, and 1 of 5 (20%) patients with a right aortic arch with an aberrant left subclavian artery. CT results were concordant with the results of bronchoscopy in all patients who underwent this procedure (n=9). Symptomatic pediatric patients with mediastinal aortic vascular anomalies have a relatively high prevalence of TM, especially those with IAC. Paired inspiratory-expiratory MDCT should be considered part of the routine preoperative evaluation of TM in symptomatic children with IAC and also has the potential to play a role in evaluating patients with other mediastinal aortic vascular anomalies.

Is Routine Preoperative Chest X-ray Indicated in Elderly Patients Undergoing Elective Surgery?

In our hospital pre-operative chest x-ray (CXR) are routinely requested without prior establishment of any medical indication for patients of 70 or more years of age who are undergoing elective surgery. The aim of this study was to determine if routine preoperative chest x-rays are justifiably indicated for elderly patients undergoing elective surgery in the University of Nigeria Teaching Hospital, Enugu. One hundred and twenty consecutive patients aged 70 or more years were studied between January 2003 and December 2005. As part of our routine preoperative evaluation, detailed history and thorough physical examination were carried out with a view to eliciting symptoms and signs that would normally indicate chest X-ray. Pre-operative ECG were also examined for presence or absence of abnormalities that could indicate chest X-ray. Preoperative chest X-rays of the 120 patients were also studied and radiological findings noted. Ninety (75%) out of 120 patients had medical indications for chest X-ray. The remaining 30 (25%) were considered to lack medical indication for chest X-ray. Overall, 105 out of the 120 (84%) patients had abnormal findings on chest X-ray. Routine preoperative chest X-rays in the elderly patients are worthwhile even without medical indication.

Abnormal venous drainage in syndromic craniosynostosis and the role of CT venography

Venous hypertension is emerging as a significant contributor to intracranial pressure in children with syndromic craniosysnostosis. This is associated with jugular foramen stenosis or atresia and with the development of collateral emissary veins. We demonstrate how computed tomography venography can document the prevalence of these emissary veins and how their visualisation plays an important role in operative planning. Patients with known syndromic craniosynostosis underwent computed tomography venography as part of their routine pre-operative evaluation. The venous drainage pattern was examined in these patients, with a special note of the presence of abnormal venous pathways. Eleven patients were recruited into the study from ages 3 months to 22 years. All had a diagnosis of syndromic craniosynostosis with six Crouzon's, four Pfeiffer's and one patient with Crouzon's and acanthosis nigricans. Nine of 11 patients had demonstrable evidences of transosseous venous drainage through an identifiable abnormal emissary vein. Four of 11 had a transosseous route as the main mechanism of drainage for the cerebral venous system. Patients with syndromic craniosynostosis often demonstrate abnormal venous anatomy, which can have serious consequences on craniofacial surgery, especially when a posterior decompression is being considered. Based on these findings, the authors assert that those children with some syndromic craniosynostosis being considered for surgery should undergo venographic studies as part of their pre-operative evaluation.

Performance at Symptom-Limited Stair-Climbing Test is Associated With Increased Cardiopulmonary Complications, Mortality, and Costs After Major Lung Resection

Exercise tests are increasingly used during preoperative evaluation before lung resection. This study assessed the association between performance at the symptom-limited stair-climbing test and postoperative cardiopulmonary morbidity, mortality, and costs after major lung resections. As part of their routine preoperative evaluation, 640 patients who had lobectomy (n = 533) or pneumonectomy (n = 107) for lung cancer from January 2000 through April 2007 performed a preoperative symptom-limited stair-climbing test. Sensitivity/specificity analysis was used to identify the best cutoff values of altitude climbed (number of steps x height of the step in m) associated with outcome. Univariate and multivariate regression analyses (validated by bootstrap) were used to test associations between preoperative and operative factors and postoperative cardiopulmonary complications, mortality, and postoperative costs. The altitude reached at the stair-climbing test was reliably associated with increased cardiopulmonary complications (p = 0.04), mortality (p = 0.02), and costs (p < 0.0001). In patients who climbed less than 12 m, cardiopulmonary complications, mortality, and costs were 2-fold (p < 0.0001), 13-fold (p < 0.0001), and 2.5-fold higher, respectively, than in patients who climbed more than 22 m. Performance at a maximal stair-climbing test was reliably associated with postoperative morbidity and mortality. We recommend the use of this simple and economic test in all lung resection candidates. Patients who perform poorly at the stair-climbing test should undergo a formal cardiopulmonary exercise test with measurement of oxygen consumption to optimize their perioperative management.

The Debate: Report an Evaluation and Management Service With Procedure or the Procedure Alone?

The Debate: Report an Evaluation and Management Service With Procedure or the Procedure Alone?

A simple subclassification of American Society of Anesthesiology III patients undergoing peripheral revascularization based on functional capacity

The American Society of Anesthesiology (ASA) classification remains the most widely used risk-stratification system in the world. However, it is not practical in patients undergoing revascularization procedures because most are classified as ASA III. We hypothesized that ASA III patients can be subdivided into two subgroups, ASA IIIA and ASA IIIB, simply based on their preoperative functional capacity measured in metabolic equivalents (METS) of <4 or > or =4, which would allow the largest group of vascular surgery patients to be appropriately subgrouped for their predicted early and late postoperative morbidity and mortality. All charts of 482 patients (99% men) who underwent revascularization for disabling claudication or critical limb ischemia between June 2001 and October 2006 were reviewed for demographics, comorbidities, operative and interventional details, postoperative complications, and outcomes defined as myocardial infarction, stroke, and death. Preoperative functional capacity information was obtained from the anesthesia records in the electronic charts. There were 35 patients (7%) in ASA II, 371 patients (77%) in ASA III (45% in ASA IIIA, 32% in ASA IIIB) and 76 patients (16%) in ASA IV. The age, albumin level, prevalence of coronary artery disease, diabetes mellitus, cerebrovascular disease, renal insufficiency (creatinine >1.5 mg/dL), critical limb ischemia, and length of stay were significantly higher in ASA IIIB than IIIA patients. Significantly more myocardial infarctions and deaths occurred in IIIB than in IIIA patients. The overall survival rate was significantly better in ASA IIIA than in ASA IIIB patients. A univariate Cox proportional model identified coronary artery disease, diabetes mellitus, chronic obstructive pulmonary disease (COPD), renal insufficiency, hypercholesterolemia, presence of critical limb ischemia, and preoperative albumin level of <3 g/dL or > or =3 g/dL as being significantly associated with survival. Multivariate analysis showed being ASA IIIA or IIIB is an independent predictor of survival, after adjusting for age, coronary artery disease, hyperlipidemia, COPD, and preoperative albumin levels. Functional capacity assessment is an integral part of routine preoperative anesthesia evaluation, and we found this to be very reliable in predicting postoperative morbidity and mortality as well as overall survival in ASA III patients undergoing peripheral revascularization. This simple modification allows ASA III patients (approximately 80% of vascular patients) to be unbundled into two very distinct subgroups, which will potentially lead to a more accurate preoperative risk assessment.

Diffusion-Weighted Single-Shot Echo-Planar Imaging with Parallel Technique in Assessment of Endometrial Cancer

The purposes of this study were to determine the feasibility of diffusion-weighted imaging (DWI) with a single-shot echo-planar sequence and parallel technique for depicting endometrial cancer and to examine the role of this technique in preoperative assessment. A total of 31 patients were recruited for MRI evaluation of suspicious endometrial lesions found on transvaginal sonography. Twenty-four of the patients were proved to have endometrial cancer (patient group), and seven to have benign diseases (control group). The MRI examinations included diffusion-weighted single-shot echoplanar sequences and contrast-enhanced T1-weighted 3D fat-suppressed spoiled gradient-echo sequences. The apparent diffusion coefficient of endometrial cancer in the patient group and of normal endometrium in the control group were measured on the apparent diffusion coefficient map of each diffusion-weighted image and compared for the two groups. In the patient group, myometrial invasion was evaluated with the two sequences. The diagnostic accuracy rates of each pulse sequence were compared. The mean apparent diffusion coefficient of endometrial cancer was 0.864 x 10(-3) mm2/s and that of benign endometrial lesions was 1.277 x 10(-3) mm2/s. The difference between the two groups was significant (p = 0.0058). The diagnostic accuracy for myometrial invasion was 61.9% for DWI and 71.4% for gadolinium-enhanced T1-weighted 3D fat-suppressed spoiled gradient-recalled echo images. In five cases, DWI provided information about tumor extent and depicted the tumor focus, findings that changed preoperative staging. DWI performed with parallel imaging technique has potential as a method for differentiating benign from malignant endometrial lesions. It also provides valuable information for preoperative evaluation and should be considered part of routine preoperative MRI evaluation for endometrial cancer.

Impact of Preoperative Ultrasonographic Staging of the Neck in Papillary Thyroid Carcinoma

To determine the frequency of occult macroscopic metastasis detected by preoperative US evaluation of the neck in patients with PTC. Papillary thyroid carcinoma (PTC) is a malignancy with a high rate of lymph node metastasis. The findings of routine thyroid ultrasonography (US) and physical examination may underestimate metastatic disease. Thus, we propose that patients diagnosed as having PTC undergo preoperative US staging of the neck. This prospective study included 60 patients diagnosed as having PTC from January 1 through June 30, 2006. Patients had undergone previous thyroid US evaluation with no palpable adenopathy. Lymph nodes were deemed suspicious by US findings with a minor axis greater than 10 mm, a minor axis greater than 50% of the major axis, or hyperechogenicity with or without microcalcifications. Metastasis was confirmed by fine-needle aspiration biopsy or frozen section analysis. Patients with confirmed metastasis underwent a neck dissection. The location of adenopathy reported by US was correlated with the pathological report. The US evaluation identified 12 of 60 patients (20%) with adenopathy suggestive of metastasis. Metastasis was confirmed in 11 of 12 patients (92%). Metastasis was found in 1 of 48 patients who had a negative US finding. Overall, sensitivity, specificity, and positive and negative predictive values were 92%, 98%, 92%, and 98%, respectively. All neck levels with suspicious adenopathy detected by US evaluation, with 1 exception, were confirmed by pathological findings. Nine patients had additional neck levels involved with microscopic disease undetected by the US evaluation. In patients with PTC, preoperative US evaluation of the neck is effective in detecting nonpalpable metastasis. Therefore, routine preoperative neck US evaluation is recommended to optimize primary surgical planning.

Clinical significance of Q-TC interval in children with sleep-disordered breathing

Aim: We investigated the usefulness of ECG (Q-Tc interval) in determining the optional treatment modality for pediatric Sleep disordered breathing (SDB). METHOD: Fifty-six children presenting with snoring and associated symptoms of obstructive SDB had adenotonsillectomy (A&T) as an optional treatment modality. All studied children had ECG as routine preoperative evaluation in the absence of polysomnographic facilities. At 12 weeks post-adenotonsillectomy ECG was repeated. A Q-Tc interval = or >0.43 was regarded as prolonged. Duration of study was 4 years (September 2002 to August 2006). RESULTS: There was disappearance of symptoms in 98.21 % of children by the second week following A&T. At 12 weeks post-A&T only 26 (46.42%) of patients were available for ECG re-evaluation. Mean pre-op versus post-op Q-Tc was 0.4482 and 0.3932 (t -5.484, df 25, p=0.000.) while mean heart rate was 106.15 and 105.19 (t -.179, df 25, p=0.859.). Adenotonsillectomy resulted in a reversal of prolonged Q-Tc to within the normal range. Five (19.23%) of the children with normal Q-Tc 0.39, 0.41, 0.40, 0.41 and 0.35 preoperatively assumed even lower values post operatively (0.37, 0.40, 0.39, 0.406 and 0.32 respectively). There was no statistical correlation between heart rates and Q-Tc intervals in the pre and post adenotonsillectomy patients. (Pearson correlation; -.058, P = 0.389 and -.266, p = .095 respectively). CONCLUSION: Prolonged Q-Tc interval can be a reasonable pointer to the severity of SDB and its correction is an objective assessment of adenotonsillectomy as an effective treatment option for childhood SDB. Global Journal of Mathematical Sciences Vol. 6 (1) 2007: pp. 41-45

Cancer in the bypassed stomach presenting early after gastric bypass

Gastric carcinoma in the bypassed stomach after Roux-en-Y gastric bypass (RYGBP) is rare but has been reported. The time from RYGBP to the presentation of cancer has ranged from 5 to 22 years postoperatively in the literature. A major concern with the current technique for RYGBP is the exclusion of the bypassed stomach and difficulty in surveillance. Thus, some surgeons recommend routine preoperative evaluation via endoscopy. Although most findings are benign, abnormalities are frequently discovered during screening endoscopy in bariatric surgery patients. We present a 45-year-old woman who was discovered to have disseminated gastric cancer involving the excluded bypassed stomach following an open RYGBP. Preoperative upper endoscopy was not performed. This case illustrates the importance of endoscopic evaluation prior to RYGBP and signifies the need for a high index of suspicion in order to recognize this problem at an early stage.

Predictive value of preoperative central corneal thickness for aphakic glaucoma in congenital cataract patients

Introduction: The purpose of this study was to determine if preoperative central corneal thickness (CCT) is a predictor of future glaucoma in infants undergoing cataract surgery. Methods: A retrospective chart review was performed for infants who underwent cataract surgery from January 1995 to June 2002. Inclusion required surgery prior to 1 year of age, preoperative CCT measurements, and follow-up of 3 years or longer. We excluded eyes with anterior segment dysgenesis, preoperative glaucoma, and microphthalmia. In patients with bilateral cataracts, one eye was randomly chosen for statistical analysis. Results: In eyes without glaucoma (n = 35), the mean CCT was 0.559 mm (CI = 0.542-0.572); mean horizontal corneal diameter was 10.17 mm, and mean age at surgery was 2.8 months. Eyes that developed aphakic glaucoma (n = 7) had a mean CCT of 0.597 mm (CI = 0.567-0.628), mean diameter of 10.21 mm, and a mean age at surgery of 1.5 months. Preoperative CCT was significantly greater in eyes that developed aphakic glaucoma compared with those who did not (p = 0.029). Neither corneal diameter nor age at the time of surgery was significantly different between the two groups. CCT and corneal diameter were weakly correlated (r = −0.026, p = 0.10). Discussion: CCT has become an important factor in glaucoma management. Our data suggest that eyes with congenital cataracts that develop postoperative glaucoma may also have increased CCT preoperatively. Surgeons should consider measuring CCT as part of the routine preoperative cataract evaluation. Conclusions: Thicker preoperative CCT in eyes with congenital cataract may have a predictive value for the development of postoperative aphakic glaucoma.

How to make steatotic livers suitable for transplantation

Improvements in the surgical and nonsurgical care of patients with end-stage liver disease have led to an expansion of the indications for liver transplantation, resulting in an increasing shortage of donor organs. Despite many attempts to expand the donor pool, such as utilizing split or living donor liver transplants, the amount of available organs is insufficient to meet the demand. Alternatives to human organs, such as bioartificial organs, xenotransplantation, or stem-cell technology do not appear to have widespread clinical applicability in the foreseeable future. It seems logical, therefore, to focus attention on organs from compromised donors—organs that are at a higher risk of postoperative complications, such as initial poor graft function (or even primary nonfunction) or biliary complications. Although there is no general consensus on the definition of a compromised, or extended-criteria, donor, most would include donors who are older ( 60 years), and who have diabetes mellitus, hypertension, renal insufficiency, or hepatic steatosis in this category. Obesity, diabetes mellitus, the metabolic syndrome, and associated nonalcoholic fatty liver disease are reaching epidemic proportions throughout the world. A recent survey has indicated that up to 30% of the population in Western societies has a certain degree of hepatic steatosis. In case of advanced degrees of steatosis, this condition may preclude certain individuals as liver donors. Although some controversy about whether all steatotic livers should be excluded from transplantation remains, and some groups have reported reasonable outcomes utilizing livers with a certain degree of steatosis, livers that are deemed steatotic are frequently discarded. The reason not to utilize a potential liver is frequently based on subjective findings of hepatic steatosis during the procurement of postmortem organs, and in most programs, potential living donors are excluded when hepatic steatosis is detected during routine preoperative evaluation. There is a growing body of evidence to argue that steatotic livers are more susceptible to ischemia-reperfusion injury and, following transplantation, have less favorable outcomes than nonsteatotic livers. Hence, if manipulations, in vivo or ex vivo, could increase the quality of these organs and improve their outcome following transplantation, the number of livers available for transplantation would increase and, thereby, reduce current waiting lists for liver transplantation. These manipulations can be divided into 2 groups, the first focusing on reversing hepatic steatosis. If reversal cannot be achieved, the other group can focus on protecting the liver from ischemia-reperfusion injury associated with steatosis. In this issue of Liver Transplantation, Bessems et al. present their data on hypothermic machine preservation of fatty livers in a rodent model of hepatic steatosis. On the basis of an elegant and well-documented study, the authors conclude that less liver damage is observed following machine preservation of steatotic livers in comparison to conventional storage and that hepatobiliary function is superior in livers preserved with machine perfusion. Although the experiments

Ocena zaburzeń krzepnięcia u dzieci zakwalifikowanych do adeno/tonsilektomii

The routine pre-operative evaluation of children undergoing elective tonsillectomy and/or adenoidectomy includes coagulation screening tests. detection of coagulation defects in children with planned tonsillectomy and/or adenoidectomy. In our study we examined 68 children with abnormal coagulation profile, age 1-17 (average 7.5), 43 male and 25 female. All children underwent coagulation tests (APTT, PT, INR, D-dimer, fibrynogen). In case of twice indicated coagulopathy we diagnosed the levels of the coagulation protein factors. After second verification 15/68 (22%) patients presented prolonged APTT and/or PT. The most common disorder was isolated prolongation of APTT--47/53 (89%), 3/53 (5.5%) had prolonged PT and 3/53 (5.5%) had both disorders in the same time. After vitamin K admission in 19/53 (36%) coagulation tests returned to normal. 13/53 (24%) patients had the factor XII deficiency, 1 patient had a low activity of von Willebrand factor and temporary deficient of factor VIII. In one case we found temporary deficiency of factors VIII and IX and one boy had isolated, temporary deficiency of factor IX. Rest of patients 21/53 (40%), in which the activity of coagulation factors were normal, underwent surgery despite prolonged APTT without any bleeding during or after surgery. The coagulation disorders in analized group of children were unstable or inessential, but in a group of 3/68 (4%) nondiagnosed disorders of coagulation tests, may due to heavy bleeding during or after surgery.

Preoperative gait analysis has a substantial effect on orthopedic decision making in children with cerebral palsy: Comparison between clinical evaluation and gait analysis in 60 patients

Background There is still some debate regarding the role of 3-dimensional gait analysis in routine preoperative evaluation of children with cerebral palsy. The aim of this prospective study was to evaluate to what extent introduction of 3-D gait analysis changes preoperative surgical planning.Method Before gait analysis, 60 ambulatory children aged 10 (4–18) years with spastic cerebral palsy had a specific surgical plan outlined, based on clinical examination by orthopedic surgeons. After gait analysis, the proposed surgical procedures were reviewed to determine the frequency with which the treatment plans changed. A multidisciplinary team assessed the gait analysis.Results Treatment plans for 42 of the 60 patients were altered after gait analysis. Surgical treatment was recommended for 49 patients whereas 11 were recommended non-surgical treatment. Of the 253 specific surgical procedures proposed, 97 procedures were not recommended after gait analysis and 65 additional procedures were recommended after the analysis. Thus, the number of procedures proposed was reduced by 13%. A total of 318 specific surgical procedures were proposed either clinically, by gait analysis, or both. There was overall agreement between the referring orthopedic surgeons and gait analysis in 156 of these 318 procedures (49%). Gait analysis proposed more surgery for psoas tenotomy and rectus femoris transfer, whereas less surgery was proposed for other soft tissue and bony procedures. There was good accordance between gait analysis recommendations and the surgery performed subsequently (92%).Interpretation Gait analysis provided important additional information that modified preoperative surgical planning to a high degree. The high accordance between recommendations and surgery performed suggests that surgeons seriously consider the gait data and treatment recommendations.

Preoperative Positron Emission Tomography to Evaluate Potentially Resectable Hepatic Colorectal Metastases

Positron emission tomography (PET) influences clinical management in the preoperative evaluation of patients with hepatic metastases from colorectal cancer. Prospective cohort study. Academic tertiary care center. From January 1, 2000, through December 31, 2002, 71 consecutive patients referred with potentially resectable hepatic metastases based on conventional imaging findings underwent PET or PET with computed tomography in the subsequent preoperative evaluation. Performance of hepatic resection was based on the results of the overall preoperative evaluation. Concordance with conventional imaging findings, identification of additional findings, and change in clinical management were analyzed. The PET findings confirmed the lesions identified by conventional imaging techniques in 64 (90%) of the patients. Additional lesions were identified on PET in 23 patients (32%). The information obtained by PET resulted in a change in clinical management in 17 cases (24%). False-positive PET findings occurred in 6 patients (8%), whereas false understaging occurred in 11 (15%). In no cases did PET findings have an adverse impact on patient outcome. Positron emission tomography provides useful information in the selection of patients with hepatic metastases from colorectal cancer being considered for surgical therapy. Such improved selection may serve to reduce the number of unnecessary surgical explorations and result in improved long-term survival in patients undergoing resection. Positron emission tomography should be integrated into the routine preoperative evaluation of patients being considered for hepatic resection of colorectal metastases.

Severe Factor V Deficiency Associated with Chromosome 1q Deletion.

Background:Coagulation factor V (FV) is an essential cofactor of the prothrombinase complex, catalyzing conversion of prothrombin to thrombin. Severe FV deficiency is a rare coagulation defect with a prevalence in the general population of approximately 1 in 1,000,000 and a variable bleeding risk (Asselta R et al. J Thromb Haemostas 2006). Genetic mutations underlying a FV-deficient hemorrhagic diathesis have been described in a limited number of cases, display considerable allelic heterogeneity, and have been due to point mutations in the FV gene located at chromosome 1q23.Here, we report a 15 year-old girl with psychomotor delay, CNS abnormalities, and a solitary left kidney - features consistent with a congenital 1q deletion including band 1q23 - who was found to have severely reduced plasma FV activity after a routine preoperative laboratory evaluation prior to an elective spinal stabilization surgery revealed a mildly prolonged prothrombin (PT, 13.2 seconds; normal 8.4 – 12 seconds) and activated partial thromboplastin (aPTT, and 38 seconds; normal 21 – 33 seconds) time. She had undergone minor surgical procedures in the past without reports of significant bleeding, and her family members were also clinically unaffected.Methods:FV procoagulant activity level was measured in the patient with an MDA-180 automated coagulation analyser (Trinity Biotech, Ireland). The patient's peripheral blood leukocytes were separated by density centrifugation and fixed in methanol:glacial acetic acid (2:1). We then performed interphase fluorescent in-situ (FISH) analysis using probes covering the FV gene and the more telomeric HPC1 gene as a control. Genomic DNA was also isolated from the patient, and the coding region (25 exons) of the FV gene amplified by polymerase chain reaction (PCR) and sequenced.Results:FV activity assays revealed a severely reduced level of 9% (normal range: 60–130%). Factor V activity levels in the patient's family members were not assessed. Peripheral blood karyotyping revealed an interstitial deletion of 1q: 46,XX,del(1)(q24.2q25.3 or q23.3q25.1).Interphase FISH analysis was performed. Red signals corresponded to the FV probe and green signals corresponded to HPC1, which is approximately 13 MB telomeric to FV. In contrast to healthy controls, the patient had a signal pattern of only 1 green HPC1 signal and 1 red FV signal, corresponding to heterozygous loss of the FV gene and adjacent chromosomal material. Sequencing of the retained allele revealed a novel hemizygous S234W mutation (encoded by exon 6). The lost serine is part of a conserved “SGP” peptide segment predicted to be a solvent-exposed region of the heavy chain of the FV protein.Conclusion:Most mutations causing FV deficiency are autosomal recessive and introduce frame shifts resulting in the generation of a premature termination codon. Karyotypic and FISH analysis of this patient revealed a novel mechanism for FV deficiency: loss of an entire FV allele as part of a chromosomal deletion, coupled with a point mutation in the other allele. Structural modeling of the consequences of the S234W point mutation, which is predicted to alter the hydrophobicity of the protein, is ongoing. Syndromes involving an interstitial deletion of 1q have been described in association with ATIII deficiency (Pallotta, Dalpra et al. 2001), but to our knowledge, this is the first description of a 1q deletion with FV deficiency.

Improved accuracy of intraocular lens power calculation with the Zeiss IOLMaster

This study aimed to demonstrate how the level of accuracy in intraocular lens (IOL) power calculation can be improved with optical biometry using partial optical coherence interferometry (PCI) (Zeiss IOLMaster) and current anterior chamber depth (ACD) prediction algorithms. Intraocular lens power in 461 consecutive cataract operations was calculated using both PCI and ultrasound and the accuracy of the results of each technique were compared. To illustrate the importance of ACD prediction per se, predictions were calculated using both a recently published 5-variable method and the Haigis 2-variable method and the results compared. All calculations were optimized in retrospect to account for systematic errors, including IOL constants and other off-set errors. The average absolute IOL prediction error (observed minus expected refraction) was 0.65 dioptres with ultrasound and 0.43 D with PCI using the 5-variable ACD prediction method (p < 0.00001). The number of predictions within +/- 0.5 D, +/- 1.0 D and +/- 2.0 D of the expected outcome was 62.5%, 92.4% and 99.9% with PCI, compared with 45.5%, 77.3% and 98.4% with ultrasound, respectively (p < 0.00001). The 2-variable ACD method resulted in an average error in PCI predictions of 0.46 D, which was significantly higher than the error in the 5-variable method (p < 0.001). The accuracy of IOL power calculation can be significantly improved using calibrated axial length readings obtained with PCI and modern IOL power calculation formulas incorporating the latest generation ACD prediction algorithms.

Importance of Routine Evaluation of the Thyroid Gland Prior to Open Partial Laryngectomy

To determine the incidence and presentation of synchronous thyroid lesions in a patient population undergoing open partial laryngectomy (OPL), and to determine whether routine preoperative evaluation of the thyroid gland prior to OPL is useful to identify synchronous thyroid lesions in order to reduce the need for reoperation in this complex patient population. Retrospective medical chart review. Academic institution. Sixty-seven consecutive patients with laryngeal tumors who had undergone OPL from 1996 to 2005. Charts of 67 consecutive patients with laryngeal tumors who underwent OPL in 1996 to 2005 have been reviewed for synchronous thyroid lesions. For all patients, reports of (1) complete preoperative examination findings, (2) inpatient course, (3) postoperative follow-up, and (4) postoperative final histopathologic findings were reviewed. For patients with synchronous thyroid lesions, reports of (1) thyroid evaluation and imaging and (2) preoperative (fine-needle aspiration), (3) intraoperative (frozen section), and (4) postoperative (final) histopathologic results for the thyroid lesions were reviewed. Incidence of synchronous thyroid lesions and laryngeal cancer in patients undergoing OPL. Eight (11.9%) of 67 (95% confidence interval, 5.3%-22.2%) patients with laryngeal tumors who underwent OPL had evidence of synchronous thyroid lesions. All 8 patients had squamous cell carcinoma of the larynx and underwent either supracricoid or supraglottic laryngectomy. In these 8 patients, synchronous thyroid lesions were incidentally detected. Four patients had papillary thyroid carcinoma, 1 had squamous metaplasia, and 3 had follicular thyroid tissue that was negative for malignancy on final pathologic examination. In 2 patients, the thyroid lesions were detected preoperatively (prior to OPL); in another 2 patients, thyroid masses were detected intraoperatively; and in 4 patients, the thyroid disease was identified postoperatively on histopathologic examination of excised cervical lymph nodes. In 2 patients, thyroidectomy was performed as a second operation after the OPL, and 1 of them had transient vocal fold paralysis for 2 months. Thyroid ultrasonography was performed in 4 patients. In 3 patients, the ultrasonography was performed after the OPL final pathologic findings indicated the presence of metastatic thyroid disease in cervical lymph nodes. Ultrasonography revealed intrathyroidal lesions in all 3 patients. Patients with laryngeal tumors who will be undergoing OPL might have occult synchronous thyroid lesions. Thyroid surgery in patients with previous OPL may have an increased potential for complication owing to postsurgical changes in the central neck region. Routine preoperative evaluation of the thyroid gland, especially with ultrasonography, to screen for occult synchronous thyroid lesions is recommended for all patients with laryngeal tumors who will be undergoing OPL. Eradication of any thyroid cancer detected preoperatively by fine-needle aspiration should be performed at the same time as OPL. Pros and cons of total thyroidectomy for indeterminate thyroid nodules should be discussed with this patient population.

Dynamic left ventricular outflow tract obstruction induced by dobutamine stress echocardiography leading to myocardial ischemia and infarction

Left ventricular outflow tract (LVOT) obstruction occurring during dobutamine stress echocardiography (DSE) occurs in approximately 15-20% of patients undergoing DSE. The clinical significance and mechanism of LVOT obstruction has been debated, but is now generally felt to result from the pharmacological effects of dobutamine in increasing inotropy and causing peripheral vasodilation. It must be realized that in rare instances, ischemia may occur and lead to wall motion abnormalities and eventually myocardial infarction. We present the case of a 70-year-old asymptomatic woman who underwent a routine pre-operative cardiac stress evaluation and was found to develop a dynamic outflow tract obstruction leading to myocardial ischemia and infarction.

Should Pre-operative Troponin be a Standard Requirement in Patients Undergoing Major Lower Extremity Amputation?

Objectives The objective of this study was to ascertain the benefit of routine pre-operative cardiac troponin I (cTnI) measurement in patients undergoing major lower extremity amputation for critical limb ischaemia. Design This was a prospective, blinded observational study. Methods All patients scheduled for lower extremity amputation, without evidence of unstable coronary artery disease were recruited prospectively over a period of 1 year. In addition to routine pre-operative evaluation, a blood sample was taken for measurement of serum cTnI. Post-operative screening was conducted for cardiac events with patients followed up to 6 weeks. Results Ten of the 44 patients included suffered a non-fatal myocardial infarction or died from a cardiac cause post-operatively. A rise in pre-operative cTnI was associated with a very poor outcome (two cardiac deaths and one post-operative myocardial infarction) and was the only significant predictor of post-operative cardiac events. Conclusion Routine pre-operative cTnI measurement may be of use to identify patients at high risk of cardiac complication who would benefit from optimization of cardiac status or in whom surgery could be deferred.