Valsava Maneuver Research Articles

Subhyaloid Hemorrhage in A Weightlifting Worker: A Case Report

Introduction. Subhyaloid hemorrhage is a sudden loss of vision, mostly caused by valsava retinopathy. We present a case report of a 24-year-old Indonesian male with a sudden decrease in vision to 1/300 in his left eye after lifting hundreds of boxes weighing 10-24 kilograms as part of his job as a warehouse keeper. Methods. We conducted literature searching to five databases (PubMed, Scopus, ProQuest, Embase, and JSTOR) and hand searching on November 20th, 2023. Results. We have selected five articles. The patient was diagnosed with subhyaloid hemorrhage. Physical exertion and valsava maneuver act as ergonomic hazards to this patient. Valsava maneuver can increase intrathoracic and intraabdominal pressure transmitted to the eye and cause rupture of retinal capillaries and detachment of internal limiting membrane. The patient had very heavy work. There was a history of kidney infection and hypertension. No other exposure was considered from out of work. This was a work-aggravated disease. Discussion. Valsalva maneuver, coughing, sneezing, vomiting, weight lifting, and heavy physical activity cause valsava retinopathy. Retinal vascular disorders, diabetes, hematological disorders, and trauma are associated with this. Subhyaloid hemorrhage can also be caused by blowing, constipation, vigorous sexual activity, spontaneous vaginal delivery, or an asthma attack. It can be spontaneously cleared or need hyaloidotomy or vitrectomy. Recurrent episodes can occur from 3 weeks to 4 years predisposed by the valsava condition. Conclusion. Valsava maneuver and weightlifting at work can cause or aggravate subhyaloid hemorrhage. Avoiding valsava maneuver, breath controlling during manual lifting, and lifting restrictions are recommended.

Flight After Stapes Surgery: An Evidence-Based Recommendation.

Recommendations for air travel after stapes surgery, specifically stapes surgery, vary, with no standard recommendation to guide patients and surgeons. According to our search, no previous article has explored the physics of middle ear changes during flight and its effects on poststapedectomy patients in a systematic way. The aim of this study is to bring together 2 arms of expertise, otology, and aviation, to produce an evidence-based recommendation for flight after stapes surgery. The database MEDLINE was searched during August 2022. The search strategy had the goal of identifying studies that discovered the effects of flying on stapes surgery patients and the effects of atmospheric pressure on middle ear structures. The articles yielded from the search strategy were transferred to the online citation manager Rayyan. Included in the review were those studies reporting patient outcomes after flying following ear surgery; additional studies included those reporting pressure changes in the middle ear and ossicular chain displacement whether in experimental or animal conditions. Modern-day commercial air travel is safe for patients who have undergone stapedotomy surgery, even very shortly after hospital discharge if they have to. If stapedotomy patients wish to fly after hospital discharge, otologists are to reassure them that it is safe to do so. Patients are to be reminded to perform a gentle Valsava maneuver about every 4 minutes during airplane descent.

Obstetrical ballooning and avulsion of levator ani muscle after vaginal delivery: a literature review

Link of Video Abstract: https://youtu.be/TWDe9uP4QX8 The levator ani muscle (LAM) is thought to be of central importance concerning pelvic organ support. 10-30% of women experience overstretched or 'ballooning' of the levator hiatus, sometimes followed by detachment or 'avulsion' of the muscle from its insertion. Both ballooning and avulsion of the LAM can occur by itself or co-exist at the same time. This literature review was conducted on multiple databases from previous studies, to help clinicians better understand the ballooning and avulsion phenomenon, thus making early diagnosis possible for earlier prolapse prevention for the patients. LAM avulsion can be diagnosed clinically using digital palpation or using imaging modalities such as ultrasound and magnetic resonance imaging (MRI). During maximal contraction (or at rest) using ultrasound, levator avulsion is indicated through a levator-urethra gap (LUG) diameter > 2.5 cm. MRI is considered highly sensitive, but it requires a higher cost and an experienced radiologist. Hiatal ballooning can be diagnosed by clinical examination based on the sum of Genital hiatus and Perineal body (Gh+Pb) and imaging with 2D, 3D, or 4D ultrasound during the Valsava maneuver. Ballooning is diagnosed clinically if Gh+Pb > 7 cm, by 2D imaging of levator hiatal anteroposterior (LHAP) diameter ≥ 6 cm, and by 3D/4D imaging of the hiatal area ≥ 25 cm2. Physiotherapeutic treatment and pelvic floor muscle (PFM) exercises can be used to treat ballooning and LAM avulsion to avoid urogynecological sequelae. There is some evidence to prevent this condition, including vitamin D consumption, epidural analgesia, kegel exercise, and vaginal dilator. PFM strength, posterior vaginal wall support, and ultrasound evidence of LAM tear can be used as potential indicators to predict pelvic floor injury. Since ballooning and avulsion of the LAM have lifelong morbidity and are not often identified early by clinicians, further research is still needed.

A Study on the Association between Korotkoff Sound Signaling and Chronic Heart Failure (CHF) Based on Computer-Assisted Diagnoses.

Background Korotkoff sound (KS) is an important indicator of hypertension when monitoring blood pressure. However, its utility in noninvasive diagnosis of Chronic heart failure (CHF) has rarely been studied. Purpose In this study, we proposed a method for signal denoising, segmentation, and feature extraction for KS, and a Bayesian optimization-based support vector machine algorithm for KS classification. Methods The acquired KS signal was resampled and denoised to extract 19 energy features, 12 statistical features, 2 entropy features, and 13 Mel Frequency Cepstrum Coefficient (MFCCs) features. A controlled trial based on the VALSAVA maneuver was carried out to investigate the relationship between cardiac function and KS. To classify these feature sets, the K-Nearest Neighbors (KNN), decision tree (DT), Naive Bayes (NB), ensemble (EM) classifiers, and the proposed BO-SVM were employed and evaluated using the accuracy (Acc), sensitivity (Se), specificity (Sp), Precision (Ps), and F1 score (F1). Results The ALSAVA maneuver indicated that the KS signal could play an important role in the diagnosis of CHF. Through comparative experiments, it was shown that the best performance of the classifier was obtained by BO-SVM, with Acc (85.0%), Se (85.3%), and Sp (84.6%). Conclusions In this study, a method for noise reduction, segmentation, and classification of KS was established. In the measured data set, our method performed well in terms of classification accuracy, sensitivity, and specificity. In light of this, we believed that the methods described in this paper can be applied to the early, noninvasive detection of heart disease as well as a supplementary monitoring technique for the prognosis of patients with CHF.

Bilateral facial colliculus syndrome caused by pontine tegmentum infarction: a case report

BackgroundBilateral facial colliculus syndrome is a rare clinical presentation in patient with pontine infarction. We herein described a case of bilateral facial paralysis and complete horizontal gaze palsy possibly caused by paradoxical embolization from patent foramen ovale related stroke.Case presentationA 55-year-old male presented with sudden onset of complete peripheral facial palsy and horizontal gaze palsy after Valsava maneuver. MRI revealed symmetric involvement of bilateral pontine tegmentum in accordance with the location of facial colliculus. CSF analysis and follow-up MRI showed no evidence of central demyelinating disease. Subsequent echocardiography revealed patent foramen ovale and closure surgery was performed.ConclusionsFacial colliculus syndrome with symmetric dorsal pontine tegmentum involvement may a rare manifestation in posterior circulation stroke.

Spontaneous Orbital Hematoma Induced by VALSAVA Maneuver

Spontaneous Orbital Hematoma Induced by VALSAVA Maneuver

Варикоцеле у дітей. Історія та сучасний стан проблеми (огляд літератури)

A literature review on the subject of varicocele in children which include historical data and question about: etiopathogenesis, epidemiology, diagnostics, treatment and long-term outcomes. The diagnostic method of varicocele unchanged until the XX century and consisted of visual examination and palpation with or without Valsava maneuver. But after entering in diagnostic protocol contrast venography, thermography of testis and ultrasound examination, this protocol have significant changes. For a long time, phlebography has been considered the «gold standard» for the diagnosis of varicocele. But the big disadvantage of this procedure is high invasiveness. Doppler ultrasound mapping has given a new impuls to the diagnosis of varicocele due to minimally invasiveand accessible. G. Liguori, C. Trombetta in their work showed that surgical treatment of varicocele should begin when the testicle size is reduced by more than 20%, or 2 ml of volume in ultrasound examination. Also, the visualization of reflux into the seminal vein is more specific in the ultrasound examination. G. Sigmund et al. introduced the concept of stop-type, shunt-type reflux into the seminal vein. However, in the case of unexplained recurrent varicocele, only antegrade venography can provide sufficient information. The review presents the classic and alternative surgical treatments of varicocele in children. Today it is safe to say that the treatment of varicocele has entered to the era of modern evidence-based medicine. A large number of studies indicate that the expansion of the testicular plexus has a progressive detrimental effect on testicular tissue and leads to a deterioration in sperm count. The methods witch used to correct varicocele earlier was traumatic, but modern surgery has brought many innovative technologies and methods of surgical correction. In addition, there have been impressive developments in bimolecular and functional sperm tests. Nowdays gold standard of surgical treatment varicocele is microsurgical subgingival varicocelectomy but this operation has one big disadvantage. This is possible damage of the testicular artery. The solution of this problem can be obtained by finding new intraoperative way of visualization and defending testicular artery and lymphatic vessels. No conflict of interest was declared by the authors. Key words: varicocele, microsurgical subgingival varicocelectomy, children.

66 Simple bedside cardiovascular autonomic examinations for predicting chronotropic incompetence

Abstract Background Simple bedside cardiovascular autonomic reflex test (CARTs) are usually used to determine cardiovascular autonomic neuropathy (CAN). CAN may contribute to chronotropic incompetence (CI) which is the inability of the heart rate (HR) to rise in proportion to an increase in metabolic demand. Determination of CI is widely based on measurement of maximum HR during exercise testing. This study aimed to evaluate the role of CARTs to determine CI. Methods We included in 105 patients using a derivation and validation sampling ratio of 2:1. CARTs were performed for analyzing heart rate variation during three parasymphathetic standard tests (deep breathing, lying to standing, Valsava maneuver) and two sympathetic standard tests (systolic blood pressure from lying to standing and diastolic blood pressure during handgrip maneuver). Variables independently associated with CI in multivariable analysis in the derivation set were assigned points based on their respective odds ratios. Results CI group showed significantly lower values of among three parasympathetic standard tests (p < 0.05) but not significantly among two sympathetic standars tests. Valsava maneuver (OR 0.1, p < 0.001, 95%CI 0.001-0.004), deep breathing (OR 0.91, p = 0.025, 95% CI 0.836-0.988), and handgrip maneuver (OR 0.85, p = 0.01, 95% CI 0.744-0.961) were found to be an independent risk factor for CI from multivariate regression analysis. The accuracy of different CART parameters in the prediction of CI was described by the receiver operating curve (ROC) analysis. Regarding logistic regression model, we constructed formula of 15 - ([12 x Valsava maneuver] + [0.1 x deep breathing] + [0.2 x handgrip maneuver]) which will show negative and positive results indicating CI and non-CI, respectively. The resulting score showed good calibration and discriminatory capacity in the derivation (Hosmer-Lemeshow x² 10.051, p = 0.186, AUC = 0.878). The difference between AUCs in the derivation and validation sets was Δ = 0.122 (p = 0.174). Conclusion The decrease in heart rate variations during Valsava maneuver and deep breathing and in diastolic blood pressure during handgrip maneuver seems to be related to development of CI. Formula of CARTs score is a useful tool for predicting CI. Final score sheet based on formula Total score CI probability <-0.1 High probaility 0.2-0.6 Intermediate probability >0.6 Low probability

Comparison of the Levator Hiatal Area

Objective: To determine the relationship of the levator hiatal area
 among nulliparous, primiparous, and multiparous women so that
 we can assess the prevalence of avulsion.
 
 Method: A cross-sectional study design was used by evaluating the
 transperineal ultrasound results of all nulliparous, primiparous, and
 multiparous women in the Obstetrics and Gynecology Clinic of
 Dr. Cipto Mangunkusumo hospital from May to December 2015. We
 analyzed the data through SPSS using one way ANOVA to compare
 the levator hiatal dimension among the groups of women during
 Valsava maneuver and at rest.
 
 Result: There were significant differences in levator hiatal area
 among nulliparous, primiparous, and multiparous women during
 Valsalva maneuver and at rest, which the mean (SD) was 22.26
 (5.45) cm2 (p=0.028) and 10.70 (2.26) cm2 (p=0.012), respectively.
 Levator ani muscle avulsion was occurred in 1 out of 46 (2.2%)
 women from the primiparous and multiparous group.
 
 onclusion: There are significant differences in levator hiatal area
 during Valsalva and at rest among the groups.
 [Indones J Obstet Gynecol 2016; 4-4: 208-211]
 
 Keywords: avulsion, levator hiatal area, multiparous, nulliparous,
 primiparous

The Influence of Childbirth Procedures to the Axial Length and Sclera Rigidity

Background: Various clinical and experimental studies attest that biochemistry and biomechanical of sclera are factors of influence shape and sclera size which is influence refraction status of the eye. Sclera streatching influenced by intraocular pressure (Valsava maneuver when bearing down effort), extracellular matrix (influenced by estrogene, progesterone and relaxin when pregnant), myopia and age.Objectives: To investigate the influence of delivery procedures of to the axial length and sclera rigidity.Methods: Samples of 60 eyes in two groups; vaginal deliveries (bearing down effort group) and operative deliveries (Caesar group) were tested in the pre and post test control design. Both groups underwent two examinations at prepartum and postpartum including visual acuity, anterior segment, posterior segment, measurement of axial length and sclera rigidity.Results: There were significant differences in the axial length mean in the bearing down effort group; the prepartum axial length is 22.81 ± 0.94 mm and the post-partum is 23.20 ± 0.80 mm. Pre-partum axial length mean is 23.05 ± 1.24 mm and increased to 23.40 ± 1.37 mm in the post-partum samples of Caesar group. This study also found that there were significant differences in the sclera rigidity mean in bearing down effort group which is 0.0144 ± 0.0006 in the prepartum and increase to 0.0163 ± 0.0060 in the postpartum. For the Caesar group, the sclerea rigidity mean was 0.0142 ± 0.0480 in the prepartum and increased to 0.0150 ± 0.0050 in the postpartum. Although no significant effects of bearing down effort to axial length and sclera rigidity was observed, the clinical results indicated that 53,85% of myopia in the bearing down effort groups experienced the increase postpartum corrected-lens approximately between -0,25 D to -0,75D and – 0, 25 D to – 1,00 D in 47,61% of myopia (Caesar groups).Conclusion: There is a significant difference in axial length and sclera rigidity prepartum and postpartum in both groups.

Spontaneous pneumomediastinum due to the Macklin effect: less is more

A 17-year-old woman presented to the Emergency Department with the abrupt onset of left hemi-facial swelling. On clinical examination, she had subcutaneous emphysema of the face, neck, and chest. She reported a prior history of asthma, without recent acute exacerbation, and she acknowledged having used cannabis and MDMA (3,4-methylenedioxy-N-methylamphetamine) a few hours before. A chest radiograph (Fig. 1a) showed diffuse subcutaneous emphysema associated with a large pneumomediastinum, consistent with the diagnosis of spontaneous pneumomediastinum due to alveolar rupture and the Macklin effect. Although there was no argument in favor of tracheal or esophageal rupture in the anamnesis, a thoracic computed tomography (CT scan) without contrast material injection was finally performed to exclude non-spontaneous pneumomediastinum (Fig. 1b–d). The CT scan confirmed the presence of diffuse pneumomediastinum with subcutaneous emphysema and air dissection into the extrapleural space of the left apex, mimicking a pneumothorax. There was no pneumothorax, rib fracture, or rupture of the trachea or esophagus. Air dissection in the central (peribronchovascular bundles) and peripheral (adjacent to the pleura) pulmonary interstitium, associated with the appearance of alveolar rupture in the middle lobe, confirmed the diagnosis of spontaneous pneumomediastinum due to alveolar rupture and the Macklin effect. The patient was afebrile with normal oxygen saturation, but had a leukocytosis (20 g/L) without elevation of the C-reactive protein (CRP). She was admitted to the thoracic surgery service for observation, and was treated with analgesics. She was discharged after a brief hospitalization of 36 h, and follow-up consultation 3 days later confirmed a marked reduction of the subcutaneous emphysema. Although spontaneous pneumomediastinum may have a striking clinical presentation, the symptoms are usually self-limited and resolve in a few days. Despite this impressive presentation, physicians should resist the temptation to over-image and hospitalize these patients, as was the case here. The Macklin effect was experimentally demonstrated by Macklin et al. in 1939. It corresponds to an alveolar rupture with air dissection along the interstitial sheaths toward the mediastinum, eventually leading to a pneumomediastinum [1]. Alveolar rupture is responsible for more than 95 % of cases of pneumomediastinum, and is more frequent than esophageal or tracheobronchial disruptions [1]. Identification of the Macklin effect on chest CT scan by visualizing air dissection along perivascular and peribronchial sheaths has been reported in 89–100 % of cases of spontaneous pneumomediastinum, but CT scan confirmation is unnecessary [1, 2]. The Macklin effect has also been implicated in 39 % of cases of pneumomediastinum following severe blunt chest trauma [3]. Spontaneous pneumomediastinum occurs predominantly in young males, and is frequently associated with respiratory diseases such as asthma and chronic obstructive pulmonary disease [2, 4]. A triggering event can be identified in 39–75 % of cases, such as an acute exacerbation of asthma, coughing, inhalation drug abuse, vomiting, physical exertion, the Valsava maneuver, or karaoke singing [2, 4, 5]. Air dissection into the pulmonary interstitium does not affect gas exchange [3]. Fever up to 38.5 C and leukocytosis with a CRP level less than 5 mg/L are & Guillaume Chassagnon gchassagnon@gmail.com

Assessing Methods of Heart Rate Variability

Heart rate variability is significantly associated with cardiovascular complications in various neurological disorders with cardiac impairment. Measures of spontaneous heart rate variability might be different from provocating tests of heart rate variability such as deep breathing and Valsava maneuver. Methods for analysis are divided into time domain methods and frequency domain methods. There are standard deviation of NN interval, standard deviation of average NN interval, root mean square of the successive differences, NN50, and pNN50 in time domain methods. Frequency domain bands can be divided into very low, low, and high frequency. Each variables are influenced by sympathetic and/or parasympathetic activity. (Korean J Clin Neurophysiol 2014;16:49-54)

Occluding the pulmonary artery to improve detection of patent foramen ovale during ventricular assist device placement

Unrecognized patent foramen ovale (PFO) in patients after left ventricular assist device (VAD) placement could cause significant hypoxemia and paradoxical embolism. We aim to improve the techniques for PFO detection in this patient population before left ventricular device initiation. We evaluated the effects of main pulmonary artery occlusion on patients' hemodynamic and detection of PFO by transesophageal echocardiography (TEE). We compared between the standard and pulmonary artery occlusion technique. Sixty-two patients with ASA physical status class IV were studied. They presented with end-stage heart failure for left VAD placement. All patients received both Valsava maneuver and occlusion of their pulmonary arteries to assess their influence on detection of PFO. Occlusion of the main pulmonary artery consistently increased right atrial to left atrial pressure gradient. The PFO detection rate using TEE was significantly improved from 0% to 10% by this maneuver compared with the Valsava maneuver. Occlusion of the main pulmonary artery is a simple and effective method to improve PFO detection by TEE before left VAD initiation.

Changes in middle cerebral artery and cerebral regional oxygen saturation (rSO2) by Valsava manoeuvre in supine, sitting and standing position: Study in healthy volunteers

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Clinical and Experimental Circulation

The PFO anatomy evaluation as possible tool to stratify the associated risks and the benefits arising from the closure

According to the current guidelines, the patent foramen ovale (PFO) is still considered a qualitative factor and, as a consequence, its closure is recommended just on the basis of its 'presence'. In the year 2008, we evaluated 25 patients (mean age 62.7) with acute cerebrovascular event and 92 patients (mean age 27.3) suffering from migraine with aura. No PFO was reported in 79 patients. A venous-to-arterial circulation shunt had been shown in 38 patients (29 subjects with migraine and 9 subjects with prior stroke). According to the number of microbubbles arrived during the Valsava manoeuvre, we found: 25 small PFO, 6 moderate PFO, and 6 severe PFO. In the baseline population with migraine (n = 92), 32% (n = 29) had a PFO. A 'large' foramen was reported in approximately 9% of the migraine subjects. In the population with prior stroke (n=25), 9 patients (36%) had a PFO. A 'large' foramen was reported in 45% of the patients with ischaemic stroke. We found embryonic recesses in 13% (n = 4) of the patients with migraine and PFO (n=29) vs. 66% (n=6) of the patients with ischaemic stroke and PFO (P= 0.01). It is possible to suppose that not all PFO have the same prognostic value. The evaluation of two anatomical characteristics can allow to identify those foramina at higher risk and, as a consequence, the patients who could have a major benefit from the closure.

Modificações topográficas da junção uretrovesical e da uretra proximal após cirurgia combinada de Marshall-Marchetti-Krantz e Burch

To study the changes in the urethrovesical junction (UVJ) and in the proximal urethra (PU) caused by the Marshall-Marchetti-Krantz-Burch (MMK-B) combined surgery through perineal ultrasonography. An interventional, longitudinal and prospective study has been conducted. Thirty-two women with stress urinary incontinence were submitted to perineal ultrasonography before and 30 days after surgery to evaluate the pubo-urethral distance (PUD), the proximal urethra length, the UVJ horizontal distance (UVJHD) and the UVJ vertical distance (UVJVD), the patient being at rest, and in effort during the Valsava manoeuvre. Results have been expressed in mean and standard deviation. The Student's t-test has been used to compare pre and postoperative results whenever the variables fulfilled the normality test criterion; otherwise, the Wilcoxon's paired test has been used. As compared with the preoperative measures, the Marshall-Marchetti-Krantz-Burch surgery has reduced the PUD at rest (14 mm x 4.3 mm) and during effort (20.8 mm x 6.4 mm); has reduced the UVJHD at rest (14 mm x 4.3 mm) and during effort (20.8 mm x 6.4 mm); has increased the PU length at rest (16.7 mm x 19.7 mm) and during effort (1.6 mm x 15.4 mm); and has increased UVJVD during effort (-5.4 mm x 14.8 mm), but has not changed it at rest (16.2 mm x 18.7 mm, p = 0.085). The Marshall-Marchetti-Krantz-Burch surgery has significantly reduced the urethrovesical junction vertical and horizontal mobility without raising the urethrovesical junction.

Diagnosis and Treatment of a Superficial Upper Eyelid Arteriovenous Malformation

Combined embolization and surgical excision as a safe treatment for a high flow superficial upper eyelid anteriovenous malformation. Introduction: Orbital arteriovenous malformations (AVM) may cause significant morbidity including chronic pain and cosmetic disfigurement. These rare lesions require a multidisciplinary approach. A case of an orbital high-flow AVM treated subsequently by an mterventional radiologist and oculoplastic surgeon is presented. Materials and methods: Clinical assessment, computed tomography and digital substruction angiography revealed a high-flow AVM. Transvenous and percutaneous embolization was followed by surgical excision. Results: A 1.5 cm, slowly growing, compressible pulsating lesion in the left upper eyelid of a 23 year old man was found. Eye motility and ophthalmologic examination were normal. Valsava manoeuvre didn't increase the size. Imaging revealed a high-flow AVM feeded by the arteria temporalis superficialis (itself feeded by the a. supraorbitalis and supratrochlearis). Draining vessels were the superior ophthalmic vein and a superficial lateral orbital vein. This malformation was first embolized. To prevent iatrogenic embolization of the sinus cavernous, the vein draining into the superior ophthalmic was occluded by a transvenous approach, followed by a percutaneous injection with diluted glue (equal amounts of glubran-2 and lipiodol). The remaining low-flow lesion was then safely excised. Conclusion: High-flow orbital AVM represent a considerable treatment challenge. Good cosmetical and functional outcome was obtained safely by subsequent embolization and surgical excision. When treating these rare malformations it is of the highest importance to coordinate the interdisciplinary efforts.

Study on intra-abdominal pressure in indirect inguinal hernia patients

To investigate intra-abdominal pressure (IAP) and its changes in patients with indirect inguinal hernia and non-hernia diseases. Supine IAP (SIAP), supine Valsava IAP (SVIAP), orthostatic IAP (OIAP) and orthostatic Valsava IAP (OVIAP) were measured by intra-vesicle pressure measurement in 19 indirect inguinal hernia patients and 20 non-hernia patients, respectively. The differences of IAP between orthostatic and supine position in quiescent condition (OSIAPD), before and after taking Valsava maneuver in supine position (SVIAPD) or in orthostatic position (OVIAPD), orthostatic and supine position when taking Valsava maneuver (OSVIAPD) were compared between the two groups. There was no significant differences in SIAP, OIAP, SVIAP, OSIAPD, SVIAPD between the two groups (P > 0.05). While patients with indirect inguinal hernia had higher OVIAP (P < 0.05). Significant differences in OVIAPD and OSVIAPD was found between the two groups (P < 0.05). The etiology of indirect inguinal hernia were related to orthostatic position, increasing IAP and changes of anatomic structures. The IAP is prone to elevated in patients with indirect inguinal hernia.

Cardiovascular impairment in children, adolescents, and young adults with type 1 diabetes mellitus (T1DM)

Left ventricular (LV) function was assessed in 42 patients (mean age +/- SD, 18.45 +/- 3.76 years; 17 males) with type I diabetes mellitus (T1DM; mean duration 9.89 years) and in 43 healthy controls (mean age +/- SD, 18.27 +/- 3.36 years; 18 males). Systolic, diastolic cardiac function and LV dimensions were assessed using M-mode and Doppler echocardiography. Neural autonomic function was assessed by measuring RR variation during deep breathing, Valsava maneuver, 30/15 ratio, and blood pressure response to standing. Fractional shortening, peak velocity of early ventricular filling (E wave), peak velocity of LV filling (A wave), E/A ratio, deceleration time, isovolumic relaxation time, LV dimensions (interventricular septum, posterior wall thickness, end diastolic diameter [EDD] and systolic diameter [ESD]) were all comparable between patients with T1DM and controls. However, in 11 T1DM patients with microalbuminuria and/or retinopathy, EDD, ESD, E/A ratio, and E wave were all lower (p = 0.0011, p = 0.019, p = 0.0011, and p = 0.030, respectively) while, A wave, heart rate, and diastolic blood pressure were all higher (p = 0.008, p = 0.0024 and p = 0.004, respectively) compared to matched for age and sex controls. Furthermore, in six of the 11 T1DM patients with microangiopathy who had E/A <1.12 (<2 SD of the control mean), significant and marginally significant correlations were found between E/A ratio and the duration of the disease as well as the mean HbA1c of the last year (r = -0.38, p = 0.011 and r = -0.287, p = 0.064, respectively). In conclusion, it has been found that impairment of diastolic, but not systolic, LV function can be detected early in young patients with T1DM and microangiopathy.

INVITED COMMENTARY

Since its introduction in 1987, the use of the right gastroepiploic artery (GEA) as a coronary artery bypass graft has been generally restricted to bypass the right coronary artery (RCA) branches at the inferior myocardial wall due to topographic proximity and graft length limitation. On the basis of clinical and angiographic data, it has been recently suggested that skeletonization of the right GEA graft may enhance its length and diameter and improve its flow. Consequently, the right GEA has stimulated much interest as a bypass graft for off-pump cases, for coronary revascularization with the aorta no-touch technique, and for construction of composite bypass conduits. The current report by Takahashi and associates presents interesting data regarding the use of the in situ right GEA as a bypass graft of the left coronary artery system. In the cases of sequential graft usage, the authors do consider the possibility of insufficient graft diameter at the anastomotic sites as a reason of graft occlusion but they do not provide any graft flow measurements and they do not comment whether these grafts were tension free. During a Valsava maneuver, the right ventricle may get distended and the section of the graft between anastomoses to RCA and left anterior descending artery (LAD) may get pressured upon and obstructed. The conclusions of Takahashi and associates regarding the sequential bypass grafts are based on a very small number of patients, whereas sufficient data on graft quality is not provided. The quality of the coronary anastomoses could have been influenced by the surgical technique used (on-pump with or without cardioplegic arrest, off-pump). On the basis of the authors' experience, caution when using the GEA as a bypass graft to the left coronary artery system is in order. In addition, it should be commented that the avoidance of graft tension and of retrograde direction of the anastomoses, and careful selection of arterial targets for sequential bypass are established conditions necessary for optimal outcome in coronary revascularization procedures. Early and Mid-Term Outcome of Anastomosis of Gastroepiploic Artery to Left Coronary ArteryThe Annals of Thoracic SurgeryVol. 78Issue 6PreviewThe performance of a bypass made to the left coronary artery using the gastroepiploic artery was examined. Full-Text PDF