Abstract: OBJECTIVE:: To determine the usefulness of ultrasound to evaluate central venous catheter misplacements and detection of pneumothorax, thus obviating postprocedural radiograph. After the insertion of a central venous catheter, chest radiograph is usually obtained to ensure correct positioning of the catheter tip and detect postprocedural complications. MEASUREMENTS AND MAIN RESULTS:: A prospective study of 111 consecutive central venous catheter procedures, using a landmark technique, was conducted in an adult intensive care unit. At the end of the procedure, a B-mode ultrasonography was first performed to assess catheter position and detect pneumothorax. Then, contrast enhanced ultrasonography was used to facilitate visualization of catheter tip, avoiding unknown right atrium positioning or artifacts. A postprocedural chest radiograph was obtained for all patients and was considered as a reference technique. Right atrium positioning was detected in 19 patients by ultrasonography, and an additional six by contrast enhanced ultrasonography. Combining ultrasonography and contrast enhanced ultrasonography yielded a 96% sensitivity and 93% specificity in detecting catheter misplacement. Concordance was 95% and kappa value was 0.88 (p < .001). Pneumothorax was detected in four patients by ultrasonography and in two by chest radiograph (concordance = 98%). The mean time required to perform ultrasonography plus contrast enhanced ultrasonography was 10 +/- 5 mins vs. 83 +/- 79 mins for chest radiograph (p < .05). CONCLUSIONS:: The close concordance between ultrasonography plus contrast enhanced ultrasonography and chest radiograph justifies the use of sonography as a standard technique to ensure the correct positioning of the catheter tip and to detect pneumothorax after central venous catheter cannulation to optimize use of hospital resources and minimize time consumption and radiation. Chest radiograph will be necessary when sonographic examination is impossible to perform by technical limitations.
Abstract: BACKGROUND: Progression of recurrent hepatitis C is accelerated in liver transplant recipients, leading to special need of non-invasive validated methods to estimate liver fibrosis. AIM: To assess the efficacy of liver stiffness measurement by transient elastography (Fibroscan) and serum parameters in predicting fibrosis stage in HCV-infected transplant recipients. METHODS: The correlation between liver fibrosis, assessed at liver histology on bioptic specimens obtained for clinical indications, and stiffness or clinico-serological indexes (Benlloch, APRI, Forns, Fibrotest and Doppler resistance index), was investigated in transplant recipients with recurrence of HCV chronic hepatitis. A total of 56 patients (of which 36 with all clinico-serological indexes), presenting with the following METAVIR fibrosis stage F1=38, F2=9, F3=8, F4=1, were enrolled in the study population. Differences between fibrosis stages were calculated by non-parametric analysis. The best cut-off for identifying significant fibrosis (F2-F4) was assessed by ROC curve analysis. RESULTS: Stiffness (median and range) was 7.7 KPa (range 4.2-13.9) in F1 and 17.0KPa (range 6.8-36.3) in >or=F2 (p<0.001). A stiffness cut-off of 10.1 KPa revealed 94% Sensitivity, 89% Specificity, 81% PPV and 94% NPV in differentiating F1 from F2-F4. The area under the receiver operator curve in the assessment of fibrosis was significantly higher for Liver stiffness (AUROC 0.943) than for any of the other non-invasive indexes (AUROCs ranging 0.591-0.815). CONCLUSIONS: Transient elastography of the liver provides good accuracy in identifying patients with significant fibrosis and performs better than non-invasive indexes based on clinico-serological parameters in transplant recipients.
Abstract: BACKGROUND: Central venous catheterization may be difficult in morbidly obese patients because anatomic landmarks are often obscured. METHODS: We evaluated the efficacy and safety of ultrasound-guided central venous cannulation in 55 patients undergoing bariatric surgery. The usefulness of ultrasonic examination combined with intraatrial electrocardiogram as a diagnostic tool for catheter misplacement was studied. RESULTS: Preliminary ultrasound examination of the neck vessels demonstrated anatomical variations in the position of internal jugular vein in 19 cases and four unrecognized asymptomatic thromboses of the right internal jugular vein. Central venous catheterization was successful in all 55 patients, in 51 with single skin puncture, and in 42 with single vein puncture. In three cases in whom the catheter was misplaced, this was detected by bedside ultrasonic examination during the procedure and immediately corrected by real-time echographic visualization. No arterial puncture, no hematoma, and no pneumothorax occurred in any patient. Successful catheter placement was also confirmed in all patients by post-operative chest X-ray. No evidence of infection or thrombosis subsequently was noted. CONCLUSIONS: The use of ultrasound guidance may increase the success rate and decrease the incidence of complications associated with central venous cannulation. The advantages of this approach is visualization of the anatomical structures at puncture site prior to skin puncture and the ability to track needle and guide-wire placement during the procedure. With its high accuracy in detecting catheter misplacement, bedside ultrasonic examination combined with intraatrial electrocardiogram may further decrease morbidity associated with misplaced central venous catheters.
Abstract: Boric acid comes as colourless, odourless white powder and, if ingested, has potential fatal effects including metabolic acidosis, acute renal failure and shock. An 82-year-old male was brought to the emergency room 3 h after unintentional ingestion of a large amount of boric acid. Clinical course was monitored by collecting data at admittance, 12 h after admission, every 24 h for 5 days and again 1 week after admission. During the first 132 h, serum and urinary concentrations of boric acid were measured. Serum boric acid levels decreased from 1800 to 530 mug/ml after haemodialysis and from 530 to 30 mug/ml during the forced diuresis period. During dialysis, boric acid clearance averaged 235 ml/min with an extraction ratio of 70%. The overall patient's condition steadily improved over 84 h after admission. In conclusion, early treatment with forced diuresis and haemodialysis may be considered for boric acid poisoning, even if signs of renal dysfunction are not apparent, to prevent severe renal damage and its complications.
Abstract: BACKGROUND: Contrast enhanced ultrasound (CEUS) is an imaging technique which appeared on the market around the year 2000 and proposed for the detection of liver metastases in gastrointestinal cancer patients, a setting in which accurate staging plays a significant role in the choice of treatment. METHODS: A total of 109 patients with colorectal (n = 92) or gastric cancer prospectively underwent computed tomography (CT) scan and conventional US evaluation followed by real time CEUS. A diagnosis of metastases was made by CT or, for lesions not visible at CT, the diagnosis was achieved by histopathology or by a malignant behavior during follow-up. RESULTS: Of 109 patients, 65 were found to have metastases at presentation. CEUS improved sensitivity in metastatic livers from 76.9% of patients (US) to 95.4% (p <0.01), while CT scan reached 90.8% (p = n.s. vs CEUS, p < 0.01 vs US). CEUS and CT were more sensitive than US also for detection of single lesions (87 with US, 122 with CEUS, 113 with CT). In 15 patients (13.8%), CEUS revealed more metastases than CT, while CT revealed more metastases than CEUS in 9 patients (8.2%) (p = n.s.). CONCLUSION: CEUS is more sensitive than conventional US in the detection of liver metastases and could be usefully employed in the staging of patients with gastrointestinal cancer. Findings at CEUS and CT appear to be complementary in achieving maximum sensitivity.
Abstract: AIM: To investigate the frequency of distinct causes of elevated transaminase levels in the range of acute viral hepatitides in patients attended in a hospital. PATIENTS AND METHOD: Patients attended in a tertiary hospital over a 3-month period who had elevation of transaminase levels (aspartate aminotransferase [AST] or alanine aminotransferase [ALT]) above 400 U/l were identified and their medical records were reviewed to determine etiology. RESULTS: A total of 106 patients were studied, of which 22 had undergone liver transplantation. In these patients, the causes of hypertransaminasemia were ischemic/reperfusion injury in 6 (27%), ischemic hepatitis in 4 (18%), acute hepatitis in 2 (9%), cellular rejection in 3 (14%), chronic hepatitis C in 4 (18%) and cholestasis in 3 (14%). In the 84 patients who did not undergo transplantation, the causes were hepatic ischemia in 24 (28%), chronic viral hepatitis in 19 (22%), toxic hepatitis in 12 (14%), pancreatico-biliary disease in 11 (13%), acute viral or bacterial hepatitis in 10 (12%), liver tumor in 3 (4%), cholestasis of pregnancy in one and unknown in 4 (5%). Ischemic lesions and pancreatico-biliary disease were more frequent in hospitalized patients while acute and chronic hepatitides were more frequent in outpatients. The worst outcomes were found in ischemic lesions and pancreatico-biliary disease. CONCLUSION: Marked elevation of transaminase levels has multiple causes. Acute viral hepatitides were a relatively infrequent cause. In transplant recipients, the most frequent causes were ischemia/reperfusion injury, while in non-transplanted patients the most frequent causes were ischemic hepatitides and acute episodes of chronic viral hepatitides. The AST/ALT ratio did not contribute to etiologic diagnosis.
Abstract: During the last decade, a significant body of evidence has accumulated, indicating that IGF-I might play a role in several pathological conditions commonly seen during aging, such as atherosclerosis and cardiovascular disease (CVD), cognitive decline, dementia, sarcopenia and frailty. A vascular protective role for IGF-I has been suggested because of its ability to stimulate nitric oxide production from endothelial and vascular smooth muscle cells. In cross sectional studies, low IGF-I levels have been associated with unfavorable CVD risk factors profile, such as atherosclerosis, abnormal lipoprotein levels and hypertension, while in prospective studies, lower IGF-I levels predict future development of ischemic heart disease. The fall in IGF-I levels with aging correlates with cognitive decline and it has been suggested that IGF-I plays a role in the development of dementia. IGF-I is highly expressed within the brain and is essential for normal brain development. IGF-I has anti-apoptotic and neuroprotective effects and promotes projection neuron growth, dendritic arborization and synaptogenesis. Collectively, these data are consistent with a causal link between the age-related decline in GH and IGF-I levels and cognitive deficits in older persons. Finally, there is evidence of a relationship between declining GH and IGF-I levels and age-related changes in body composition and physical function. However, few studies have documented a precise role of IGF-I in the development of sarcopenia, frailty and poor mobility. We have recently documented that serum IGF-I is significantly associated with measures of muscle strength and physical performance in men and to a lesser extent in women. In conclusion, IGF-I is a pleiotropic hormone that in older persons may positively affect the cardiovascular system, the central nervous system and physical function.
Abstract: PURPOSE: To examine whether serum insulin-like growth factor 1 (IGF-1) and IGF binding protein 3 (IGFBP-3) concentrations, determined early after the onset of stroke, are predictive of clinical outcome in elderly patients. METHODS: The sample comprised 85 patients (mean [+/- SD] age, 83 +/- 7.4 years; range, 67 to 99 years; 34% male) who were admitted with acute stroke to a geriatric ward between January 1998 and June 2000, and 88 control patients who were similar in age and sex. Clinical and laboratory assessments, computed tomographic scan of the head, carotid ultrasonography, and electrocardiography were employed to define the clinical and etiologic stroke subtype. Fasting blood samples were collected within 24 hours of admission for IGF-I and IGFBP-3 measurement. Univariate and multiple logistic regression analyses, with adjustment for other related clinical covariates, were used to assess the relation of IGF-I and IGFBP-3 to poor outcome, defined as severe disability (Barthel index <60/100) or death, at 1 month (or at discharge), 3 months, and 6 months. RESULTS: Mean (+/- SD) IGF-1 levels were lower in patients with stroke than in controls (69 +/- 45 ng/mL vs. 102 +/- 67 ng/mL, P adjusted for age = 0.001). The mean IGF-1/IGFBP-3 molar ratio was also lower in stroke patients (0.12 +/- 0.07 vs. 0.19 +/- 0.09, P adjusted for age <0.0001). However, there was no relation of hormone levels to either the clinical subtype of stroke or the extent of neurologic impairment. IGF-1 levels were inversely related to poor outcome (mainly death) at 3 and 6 months, independent of other clinical covariates that were highly predictive of outcome, such as age and stroke scale score on admission (hazard ratio for death at 6 months for each 20-ng/mL increase = 0.7; 95% confidence interval: 0.5 to 0.9). An independent association of the molar ratio with death at 3 and 6 months was also found. CONCLUSION: Low levels of circulating IGF-1 may predict the clinical outcome of stroke in elderly patients.
Abstract: Heart failure is a complex syndrome characterized by the activation of hemodynamic, immunologic and neurohormonal systems, which have beneficial effects in the short run, but will ultimately lead to secondary end-organ damage with worsening of LV remodeling and subsequent cardiac decompensation. A very important role seems to be played by modifications of the pituitary hormone systems. Due to the neurohormonal activation there is an increase in the activity in the renin angiotensin system, in the adrenergic nervous system, and in the cytokine system. In heart failure there is a decrease in many anabolic hormones, such as a decrease of GH and IGF-I, of DHEA/DHEAS with normal or increased F, and a decrease of LH and sex steroids, resulting in an important catabolic drive, capable of contributing to the development of cardiac failure and to sarcopenia and/or cachexia, frequently observed in the advanced stages of the disease. However, these hormone alterations have been described in relatively young patients with chronic heart failure, since the mean age of all the subjects studied was of about 60 yr and none of the studies have specifically addressed this issue in the very old patients, who represent the largest portion of population affected by this pathological condition. The role of hormone replacement therapy needs to be verified in a population of elderly patients with heart failure.
Abstract: BACKGROUND: The role of antibiotic therapy on Salmonella faecal excretion is controversial. Acute Salmonella gastroenteritis induces long-lasting digestive symptoms in up to one-third of subjects. The role of antimicrobial therapy on persistent post-infectious symptoms is unknown. AIM: To investigate the role of antibiotic therapy on long-term germ faecal excretion and digestive symptoms after Salmonella infection. SUBJECTS AND METHODS: 1543 subjects [518 aged between 3 and 5 years (35.3%); 950 between 6 and 10 years (64.7%) and 75 adults (4.9%)] involved in a single outbreak of Salmonella enteritis fulfilled the study criteria by repeating stool cultures and answering a symptom questionnaire 3 months post-infection. RESULTS: 327 subjects (21.2%) were treated with antibiotics during the acute infection [121 children aged 3-5 years (23.4%), 175 children aged 6-10 years (18.4%) and 31 adults (41.3%)]. Antibiotic treatment did not affect Salmonella excretion at any of the time points studied up to three months post-infection in any age group as compared to age-matched untreated controls. Persistent digestive symptoms were more common among the patients treated with antibiotics (9.5% vs. 2.9%; P=0.003). CONCLUSIONS: Antibiotic therapy does not affect Salmonella enteritis excretion. Digestive symptoms after clearance of the infectious agent are significantly higher in patients treated with antibiotics during acute gastroenteritis.
