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These patients should be considered in two groups: high transvalvular gradients (mean gradient > 40 mm Hg) and low transvalvular gradients (mean gradient < 30 mm Hg) cheap 200mg topamax amex 7mm kidney stone treatment. Despite a substantial operative mortality buy generic topamax 200mg online medicine 122, survival appears improved in those treated surgically compared with medical management purchase topamax canada medications with aspirin, especially if they demonstrate contractile reserve when challenged with dobutamine. Contractile reserve is defined as the ability to increase in stroke volume by >20% from baseline. Dobutamine infusion will generate an increase in cardiac output without a significant increase in the transvalvular pressure gradient. Low transvalvular gradients can also be seen in patients in which the peak aortic valve gradients are not accurately detected or there are errors in measurement. Careful evaluation of valve hemodynamics and valve anatomy is important to ensure that the valve is truly severely narrowed. Surgical removal of the membrane leading to subaortic obstruction is indicated for symptomatic patients or for asymptomatic patients with a peak pressure gradient >50 mm Hg. Surgery can also be considered in asymptomatic patients with peak gradient >30 mm Hg if they are planning to become pregnant or wishing to participate in competitive sports. The ventricle responds to added wall tension by compensatory eccentric hypertrophy of myocytes. The left ventricle produces a larger total stroke volume with each contraction, preserving normal effective forward stroke volume. The effective forward stroke volume and cardiac output fall acutely, potentially resulting in hypotension and cardiogenic shock. The tachycardia that accompanies cardiac deterioration helps shorten the diastolic-filling period during which the mitral valve is open. If left untreated, these patients quickly progress to total cardiovascular collapse. When severe chest pain is part of the initial clinical presentation, aortic dissection must be strongly suspected. A diastolic thrill may be palpable in the second left intercostal space, as may a systolic thrill caused by increased aortic flow. S may be soft, singly split (P obscured by the2 2 diastolic murmur) or paradoxically split. An S is3 4 often present and represents left atrial contraction into a poorly compliant left ventricle. The Austin Flint murmur is a middle-to-late diastolic rumble that is believed to be caused by vibration of the anterior mitral leaflet as it is struck by the regurgitant jet or by turbulence in the mitral inflow from partial closure of the mitral valve by the regurgitant jet. Unlike the murmur of true valvular mitral stenosis, the Austin Flint murmur is not associated with a loud S or with an opening snap. It reflects the increased ejection rate and large stroke volume traversing the aortic valve. The physical examination may be most notable for signs of hemodynamic compromise, such as hypotension, tachycardia, pallor, cyanosis, diaphoresis, cool extremities, pulmonary congestion, and altered mental status. The heart size is often normal, and the point of maximal intensity is not displaced laterally. When aortic dissection is suspected, blood pressures should be taken in all extremities to detect the differences. The systolic murmur reflecting increased flow across the aortic valve may be heard but is usually not loud. Aortic dissection can lead to a widened mediastinum and/or a widened cardiac silhouette due to pericardial effusion. Other blood tests may help in elucidating suspected underlying conditions such as connective tissue disorders or if endocarditis is possible. Bacterial endocarditis, which can cause leaflet fibrosis and retraction, leaflet perforation, or flail of the valve cusp, should be suspected if a vegetation is detected. Aortic root abnormalities are also well visualized in the parasternal long-axis view. Aortic root dilation is most often idiopathic, although Marfan syndrome, Ehlers–Danlos syndrome, ankylosing spondylitis, Reiter syndrome, rheumatoid arthritis, syphilis, and giant cell arteritis are other potential causes. In the parasternal long axis, the transducer should be moved up one interspace to assess the ascending aorta. Infective destruction of the aortic wall and proximal aortic dissection flaps may occasionally be visualized on transthoracic images. The pressure half-time of the aortic regurgitant velocity is defined as the time required for the pressure gradient across the aortic valve to fall to half of its initial value. Pulsed wave Doppler echocardiography should be performed in the proximal descending aorta to establish the presence of diastolic flow reversal. Flow reversal may also be seen with other conditions that cause blood to leak out of the arterial system such as patent ductus arteriosus or sizeable arteriovenous fistula. Stress echocardiography is useful for assessing functional capacity and unmasking symptoms in patient previously classified as being asymptomatic or with equivocal symptoms. It can also assess for contractile reserve, which if absent is predictive or the development of systolic dysfunction both at follow-up (medical therapy) and postoperatively. It is also important to acknowledge that afterload increases substantially with exercise, which can precipitate a fall in ejection fraction. The decision to perform cardiac catheterization in younger patients should be made on an individual basis after assessment of the patient’s cardiac risk profile. Caution should be exercised when manipulating catheters in patients with Marfan syndrome or cystic medial necrosis of the aortic wall to minimize the risk of vascular trauma. Ninety percent of such patients remain asymptomatic at 3 years, 81% at 5 years, and 75% at 7 years after the diagnosis is made. There is increasing evidence that the natural history may be less favorable especially in those who do not undergo surgical intervention. In severe cases, temporary transvenous atrial/ventricular pacing and/or intravenous inotropic agents may be required for temporary hemodynamic support. The goal of medical therapy in this setting is to maximize forward cardiac output and minimize propagation of aortic dissection if present. However, an observational study of 31 patients in Germany was performed using the JenaValve with a 30-day mortality of 12. The JenaValve is a porcine root valve sewn to a Nitinol self-expanding stent fitted with an outer porcine pericardial patch or skirt. The device also features a fixation clip to firmly anchor the valve despite the absence of calcification. Some patients with leaflet perforation caused by infectious endocarditis may also be candidates for repair in which a pericardial patch is sewn over the defect. This is likely due to the hemodynamic changes produced by eradicating the regurgitation. Slow improvement with normalization or at least stabilization of function at about 6 months is common in these patients. Valve replacement can be performed without infection of the prosthesis in active endocarditis, even when antibiotics have only recently been started. An aortic valve homograft is the preferred prosthesis in the setting of endocarditis.

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Perinatal brain injury: the role of Their existence is based on their association with generic topamax 200mg line treatment 2014, and the development in vulnerability purchase topamax us 72210 treatment. Anaesthesiology 2003; 98: complicated interplay between purchase topamax 200 mg medicine zyrtec, astrocytes or neurons in 1039–1041. Astrocytic activation and In cardiac surgery, serious problems arise as serum lev- delayed infarct expansion after permanent focal ischemia in els may be contaminated, at least in the early time inter- rats: part I: enhanced astrocytic synthesis of S-100β in the val afer surgery. Biochemical markers should not be periinfarct area precedes delayed infarct expansion. J Cereb expected to naturally correlate directly with outcome, but Blood Flow Metab 2002; 22: 711–722. More research is warranted, not ings of global central nervous system hypoperfusion. Intracellular and extracellular roles of S100 pro- release of extracellular amino acids in both normo and teins. J Cardiothorac imaging and neuropsychological changes after coronary Vasc Anesth 2000; 14: 698–701. Diffusion-weighted mag- fluid and serum in patients with no previous history of neu- netic resonance imaging and neurobiochemical markers rological disorder. Calcium and fos spective study using neuropshychological assessment and involvement in brain-derived Ca(2+)-binding protein (S100)- diffusion-weighted magnetic resonance imaging. Movement of cerebrospinal fluid within the cra- markers in serum during and after experimental settings of niospinal space when sitting up and lying down. Continuous versus inter- marker of blood-brain barrier function and brain lesions. Measurement of neurotransmitter release by brain barrier associated with cardiopulmonary bypass in intracranial dialysis. Dextrorphan brospinal fluid concentration of S-100 protein during and inhibits the release of excitatory amino acids during spinal after thoracoabdominal aortic aneurysm surgery: is S-100 cord ischemia. Ann Thorac Surg tionship between evoked potentials and measurements of 2003; 76: 1215–1226. J Vasc Surg 1999; 30: Cortical brain microdialysis and temperature monitoring 293–300. S100B protein in clinical diagnostics: assay markers of cerebrospinal ischemia after repair of aneurysms specificity. S-100 proteins: relationships with membranes and trations in cerebrospinal fluid and blood during carotid end- the cytoskeleton. Prospective compara- specific enolase and S100B in cerebrospinal fluid after severe tive study of brain protection in total aortic arch replace- traumatic brain injury in infants and children. Pediatrics ment: deep hypothermic circulatory arrest with retrograde 2002; 109: E31. Are serum S100β with mammalian and arthropod junctional membrane pro- proteins and neuron – specific enolase predictors of cerebral teins. Impact of retro- a potential marker for cerebral events during cardiopulmo- grade cerebral perfusion on S100β release during hypother- nary bypass. Ann Thorac Surg value of S-100β and neuron-specific enolase serum levels for 1999; 68: 2202–2208. Ann Thorac Surg 2001; 71: Protein S-100beta in brain and serum after deep hypother- 1512–1517. S100B as a pre- analysis of serum concentrations of protein S-100B and glial dictor of size and outcome of stroke after cardiac surgery. Lund malignant course of infarction in patients with acute middle University, Sweden, 2001. Elevated as a surrogate marker for successful clot lysis in hyper- serum levels of S-100 after deep hypothermic arrest correlate acute middle cerebral artery occlusion. S-100β release in hypo- value of S-100β and neuron-specific enolase serum levels for thermic circulatory arrest and coronary artery surgery. Ann Thorac Surg blood after cardiac surgery is a powerful predictor of late 1999; 68: 1225–1229. Serial measurement of with neurologic complications after aortic operation using serum S-100B protein as a marker of cerebral damage after circulatory arrest. Role of neurobio- after out-of-hospital cardiac arrest: prediction by cere- chemical markers of damage to neuronal and glial brain brospinal fluid enzyme analysis. Time course of psychological changes after cardiopulmonary bypass for serum neuron-specific enolase: a predictor of neurological coronary artery bypass grafting. Release of brain- ship between serum S-100β protein and neuropsychologi- specific creatine kinase and neuron-specific enolase into cal dysfunction after cardiopulmonary bypass? J Thoracic cerebrospinal fluid after hypothermic and normothermic Cardiovasc Surg 2000; 119: 132–137. Ann Thorac Surg 2000; 69: in cerebrospinal fluid during thoracoabdominal aortic 750–754. Biochemical enolase is a molecular marker for peripheral and central markers for brain damage after cardiac surgery – time neuroendocrine cells. Neuron-specific eno- tials for identifying adverse neurological outcome after lase concentrations in serum and cerebrospinal fluid in thoracic and thoracoabdominal aortic aneurysm surgery. Neurone- lary acidic protein in serum after traumatic brain injury specific enolase and Sangtec 100 assays during cardiac and multiple trauma. Finding severely obstructive disease is score will have (silent) obstructive coronary artery dis- rare, and the overall prognosis of asymptomatic patients ease. In these patients a low threshold to ischemia detec- without detectable coronary calcium is excellent (<1 % tion seems reasonable. Exercise electrocardiography has a high most useful to exclude coronary artery disease in patients specifcity but a low sensitivity, using invasive angiogra- with a low-to-intermediate pretest likelihood of disease. Just as moderate obstructive disease to assess hemodynamic there are patients who are unsuitable to undergo stress signifcance. Methods to assess functional signifcance of coro- nary stenosis by computed tomography are under 4. Whether the technique should be used as the initial A simple calcium scan may allow exclusion of severe test in low-to-intermediate risk patients followed by disease in a substantial number of patients and is associ- functional testing in patients with obstructive disease or ated with excellent outcome. However, because of the secondary to functional tests that cannot be performed potentially devastating consequences and the possibly 35 4 4. The applicability of these results and limited to exclude an acute coronary syndrome with a high nega- low risk patients. No clinical beneft was demonstrated tive predictive value, whereas the positive predictive and cost-efectiveness will be afected by local logistics value appears to be somewhat lower in acute patients. Routine performance of a so-called cance of lesions, which may be unpredictable in the pres- 4 triple rule-out scan for exclusion of myocardial infarc- ence of collateral perfusion of the myocardium. Terefore, tion, pulmonary embolism, and aortic dissection has complementary functional information will ofen be needed been investigated, but shows limited beneft.

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While 13 of the 17 knees had satisfactory clinical results order topamax master card medicine and science in sports and exercise, 10 of the 11 patients with radiographic evaluation showed osteoarthritic changes purchase topamax 100 mg on line when administering medications 001mg is equal to, including fattening of the lateral femoral condyle purchase discount topamax line symptoms 14 dpo, spurring, sclerosis, and osteophyte formation. Eighteen meniscectomies in 15 patients for a discoid lateral meniscus were evaluated at an aver- age of 17 years postoperatively. Clinical results were good or excellent in 13 knees, and no degen- erative changes were seen in the 9 knees (8 patients) for whom radiographs were obtained at latest follow-up. Physical Examination (See Procedure 1) • Inside-out, outside-in, and all-inside techniques • Presence and size of effusion or localized perimeniscal fuid cyst (see also Procedure 8) for meniscal repair may • Standing alignment be considered depending on the tear pattern, location, and degree of displacement. Step 1: Examination Under Anesthesia • Increased meniscal laxity without evidence of a discrete tear may indicate a tear at the • The presence of a perimeniscal cyst or fuid mass, passive range of motion, meniscal root insertion. Step 4: Meniscus and Rim Preparation • Alternate viewing and working portals to gain best access to the meniscal tear. Step 3: Surgical Technique • Sutures are placed in a posterior-to-anterior fashion. With 28 months’ follow-up, no statistically signifcant differences were seen between the two groups. The authors did conclude, however, that longer follow-up was necessary to see if any differences surfaced beyond 2 years and to determine what the incidence of articular surface damage was from use of arrows. All repairs healed in the outside-in group, 95% healed in the inside-out group, and 35% healed in the all-inside group (p <. Oper- ating time was 39 minutes for outside-in, 18 minutes for inside-out, and 14 minutes for all-inside (p <. Thirty-six inside-out meniscus repairs were evaluated by second-look arthroscopy at a mean follow-up of 5 months. Eighty-four percent of the meniscus repairs were graded as good or excel- lent, whereas 16% were graded as poor. Of all repairs, 11 patients (24%) experienced repair failure with secondary meniscal débridement, with 11% classifed as atraumatic failure. Advantages cited included ease of accessing the mid-body and anterior meniscus and avoiding neurovascular damage with- out a large posterior incision. A total of 198 meniscal tears with a major segment in the central avascular region were repaired with an inside-out technique and followed an average of 18 months. Eighty percent were asymp- tomatic for knee symptoms, and 20% required repeat arthroscopic surgery for symptoms. Of the 91 meniscus repairs evaluated arthroscopically, 25% were healed, 38% were partially healed, and 36% failed. While there were no signifcant differences in failure rates between the groups, the follow-up was 3. Steenbrugge F, Verdonk R, Verstraete K: Long-term assessment of arthroscopic meniscus repair: a 13- year follow-up study, Knee 9:181–187, 2002. Eighty-eight percent had good or excellent results at latest follow-up, and most of these patients had no Fair- banks changes on follow-up radiographs. Forty-fve percent had complete healing, 32% had partial healing, and 24% had no evidence of healing. Poor healing was seen in the posterior horn of the medial meniscus; the remaining locations of the medial meniscus and the lateral meniscus healed normally. However, a hypertrophic fat pad that limits visualization of the meniscus will require débridement. This is used to determine the depth gauge or hard “stop” of the implant to prevent overpenetration while allowing for adequate soft-tissue clearance and implant deployment on the capsule. Once in ideal position, the to the meniscal tear, which often requires capsular implant may be deployed using the trigger mechanism. Stability and adequate burying of implant should be confrmed prior to • Rigid implants or those with prominent proceeding to the second pass. Under continued arthroscopic visualization, a knot pusher, arthro- between implant passes. Often, meniscal root tears are scarred peripherally in a nonanatomic position, • Attempted meniscal root repair will be largely and continued radial sectioning must be performed to afford adequate mobility. The authors evaluated the biomechanical characteristics of multiple all-inside repair devices with the traditional gold standard, vertical mattress inside-out repair technique using various high- tensile sutures. The authors present a comprehensive review of the important functional and biomechanical reper- cussions of meniscal root tears, which are defned as direct root avulsions from the tibial plateau or radial tears directly adjacent to these root attachments. When torn, relative meniscal extrusion and loading behavior comparable to a complete meniscectomy may result, while direct anatomic repair can result in restoration of normal loading mechanics and potentially diminish the risk for subsequent tibiofemoral arthritis. Forty-two meniscal tears in 37 patients were prospectively evaluated over an average follow-up of 24. All tears were in the red-red or red-white zones, and all had a peripheral meniscal rim of at least 2 mm and an average tear length of 2. All repairs healed in the outside-in group, 95% healed in the inside-out group, and 35% healed in the all-inside group (p <. Oper- ating time was 39 minutes for outside-in, 18 minutes for inside-out, and 14 minutes for all-inside (p <. The modifed Mason–Allen suture confguration demonstrated the highest maximum load and yield load on biomechanical cyclical testing porcine medial meniscal root tears, with superiority to hori- zontal mattress sutures or modifed loop stitches. However, two simple stitches may also represent an alternative given its similarly favorable stiffness and relative technical ease. All tears were verti- cal tears and located within the red-red or red-white zones. At an average follow-up of 18 months (14–28 months), there were six failures, giving a success rate of 90. In a cadaveric study comparing three techniques for meniscal repair, inside out meniscal repair demonstrated higher gap formation than either suture-based or anchor-based all-inside meniscal repair with cyclical loading. There were no statistically signifcant differences in stiffness between the three repair techniques, whereas the all-inside suture-based and inside-out repair techniques demonstrated higher loads to failure than the anchor-based, all-inside repairs. Based on the available literature, the existing literature reveals that failure rates of all-inside menis- cal repair (24. Fifty-four meniscal tears in 46 patients who underwent all-inside meniscal repair with the Rapid- Loc device were retrospectively reviewed after at least 2 years of follow-up (mean 34. Symptomatic patients were evaluated by magnetic resonance arthrography and repeat arthroscopy. Predictive variables for failure included bucket-handle tears, multiplanar tears, tear length greater than 2 cm, and chronicity longer than 3 months. This laboratory analysis compares two all-inside repair devices with two different suture-based, inside-out repair techniques in a laboratory porcine model. The authors identifed that inside-out suture repair had similar biomechanical properties with cyclical loading and demonstrated no superiority relative to all-inside repair constructs. While there were no signifcant differences in failure rates between the groups, the follow-up was 3½ years shorter for the meniscal arrow repairs. All devices survived cyclic loading with no sig- nifcant difference in displacement.

Each questionnaire has a heading and space to insert the number purchase cheap topamax on line symptoms stroke, date and location of the interview buy topamax us symptoms 0f ovarian cancer, and buy topamax 200 mg lowest price medications list, if required, the name of the informant. Sufficient space is provided for answers to open­ended questions, categories such as ‘other’ and for comments on pre-categorized questions. Self-administered (Written) Questionnaires All steps discussed above apply to written questionnaires as well as to guides/questionnaires used in interviews. For written questionnaires, however, clear guidelines will have to be added on how the answers to questions should be filled in. Self-administered questionnaires are most commonly used in large- scale surveys using predominantly pre-categorized answers among literate study populations. As a response rate of 50% or less to written questionnaires is not exceptional, these tools will rarely be used in small­scale studies. In exploratory studies which require intensive interaction with informants in 200 Research Methodology for Health Professionals order to gain better insight in an issue, self­administered questionnaires would be inadequate tools. Steps • Meeting and informing the opinion leaders and key personnel the date and purpose of the study/ interview. Interviewer’s cloths should be culturally acceptable and as simple as possible (no fancy dresses, high heels or tight jeans in rural areas). When interviewer and informant are of opposite sex, more physical distance will usually be required than when they are of the same sex. This includes designing the forms for recording the measurements, choosing the software for data editing, dummy tabulations, etc. Data represent the information that will ultimately allow investigator to describe phenomena, predict events, identify and quantify differences between conditions, and establish the effectiveness of interventions, because of their critical nature. In addition to ensuring the confidentiality, the security of personal data is to be planned. The researcher should carefully plan how the data will be logged, entered, transformed and organized into a database that will facilitate accurate and efficient statistical analysis. Logging and Tracking Data Any study that involves data collection will require some procedure to log the information as it comes in and track it until it is ready to be analyzed. Without a well-established procedure, data can easily become disorganized, un-interpretable, and ultimately unusable. The recruitment log is a comprehensive record of all individuals approached about participation in a study. The log can also serve to record the dates and times that potential participants were approached, whether they met eligibility criteria, and whether they agreed and provided informed consent to participate in the study. Importantly, for ethical reasons, no identifying information should be recorded for individuals who do not consent to participate in the research study. The primary purpose of the recruitment log is to keep track of participant enrollment and to determine how representative the resulting cohort of study participants is of the population that the researcher is attempting to examine. Data Screening Immediately following data collection, but prior to data entry, the researcher should carefully screen all data for accuracy. The promptness of these procedures is very important because research staff may still be able to re- contact study participants to address any omissions, errors, or inaccuracies. In some cases, the research staff may inadvertently have failed to record certain information (e. In such instances, the research staff may be able to correct the data themselves if too much time has not elapsed. Because data collection and data entry are often done by different research staff, it may be more difficult and time consuming to make such clarifications once the information is passed onto data entry staff. One way to simplify the data screening process and make it more time efficient is to collect data using computerized assessment instruments. Computerized assessments can be programmed to accept only responses within certain ranges, to check for blank fields or skipped items, and even to conduct cross-checks between certain items to identify potential inconsistencies between responses. Another major benefit of these programs is that the entered data can usually be electronically transferred into a permanent database, thereby automating the data entry procedure. Although this type of computerization may, at first glance, appear to be an impossible budgetary expense, it might be more economical than it seems when one considers the savings in staff time spent on data screening and entry. Whether it is done manually or electronically, data screening is an essential process in ensuring that data are accurate and complete. Generally, the researcher should plan to screen the data to make certain that– Data Management, Processing and Analysis 203 1. Constructing a Database Once data are screened and all corrections made, the data should be entered into a well-structured database. When planning a study, the researcher should carefully consider the structure of the database and how it will be used. In many cases, it may be helpful to think backward and to begin by anticipating how the data will be analyzed. This will help the researcher to figure out exactly which variables need to be entered, how they should be ordered, and how they should be formatted. Moreover, the statistical analysis may also dictate what type of program you choose for your database. For example, certain advanced statistical analysis may require the use of specific statistical programs. While designing the general structure of the database, the researcher must carefully consider all the variables that will need to be entered. Forgetting to enter one or more variables, although not as problematic as failing to collect certain data elements, will add substantial effort and expense because the researcher must then go back to the hard data to find the missing data elements. The Data Codebook In addition to developing a well-structured database, researchers should take the time to develop a data codebook. A data codebook is a written or computerized list that provides a clear and comprehensive description of the variables that will be included in the database. Moreover, it serves as a permanent database guide, so that the researcher, when attempting to reanalyze certain data, will not be stuck trying to remember what certain variable names mean or what data were used for a certain analysis. Ultimately, the lack of a well-defined data codebook may render a database un-interpretable and useless. At a bare minimum, a data codebook should contain the following elements for each variable: • Variable name • Variable description • Variable format (number, data, text) • Instrument or method of collection • Date collected • Respondent or group • Variable location (in database) • Notes 204 Research Methodology for Health Professionals Data Processing–Quantitative Data Data can be processed manually (using data master sheets or manual compilation of the questionnaires) or by computer using a micro-computer and existing software/self-written programs for data analysis. It involves categorizing the data, coding, and summarizing the data in data master sheets, manual compilation without master sheets, or data entry and verification by computer. Categorizing Categorical variables and numerical variables are to be categorized separately; otherwise if it comes to notice during data analysis that the categories had been wrongly chosen, one cannot reclassify the data anymore. Coding If the data are to be entered in a computer for subsequent processing and analysis, it is essential to develop a coding system. For computer analysis, each category of a variable can be coded with a letter, group of letters or word, or be given a number. For example, the answer ‘yes’ may be coded as ‘Y’ or 1; ‘no’ as ‘N’ or 2 and ‘no response’ or ‘unknown’ as ‘U’ or 9. When finalizing the questionnaire, for each question one should insert a box for the code in the right margin of the page.