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V. Jarock, M.S., Ph.D.

Medical Instructor, West Virginia University School of Medicine

Posterior vaginal wall defects and their relation to measures of pelvic floor neuromus-cular function and posterior compartment symptoms. Veit-Rubin N, Digesu A, Swift S, Khullar V, Kaelin Gambirasio I, Dдllenbach P, et al. Chinese validation of Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. Validation of the Pelvic Floor Distress Inventory-20 and the Pelvic Floor Impact Questionnaire-7 in Danish women with pelvic organ prolapse. A modified anterior com-partment reconstruction and Prolift-a for the treat-ment of anterior pelvic organ prolapse: a non-inferiority study. Medium-term clinical outcomes follow-ing surgical repair for vaginal prolapse with tension-free mesh and vaginal support device. Outcome and efficacy of a transobturator polypropylene mesh kit in the treat-ment of anterior pelvic organ prolapse. Monoprosthesis for anterior vaginal prolapse and stress urinary incontinence: midterm results of an international multi-centre prospective study. Transvagi-nal mesh surgery for pelvic organ prolapse-Prolift+M: a prospective clinical trial. Vaginal prolapse repair using the Prolift kit: a registry of 100 succes-sive cases. Transvaginal mesh repair of pelvic organ prolapse by the transobturator-infracoccygeal hammock technique: long-term ana-tomical and functional outcomes. Trocarless system for mesh attachment in pelvic organ prolapse repair-1year evaluation. Combined anterior trans-obturator mesh and sacrospinous ligament fixation in women with severe prolapse-a case series of 30 months follow-up. Pelvic reconstruction with mesh for advanced pelvic organ prolapse: a new economic surgical method. Out-comes and complications of transvaginal and abdominal custom-shaped light-weight polypropylene mesh used in repair of pelvic organ prolapse. Laparoscopic sacrocolpopexy with bone anchor fixation: short-term anatomic and functional results. Vaginal mesh colpopexy for the treatment of concomitant full thickness rectal and pelvic organ prolapse: a case series. Mid-term outcome of laparoscopic sacrocolpopexy with anterior and posterior polyester mesh for treatment of genito-urinary pro-lapse. A nov-el technique for the management of advanced uter-ine/vault prolapse: extraperitoneal sacrocolpopexy. Laparo-scopic sacrocolpopexy: an observational study of functional and anatomical outcomes. Laparoscopic extraperitoneal uterine suspen-sion to anterior abdominal wall bilaterally using syn-thetic mesh to treat uterovaginal prolapse. Synthetic Graft Augmentation in Vaginal Prolapse Surgery: LongTerm Objective and Subjective Outcomes. Long-term outcomes of synthetic transobturator nonabsorbable anterior mesh versus anterior colporrhaphy in symp-tomatic, advanced pelvic organ prolapse surgery. Modified laparoscopic extraperitoneal uterine sus-pension to anterior abdominal wall: the easier way to treat uterine prolapse. Subjective and objective results 1 year after robotic sacrocolpopexy using a lightweight Y-mesh. Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse after failed transvaginal polypropylene mesh sur-gery. A preliminary report on pelvic floor recon-struction through colpocleisis from 2001 to 2007 at the University Hospital of the Puerto Rico Medical Center. Bilateral anterior sacrospinous ligament suspension associated with a paravaginal repair with mesh: short-term clinical results of a pilot study.

Occasionally patients will require general anaesthetic, particularly patients who are listed for lead extraction. There is a small risk (1:50) of a pneumothorax; often these do not require drainage. There is a small risk of tamponade and this should be considered urgently as a differential if the patient has any suggestive symptoms or signs. Most operators prefer a green or at least pink venous catheter in the left antecubital fossa, with a long extension line connected. This is to allow a venogram to be performed if there is difficulty in venous access. If the patient has signs or symptoms of underlying sepsis, this should be fully treated before implanting the pacemaker. A chest X-ray is required post-implant to confirm lead position and exclude a pneumothorax (not seen after cephalic only implants). If you are unsure about the pacemaker lead positions, consult a senior to ensure that they are appropriate. Additional checks and device manipulation may be required with defibrillators and biventricular devices. Please check the procedure report for any additional instructions, such as instructions regarding anticoagulation or change in medication (such as recommencing rate-limiting drugs in patients with tachycardia-bradycardia syndromes). Patients should be advised of the risk of palpitations and possible syncope during the procedure. For patients undergoing ablation procedures the risks of complications should be discussed. Patients may need an overnight stay, depending on when the procedure finishes, and have adult accompaniment when discharged. Access is usually via the right groin and ablation normally performed on the right side of the heart. Some patients have ablation on the left side via the aorta, patent foramen ovale or trans-septal approach. Some will require an overnight stay but many are now performed as day case procedures. In these patients an echocardiogram will be required to confirm there is no pericardial effusion. Also there is a risk of thromboembolism - therefore antiplatelets will be required in most patients treated with ablation unless already anticoagulated. The care is the same as for simple ablation but consider these issues: Blood pressure may fall due to sedation but also rule out pericardial effusion as a cause. All patients undergoing a complex ablation procedure or left-sided procedure must have an echo pre-discharge to exclude an effusion. In this case the drug is usually stopped the day before the procedure and must be restarted on the evening of the procedure. Again check the plan in the notes and if any problems contact the consultant in charge. Indications include severe refractory ischaemia, hypotension (systolic blood pressure less than 90 mmHg or 30 mmHg below baseline mean arterial pressure) of cardiac origin that is not responsive to other interventions; cardiogenic shock that is not quickly reversed with pharmacologic therapy; acute mitral regurgitation, particularly due to papillary muscle rupture, or ventricular septal rupture. Relative contraindications: uncontrolled sepsis; abdominal aortic aneurysm; severe bilateral peripheral vascular disease; uncontrolled bleeding disorder; prosthetic ileofemoral grafts/iliac artery stents. The distal tip is positioned 1 - 2 cm distal to the origin of the left subclavian artery or at the level of the carina. Inflation occurs immediately after aortic valve closure and deflation just before aortic valve opening. Inflation and deflation of the balloon has two major consequences: Blood is displaced to the proximal aorta by inflation during diastole. Common and potentially life threatening complications include: limb and renal ischaemia; vascular laceration necessitating surgical repair; major haemorrhage; and cerebrovascular accident. Rapid inflation and deflation of the balloon causes trauma to red blood cells and platelets, commonly resulting in anaemia and/or thrombocytopenia.

Understand the techniques, physiology, advantages, and disadvantages of the different types of exercise (cycle, treadmill, hand-grip exercise) 7. Understand the physiologic principles related to electrocardiographic responses to exercise 8. Understand the physiologic principles involved in the ventilatory response to exercise 9. Know how to determine gradients and pressure measurement from Doppler-derived velocity measurements 3. Know how Doppler-derived velocity measurements compare to direct-pressure gradient determinations 4. Know the indications for, risks of, and limitations of transesophageal, stress, and fetal echocardiography 7. Know the indications and contraindications for and risks of cardiac catheterization b. Know the most appropriate positional view to obtain optimal angiographic visualization of the targeted cardiac and vasculature structure of interest c. Know the normal and potential abnormal courses of a cardiac catheter during cardiac catheterization and angiography 2. Know how to calculate myocardial oxygen consumption from data measuring coronary blood flow and oxygen saturation 2. Understand the concept, use, and limitations of the Fick method to determine blood flow (systemic and pulmonary) 3. Recognize important sources of measurement error when quantifying ventricular function by invasive methods 3. Interventional catheterization: balloon angioplasty/valvuloplasty/stent placement and angiography a. Understand the factors associated with angioplasty (eg, indications, contraindications, risks, and limitations) c. Know how to perform angioplasty of native and postoperative pulmonary branch stenosis d. Understand the factors associated with use of angiography (eg, risks, risk management, complications, and contraindications) g. Know the methods for and limitations of calculations of pulmonary and systemic vascular resistance and its application h. Understand the factors associated with stent placement (eg, indications, contraindications, risks, and limitations) j. Understand medical management implications following stent placement in lesions l. Understand the factors associated with dilation of bioprosthetic valves/conduits (eg, indications, contraindications, risks, and limitations) n. Understand the factors associated with bioprosthetic valves/conduits (eg, indications, contraindications, risks, and limitations) o. Know the indications, contraindications, risks, and limitations of atrioseptostomy b. Understand the factors associated with transeptal puncture (eg, indications, contraindications, risks, and limitations) 5. Understand the factors associated with occlusion techniques (eg, indications, contraindications, risks, and limitations) 2. Plan appropriate management and follow-up evaluation relative to complications of occlusion devices 5. Plan prophylactic management of thrombosis following the use of an occlusion device 6. Understand the basic principles and techniques of latest interventional technologies F. Know the indications, contraindications, risks, and limitations of radionuclide angiocardiography 2. Recognize the clinical implications of normal and abnormal findings on lung perfusion scans and ventilation/perfusion scans H.

In order to achieve a quick diagnosis we recommend a hs-TnI level is taken on admission and again at 1 hour. Only one hs-TnI level is required if the onset of symptoms was 3 or more hours previously. If there is uncertainty, a further sample can be taken a further 2 hours later (3 hours after the first). Second hs-TnI levels can be useful to assess whether the elevation is static, rising or falling. Several studies have shown that earlier sampling allows for earlier diagnosis or exclusion of acute coronary syndromes (11;12). Clinical judgment must still apply and a normal hs-TnI series should not always result in automatic discharge. Measurement of hs-TnI should be restricted to appropriate patients, and specifically when an acute coronary syndrome is suspected. In the setting of suspected acute coronary syndromes, a normal hs-TnI series (or an intermediate level with no rise), suggests a good prognosis. If patients are deemed to warrant further investigations in the form of functional imaging or angiography, a judgment needs to be made as to whether these tests have to be done as in-patients. In patients with no rise in hs-TnI, outpatient investigations should be seriously considered. Hs-TnI should only be measured if it is going to alter the management of the patient. A number of patients with coronary spasm and coronary embolism will also have been included. The benefit of urgent revascularisation (stent-based) treatment is predominantly through treatment of culprit (plaque rupture) lesions coupled with the more diffuse action of drugs. There may be an incidence of false positive elevation of hs-TnI in patients with advanced renal failure and positive results in these patients should be viewed with caution (especially if creatinine is over ~ 221 µmol/L (13;14). A rise in serial hs-TnI levels in patients with renal failure is however likely to be due to myocardial injury. Occasionally, elevated hs-TnI may be seen in patients with severe congestive cardiac failure (16) and in myocarditis (17) and following prolonged tachyarrhythmias. Other conditions in which hs-TnI may be elevated are aortic dissection, aortic stenosis, hypertrophic cardiomyopathy, Takotsubo (18;19) 20 cardiomyopathy, malignancy, stroke and severe sepsis. Generally, hs-TnI levels do not seem to rise in the majority of patients who have undergone cardioversion (21;22). Hs-TnI levels may remain elevated for several days and care should be taken in their interpretation in the context of re-admissions within a couple of weeks of a myocardial infarction. A couple of serial hs-TnI levels will help by determining whether the level is falling (older event) or rising (recent event). Patients presenting with left bundle branch block that is thought to be of new onset, and in the context of symptoms consistent with myocardial infarction should be treated in the same manner. All patients presenting within 12 hours of the onset of symptoms should be considered for urgent revascularisation (see page 50). Blood Tests All patients should have a full biochemical screen on admission including lipid profile, random glucose and an HbA1c assay performed. Cardiac enzymes including hs-TnI should be done on admission as outlined previously (page 44). Drugs can also cause an elevation and these include colchicine, haloperidol, prochlorperazine, quinidine, tricyclics and lipid lowering drugs (including statins and fibrates). Urea and electrolytes should be measured on days 1 and 2 to determine renal function and, in particular, to determine potassium levels. More frequent and/or prolonged assessment is required in patients with low output cardiogenic shock, preexisting renal disease or hypotension. Liver function tests may be abnormal in patients with significant right heart failure and should be measured on the initial sample and thereafter if abnormal.