The aim of the study was auditing medical records examine postoperative blood glucose levels after undergoing CABG surgery. Furthermore the aim was to determine if the ward staff abides the local guidelines frame of reference concerning each ward, regarding blood glucose measurements and blood glucose levels. The study included 70 patients undergoing CABG surgery at the cardiothoracic surgery, Uppsala University Hospital. The study was conducted by retrospective medical record auditing. Studied factors were postoperative blood glucose levels, number of registered blood glucose measurements, a current diagnosis of DM and preoperative HbA1c. Mean level of blood glucose levels stayed continuously above the local guidelines frame of reference for both TIVA/TIMA and the care ward throughout the continuity of patient care. The number of registered blood glucose measurements per postoperative day at TIVA/TIMA where within the local guidelines. The result showed that the local guidelines frame of reference concerning the ward were not reached. A difference could be seen between patients with DM and patients without DM regarding the previously mentioned factors. Preoperative elevated levels of HbA1c could have influenced the number of postoperative blood glucose measurements. Recommendations will therefore be too audit the current local guideline that concerns the treatment, therapy goals and the number of blood glucose measurements. Establishing criterions regarding termination of blood glucose measurements and the transfer day between TIVA/TIMA and the care ward are recommended.

The ultimate success of bypass surgery depends on the construction of a technically perfect bypass graft to an appropriate coronary vessel using a conduit which will remain durable for the lifetime of the patient. This thesis explores methods to improve coronary surgery by enhancing intraoperative imaging and conduit selection in the operating room. It is known that technical errors in graft construction cause failure of up to 12% of coronary bypass grafts in the operating room. We performed investigations of a new technique of intraoperative fluorescence angiography using indocyanine green dye to determine graft patency. We developed optimal methods of obtaining images and preliminary investigations revealed the technique was highly reproducible. In a follow-up trial, we demonstrated that over 80% of technical errors which would otherwise have been missed were identifiable with indocyanine green angiography, while only 25% of these errors were identified by transit-time ultrasonic flow measurement, the current clinical standard. We also determine that coronary surgery with indocyanine green angiographic graft patency verification was associated with less perioperative myocardial injury than bypass surgery without graft patency assessment. The long term graft patency of saphenous vein grafts is sub-optimal, with over 40% of such grafts totally occluded and a further 30% significantly diseased at ten years. We attempted to improve these outcomes by increasing the use of arterial grafts, which are less prone to intimal hyperplasia. In a multicentre clinical trial, we demonstrated a 40% relative risk reduction in graft occlusion at one year when radial arteries were used as bypass conduits versus saphenous veins. We identified that women and patients with small coronary vessels maximally benefited from radial artery bypass grafts. Conversely, in settings of less severe target vessel stenosis or concomitant peripheral vascular disease, saphenous veins performed as well as radial arteries. We have demonstrated that high quality imaging to identify technical errors during the operation, increased use of radial artery grafts and careful consideration of individual patient and target vessel characteristics can all improve graft patency. Future studies will be aimed at identifying the role of intraoperative imaging and arterial grafting in improving long-term clinical outcomes.

No description available.

The ultimate success of bypass surgery depends on the construction of a technically perfect bypass graft to an appropriate coronary vessel using a conduit which will remain durable for the lifetime of the patient. This thesis explores methods to improve coronary surgery by enhancing intraoperative imaging and conduit selection in the operating room. It is known that technical errors in graft construction cause failure of up to 12% of coronary bypass grafts in the operating room. We performed investigations of a new technique of intraoperative fluorescence angiography using indocyanine green dye to determine graft patency. We developed optimal methods of obtaining images and preliminary investigations revealed the technique was highly reproducible. In a follow-up trial, we demonstrated that over 80% of technical errors which would otherwise have been missed were identifiable with indocyanine green angiography, while only 25% of these errors were identified by transit-time ultrasonic flow measurement, the current clinical standard. We also determine that coronary surgery with indocyanine green angiographic graft patency verification was associated with less perioperative myocardial injury than bypass surgery without graft patency assessment. The long term graft patency of saphenous vein grafts is sub-optimal, with over 40% of such grafts totally occluded and a further 30% significantly diseased at ten years. We attempted to improve these outcomes by increasing the use of arterial grafts, which are less prone to intimal hyperplasia. In a multicentre clinical trial, we demonstrated a 40% relative risk reduction in graft occlusion at one year when radial arteries were used as bypass conduits versus saphenous veins. We identified that women and patients with small coronary vessels maximally benefited from radial artery bypass grafts. Conversely, in settings of less severe target vessel stenosis or concomitant peripheral vascular disease, saphenous veins performed as well as radial arteries. We have demonstrated that high quality imaging to identify technical errors during the operation, increased use of radial artery grafts and careful consideration of individual patient and target vessel characteristics can all improve graft patency. Future studies will be aimed at identifying the role of intraoperative imaging and arterial grafting in improving long-term clinical outcomes.

INTRODUCCIÓN:La obesidad mórbida (Índice de Masa Corporal (IMC) mayor o igual a 40 Kg/cm2) es una enfermedad altamente extendida en la sociedad occidental, que se encuentra asociada con una importante co-morbilidad (enfermedades metabólico-endocrinas, respiratorias, digestivas, vasculares, cardiacas, psicosociales, elevado riesgo de algunos tipos de cáncer, etc). De las estrategias empleadas para el tratamiento de la obesidad, limitación de la ingesta y/o incremento del gasto energético o la cirugía bariátrica, sólo esta última se ha mostrado como el método más efectivo, ya que el éxito que se logra en la mayoría de los casos justifica la cirugía.OBJETIVO:Ver cómo se comportan estos pacientes ante el estrés agudo que supone una intervención quirúrgica como la cirugía bariátrica, cómo cambian estos parámetros, que ya se encuentran alterados por el hecho de ser obesos mórbidos, y si son capaces de reaccionar ante el estrés agudo que supone la cirugía bariátrica. PACIENTES Y MÉTODOS:El estudio utilizó un grupo de 34 pacientes con obesidad mórbida, con una media de edad de 48 años, que fueron sometidos a cirugía bariátrica en el Hospital Universitario de la Vall d'Hebron de Barcelona. Se valoraron muestras de plasma de estos pacientes en los siguientes tiempos: un mes antes de la cirugía, el mismo día de la cirugía, antes de la intubación del paciente, cuando el paciente ya está extubado y ha pasado el efecto de la anestesia, a las 24 horas post-cirugía y un mes después de la cirugía. Además se realizaron medidas antropométricas un mes antes de la cirugía y al mes de la misma.PRINCIPALES RESULTADOS:Al margen de las alteraciones de base que presentan este grupo de pacientes obesos mórbidos en los parámetros que hemos medido en este trabajo y que son atribuibles únicamente a la obesidad mórbida y sus comorbilidades, en relación con el estrés pre y postcirugía, podemos concluir que: 1. El estrés quirúrgico durante el perioperatorio, provoca un incremento en la glucosa (marcador de estrés agudo) sin incremento en la insulina y un aumento significativos de la de la ACTH y el cortisol.2. La respuesta de la PCR al estrés agudo se mantiene conservada, a pesar de estar elevada de base en los pacientes obesos.3. La disminución en los parámetros antropométricos no se puede atribuir al estrés, aunque ya que se inician en la fase aguda del mismo, por tanto se deben atribuir a la cirugía bariátrica.4. La mejoría de la resistencia insulínica (HOMA-IR) al mes de la intervención se debe a la mejoría de los parámetros antropométricos.5. El aumento de los ácidos grasos en el postoperatorio se debe, probablemente, al efecto del cortisol ante el estrés agudo. En cambio el aumento de los NEFA que se observa al mes de la intervención, posiblemente, se debe a la movilización de los mismos desde el tejido graso.6. La disminución de la leptina, en el postoperatorio se debe, probablemente, al aumento de la ACTH que ocurre en relación al estrés agudo de la cirugía.7. La disminución del PAI-1 que ocurre al mes de la intervención se debe atribuir, en un principio, a la disminución de la grasa corporal y a la mejoría de la resistencia insulínica. / INTRODUCTION:Morbid obesity is a widely spread disease in Western society. It is associated with an important comorbidity. Amongst the strategies used for the treatment of obesity, bariatric surgery is the most effective method.GOALS:To observe the behaviour of these patients before the acute stress involved in the bariatric surgery. To observe the changes in the ACTH, cortisol, and glucose, which are already altered because of the obesity itself, and to determine whether these patients are capable of reacting to the acute stress involved in the surgery. PATIENTS AND METHODS:A group of 34 morbid obese patients were used. The group underwent bariatric surgery. Plasma samples were assessed. These samples were obtained under the following timeline: a month before surgery, the day of surgery (before intubation and after extubation, once the effects of the anaesthesia were over), 24 hours post-surgery and a month after surgery. Furthermore, anthropometric measures were taken a month before surgery and a month alter surgery. CONCLUSIONS:Bariatric surgery provokes a series of changes in the postoperative period due both to the loss of adipose tissue and the surgical stress.The significant fat loss that takes place one month after surgery is a consequence both of the reduction of the intake and the loss of absorptive surface area.The weight loss that takes place in these patients one month after surgery produces a clear improvement in insulin resistance, thrombotic risk, and the lipid profile.During the surgical stress an alteration is produced in the parameters of acute stress. Such as glucose, ACTH and cortisol, the latter being the probable responsible of the increment of the NEFA and the PCR that we observed in the perioperatory period.

Syfte: Att beskriva orsaker till brister i uppföljning, dess effekter och den motivation som sjuksköterskor kan möta hos patienter som är gastric bypass opererade i samband med fortsatta livsstilsförändringar och ökad livskvalitet, samt att som kvalitetsgranskning redogöra för undersökningsgrupper, deltagare och bortfall i artiklarna. Metod: Litteraturstudie med deskriptiv design. Sökning av kvantitativa och kvalitativa vetenskapliga artiklar i databaserna CINAHL och Pubmed. Artiklarnas resultat har sedan utifrån syfte och frågeställningar analyserats. Resultat: Det är betydelsefullt att få patienterna att komma på uppföljande återbesök för att hjälpa de till fortsatt livsstilsförändring. Högt BMI innan operationen kunde vara orsak till brister i att komma till uppföljning och återbesök vilket medförde förlust av stöd och hjälp till att följa dieten, samt att komplikationer upptäcktes sent och att information gick förlorad. Även om livskvaliteten ofta förbättrades markant så upplevde många en mer bristande grad av livskvalitet än förväntat och depression förekom. Hinder till motivation till förändrad livsstil och förbättrad livskvalitet kunde vara att pressas för hårt vilket kunde innebära att patienterna ofta ledsnade helt på att röra på sig. Slutsats: För att uppnå viktminskningsresultat och en förbättrad livskvalitet genom motiverande samtal behövs kunskap om hinder till motivation. Uppföljning och återbesök behöver prioriteras både av patienter och av sjuksköterskor.

Syfte: Syftet med denna litteraturstudie var att sammanställa och beskriva faktorer som är av betydelse för långsiktigt viktminskningsresultat, mer än tre år efter gastric bypass. Metod: För att besvara studiens syfte gjordes en litteraturstudie med deskriptiv design. Studien har baserats på fjorton vetenskapliga artiklar som har sökts fram via Medline samt genom manuell sökning. Resultat: Studien visade att faktorer som var av betydelse för långsiktigt viktminskningsresultat var kost, fysisk aktivitet, beteende, uppföljning, preoperativ viktnedgång samt medicinska faktorer såsom utvidgning av magsäck och gastrojejunal stomi. God kostkvalitet och utövande av fysisk aktivitet visade sig ha ett signifikant samband med långsiktig viktminskning. Beteenden såsom kontroll över matbegär och ätvanor var av stor betydelse. Hetsätning visade sig påverka viktresultatet negativt. Patienter som gick på uppföljning visade större viktminskning på lång sikt liksom patienter som lyckades minska i vikt före operationen. Slutsats: Långsiktigt viktresultat efter gastric bypass kan förbättras genom rätt kost, fysisk aktivitet, långsiktig uppföljning samt genom att tidigt upptäcka ohälsosamma ätbeteenden. Mer forskning krävs angående faktorer som påverkar viktresultatet på lång sikt och vad sjukvården kan göra för att påverka dessa.

Submarine channels are important conduits for sediment in deep marine environments, and understanding their formation is critical to modeling basin fill processes. Most models describing channel evolution focus on turbidity currents as the erosive and constructive force in channel initiation. However, slope failure and slumping can be significant drivers of channelization, particularly in upper slope and ramp environments. Determining the relative roles of slumping and erosion by turbidity currents can provide important insight into the timing of channelization and the geometries of subsequent deposits. Samples were collected from Guadalupe Mountains National Park from two primary localities at Salt Flat Bench (Figure 2). Three vertical sections were measured at both locations. A total of 16 samples were collected for petrographic analysis and X-ray fluorescence (XRF) imaging. Spectacular outcrop quality makes the Middle Permian Brushy Canyon Formation in Guadalupe Mountains National Park an ideal location for the study of early channel evolution. A detailed facies analysis of fine-grained channel deposits was conducted in the Upper Brushy Canyon Formation in the Salt Flat Bench outcrops. After channelization, an interval of relative condensation dominated by hemipelagic settling of organic matter and silt was followed by an interval of incomplete sediment bypass by turbidity currents. This sequence of events suggests that sea level was at a relative highstand at the time of channel inception, whereas channel inception by turbidity currents is expected during a lowstand. Slumping rather than erosion by turbidity currents is the most likely mechanism to have initiated a channel at the study area. There is no evidence for the existence for high energy currents until after the interval of condensation. However, the action of weak contour currents during early channel evolution is observed in outcrop and microtextural features. Early carbonate cementation of channel-lining silts may have stabilized the slump surface with respect to erosion by later turbidity currents.

Thesis (M.S.)--Rutgers University, 2009. / "Graduate Program in Biomedical Engineering." Includes bibliographical references (p. 89-94).

Thesis (M.S.)--East Carolina University, 2009. / Presented to the faculty of the Department of Exercise and Sport Science. Advisor: Timothy P. Gavin. Title from PDF t.p. (viewed May 25, 2010). Includes bibliographical references.