Abstract: Management of critically ill patients requires rapid and safe diagnostic techniques. Ultrasonography has become an indispensable tool that supplements physical examination in the intensive care unit. It enables early recognition of neurological emergencies, assists the diagnosis of abdominal and lung pathologies, and provides real-time information on the cardiac performance of critically ill patients. Furthermore, it detects possible infectious sites and renders therapeutic invasive procedures more convenient and less complicated. Whole-body ultrasound in the hands of adequately trained intensivists has the ability to reinvigorate the physical examination, without subjecting the patient to excessive irradiation and the risks of transport.
Abstract: Unidirectional Doppler is a common diagnostic tool by the Reconstructive Microsurgeons; however, it may generate false signals and surely provides less imaging data as compared to duplex ultrasonography. We have reviewed the use of Portable Duplex Ultrasonography (PDU) in 16 patients who underwent complex soft-tissue/bone reconstruction, aiming to determine its role in the design and management of free tissue transfer. According to our data, there were modifications either of the surgical plan and/or of patient's management, based on PDU findings, in 10 out of 16 patients (62.5%). The use of ultrasound directed to subtle modifications in three patients (19%), but to significant changes of the surgical plan in four patients (25%). Also, the use of ultrasound improved significantly the postoperative management in three patients (19%). Thus, significant impact of PDU in patient's treatment was recorded in 44% of cases. Portable ultrasound represents generally available method for preoperative, intraoperative, and postoperative diagnosis and decision-making in free tissue transfer, hence could replace in the near future the unidirectional Doppler in the hands of Microsurgeons.
Abstract: OBJECTIVE: Transcranial Doppler sonography (TCD) provides accurate confirmation of cerebral circulatory arrest (CCA) in brain death (BD), but is not feasible in patients with absent temporal bone windows. We added the transorbital approach in the TCD protocol for the diagnosis of CCA and compared findings with angiography. Furthermore, we evaluated whether reporting the angiographic and sonographic confirmation of CCA to relatives of brain-dead patients improves their comprehension and satisfaction with the medical information. PATIENTS AND METHODS: Eighty-two clinically brain-dead patients underwent 4-vessel angiography, TCD of the basilar and middle cerebral arteries, and transorbital Doppler sonography (TOD) of the internal carotid arteries. Relatives were randomly allocated to 41 in whom BD was presented as a clinical diagnosis (group A) and to 41 in whom BD was presented as a clinical diagnosis confirmed by TCD and angiography (group B). Comprehension and satisfaction of the relatives were assessed using an interview and a questionnaire. RESULTS: Both angiography and TCD verified CCA in all cases (k = 1). In 11 patients with failure of the transtemporal approach, CCA was confirmed by the transorbital recordings. The addition of TOD enabled 15.5% more cases of CCA to be diagnosed by TCD. Group B exhibited improved comprehension and satisfaction rates (P < .05). CONCLUSIONS: The addition of TOD increases the efficacy of TCD in confirming CCA in BD. Reporting confirmation of CCA to families of brain-dead patients may improve their comprehension and satisfaction with the provided medical information.
Abstract: We refer to a very rare case of catheter-related thrombosis in a trauma patient with persistent left and absent right superior vena cava. The role of ultrasound examination in the early diagnosis and treatment of thrombosis in the setting of intensive care unit (ICU) is thoroughly discussed. A 30-year-old man was admitted to the ICU due to multiple trauma. Six days after right internal jugular vein (IJV) catheter insertion, and during a vascular ultrasound examination, an IJV catheter-related thrombosis was diagnosed. Hence, the catheter was removed, and a follow-up ultrasound examination revealed thrombus remnant in the IJV extended into brachiocephalic vein. Subsequently, to exclude a possible extension of the thrombus in the superior vena cava, a transesophageal echocardiography (TEE) examination was performed. The latter revealed a distended coronary sinus and the presence of persistent left superior vena cava (PLSVC). Additionally, TEE examination disclosed thrombus remnant within the PLSVC that was also confirmed with CT venography. Anticoagulant therapy was started thus preventing major complications such as coronary sinus obstruction. This case underlines the role of cardiovascular ultrasound examination as an important tool in performing variety of monitoring in the setting of the ICU.
Abstract: AIM: We evaluated the utility of impedance cardiography (IC) in elderly hemodialysis (HD) patients with coronary artery disease (CAD). PATIENTS AND METHODS: Seventy-five HD patients (30 with CAD) participated. IC cardiac output (ICCO), systemic vascular resistance and pulse pressure (PP) were calculated at baseline, and 30 and 180 days after study entry. ICCO was compared to echocardiography cardiac output (ECO). Relationships of IC measurements and cardiovascular mortality were assessed. Patients were followed up for 6 years after study entry or until death due to cardiovascular events. RESULTS: ICCO and ECO were strongly correlated (r = 0.94, p < 0.001). ICCO correlated inversely with PP (r = -0.61; p < 0.001). Thirty fatal cardiovascular events were recorded. Using the bayesian' information criterion, multivariate Cox regression models revealed that increased PP and New York Heart Association (NYHA) class as well as decreased diastolic blood pressure (DBP) were predictors of cardiovascular mortality. Having a DBP <60 mm Hg (adjusted for NYHA) yielded a hazard ratio of 2.8 (95% confidence interval = 1.2-6.7). CONCLUSION: IC accurately estimates the hemodynamic status in HD patients with CAD. Deterioration of cardiovascular performance expressed by decreased DBP values, adjusted for NYHA, may help to predict outcome.
Abstract: AIMS: Patients with heart failure (HF) show abnormal arterial stiffening. METHODS AND RESULTS: We examined 60 patients (52.1 +/- 12, 8 years) with non-ischaemic dilated cardiomyopathy (NIDC), New York Heart Association II-III, in sinus rhythm, left ventricular ejection fraction 30.1 +/- 8.6%, and 44 normals. All subjects underwent an echocardiographic study and a cardiopulmonary exercise test. We evaluated the segmental proximal aorta (AO) pulse wave velocity (PWV) in the region of aortic arch with a new echo-method: from the suprasternal view, the distance between ascending and descending AO was measured with two-dimensional ultrasound, and the aortic flow wave transit time (TT) was measured with pulsed-wave Doppler. Pulse wave velocity was calculated as aortic distance/TT. Patients showed increased PWV (7.4 +/- 2.9 vs. 4.8 +/- 1.1 m/s, P < 0.001), compared with controls. Patients with advanced left ventricular (LV) (restrictive or pseudo-normal filling pattern) diastolic dysfunction showed increased PWV (8.6 +/- 2.6 vs. 6.6 +/- 2.9 m/s, P = 0.01) and reduced peak and predicted (for age, sex, and body mass) VO(2) (both P < 0.001), compared with those with mild diastolic dysfunction (delayed relaxation filling pattern). Pulse wave velocity was significantly correlated with the LV mass (r = 0.32, P = 0.01), the peak spectral tissue Doppler imaging systolic wave (r = -0.34, P = 0.006), the LV diastolic filling pattern (r = 0.42, P = 0.001), and the peak (r = -0.47, P < 0.001) and predicted VO(2) (r = -0.579, P < 0.001). CONCLUSION: Patients with NIDC showed increased proximal aortic stiffness, which relates to LV systolic and diastolic function and exercise capacity. The echocardiographic assessment of the regional aorta PWV seems to be clinically important.
Abstract: INTRODUCTION: Peripheral T-cell lymphoma of the unspecified variant is a highly aggressive subtype of T-cell non-Hodgkin's lymphoma. This is the first reported case of this type of lymphoma presenting as an ischemic stroke in a woman. CASE PRESENTATION: A previously healthy 23-year-old woman presented with fever and hemiplegia. She was subsequently intubated after scoring 7 out of 15 at the Glasgow Coma Scale. Brain computed tomography scans of the patient depicted a massive sylvian infarction while an abdominal computed tomography scan revealed multiple enlarged abdominal lymph nodes and a retroperitoneal mass adjacent to the left psoas muscle. A diagnostic work up for inherited thrombophilia yielded negative results. Blood and cerebrospinal fluid cultures for infectious agents also gave negative results. A biopsy of the retroperitoneal mass guided by computed tomography was inconclusive. A biopsy of an enlarged inguinal lymph node of the patient, combined with an immunophenotypic analysis, revealed an unspecified variant of peripheral T-cell lymphoma. The patient underwent chemotherapy but developed multiple organ failure. She died 26 days after she was admitted to our intensive care unit. CONCLUSION: Peripheral T-cell lymphoma of the unspecified variant is a highly aggressive subtype of peripheral T-cell lymphomas. The latter exhibit no consistent immunophenotypic, genetic, or clinical features. Clinicians should be aware of atypical clinical presentations of the above lymphomas such as ischemic stroke.
Abstract: Hyperlipidaemic diets induce increase in serum lipid profile (total cholesterol, triglycerides, LDL etc). It has also been proven that stress interferes in lipid metabolism. Many drugs modify their pharmacokinetic properties in presence of lipoproteins, as a result of alterations in their plasma protein and tissue binding. Lidocaine, a synthetic amide, used as a local anesthetic and secondary as antiarrhythmic agent is also protein bound and therefore conditions, which favor lidocaine dissociation from plasma proteins, modify its pharmacokinetic profile. The purpose of this study was: To investigate and compare the effects of stress( cold water 4 degrees C swimming of 20 days duration) and various high lipid diets (olive oil, butter, sunflower oil) on the serum and tissue (liver and tongue) levels of 14C lidocaine.
Abstract: We report a case of a female patient with acute renal failure due to polyarteritis nodosa. Her clinical course was initially complicated by an unusual form of hypertensive encephalopathy called reversible posterior leukoencephalopathy syndrome (RPLS). Soon afterwards she developed cardiogenic shock; she was intubated and admitted to our ICU. Echocardiography and pertinent laboratory data were suggestive of takotsubo cardiomyopathy (TTC), a rare form of stress-induced, reversible cardiac dysfunction. We hypothesized that TTC was pathophysiologically linked to RPLS, presumably through an overstimulation of the sympathetic nervous system. Both RPLS and TTC turned out to be totally reversible conditions, and intensive echocardiographic monitoring was of great importance in order to optimize the hemodynamic support in our patient.
Abstract: BACKGROUND: The authors compared the intubation success rate of straight reinforced tracheal tubes emerging from the Airtraq laryngoscope (Prodol Meditec S.A., Vizcaya, Spain) with standard preformed polyvinyl chloride tracheal tubes in anesthetized patients. METHODS: The authors randomly allocated 347 adult patients to be intubated with standard polyvinyl chloride tracheal tubes, standard straight wire-reinforced tracheal tubes, or silicone straight wire-reinforced tubes, through either the larger or the smaller adult laryngoscope sizes. The possible influence of laryngoscope size, tube size, and tube type on intubation failure was examined. RESULTS: Success rates were 100% for polyvinyl chloride tracheal tubes, 78.5% for standard wire-reinforced tracheal tubes, and 75.4% for silicone wire-reinforced tubes (P < 0.01). Compared with the former, patients in the straight standard and silicone wire-reinforced tube groups required more optimization maneuvers (4.1% vs. 42.1%; P < 0.01) and more attempts at successful intubation (0% vs. 7.3%; P < 0.01). The angle created by the tube emerging from the Airtraq guiding channel was inversely correlated to the ratio of the endotracheal tube OD to the width of the channel in the standard and silicone wire-reinforced tube groups (r = -0.95 and r = -0.82, respectively; P < 0.01). Finally, a decrease in 0.1 of the above ratio was associated with a 3.1 (95% confidence interval, 1.9-5.2; P < 0.01) times increase in the odds ratio of intubation failure. CONCLUSIONS: Standard polyvinyl chloride tracheal tubes were found to be superior compared with standard and silicone straight wire-reinforced tubes for intubation through the Airtraq laryngoscope. In the latter groups, a decrease of the ratio of their OD to the width of the Airtraq guiding channel resulted in increased intubation failure.
Abstract: INTRODUCTION: The mortality of listerial rhombo-encephalitis exceeds 26% and may involve otherwise healthy patients. A case is presented of a man with fatal listerial infection of the central nervous system that was monitored in an intensive care unit. CASE PRESENTATION: A 42-year-old, previously healthy man was admitted with fever of 39 degrees C, blurred vision, confusion and headache. He had right-sided central facial paresis, bilateral absent gag reflex and bilateral cerebellar ataxia. After a few hours, he became septic and developed bilateral vocal cord paralysis and airway obstruction. He was intubated and put on mechanical ventilation. Computed tomography brain scans revealed multiple frontal hypodense areas and slight hydrocephalus. Cerebrospinal fluid findings included pleocytosis of 4200 cells/muL (77% neutrophils), protein of 114 mg/dL and normal glucose levels. Listerial infection was suspected; therefore ampicillin was added to his initial therapeutic regimen, already including ceftriaxone and gentamicin. All cultures were negative, and no immunologic abnormality could be documented, but the patient's clinical condition deteriorated rapidly. Continuous neuromonitoring by means of transcranial Doppler and optic nerve sonography along with follow-up computed tomography brain scans confirmed the severity of the brain damage; hence, dexamethasone and mannitol were also administered. The patient was clinically documented as 'brain dead' 7 days after his admission to the intensive care unit; thereafter, blood- and post-mortem brain tissue cultures grew Listeria monocytogenes. CONCLUSION: This case report illustrates the importance of neuromonitoring in patients with severe brain damage. We also show that, despite prompt antibiotic treatment and dexamethasone administration, listerial infection of the central nervous system can be lethal.
Abstract: BACKGROUND: Increased aortic stiffness has been found in heart failure (HF), but the underlying mechanisms remain to be elucidated. The aim of the present study was to examine the association between aortic stiffness and neurohumoral activation in patients with nonischemic dilated cardiomyopathy (NIDC). METHODS AND RESULTS: We examined 101 patients with NIDC, New York Heart Association Class II-III, LVEF 33.3 +/- 11.6%, and 33 controls. All subjects underwent blood sampling for plasma concentrations of renin, aldosterone, C-reactive protein (CRP), and brain natriuretic peptide (BNP). We evaluated the pulse wave velocity (PWV) of the proximal aorta in the region of the aortic arch with a new echo application. Patients showed increased PWV (P < .001), and increased plasma levels of log-renin (P < .001), log-aldosterone (P = .01), CRP (P = .01), and log-BNP (P = .01) compared with controls. PWV was correlated with log-BNP (r = 0.63, P < .001) and log-aldosterone (r = 0.34, P < .001) levels, with LV end-diastolic (r = 0.27, P = .01) and end-systolic (r = 0.33, P = 0.003) volumes, and the PW-tissue Doppler imaging systolic wave (r = -0.27, P = .006) and the E/e' ratio (r = 0.45, P < .001). Linear regression analysis showed that log-BNP levels were independently associated with PWV. CONCLUSIONS: In patients with HF from NIDC, there is evidence of increased aortic stiffness that is correlated with LV shape and function. Although aldosterone levels seem to influence the aortic PWV, BNP levels are the best independent predictor of increased PWV.
Abstract: OBJECTIVE: Despite advantages of ultrasound-guided peripheral nerve blocks as compared with established techniques, various limitations may exist. We present 2 trauma patients in whom the usefulness of ultrasound techniques was limited by edema and subcutaneous air. CASE REPORT: Two male patients were admitted to the Intensive Care Unit due to multiple trauma. In the first patient, tissue edema and obesity (body mass index, calculated as weight [kg]/height [m(2)] = 35), and in the second patient, subcutaneous emphysema, were significant limitations for the application of ultrasound-guided peripheral nerve blocks. These factors made 2-dimensional ultrasound imaging difficult despite the use of tissue harmonic technique and advanced ultrasound equipment. Neurostimulation technique alone, or combined with ultrasound imaging eventually led to successful nerve block. CONCLUSIONS: Ultrasound technique limitations do exist. We present 2 conditions, edema and subcutaneous air, which contributed to ultrasound failure to provide a clear image of the targeted nerves.
Abstract: INTRODUCTION: The optic nerve sheath diameter (ONSD) may be increased in brain-injured patients, especially children, with intracranial hypertension. We investigated whether measurements of ONSD correlated with simultaneous noninvasive and invasive measurements of the intracranial pressure (ICP) in brain-injured adults. METHODS: Seventy-six critical care patients (58 males; 47 +/- 18 years old) were included in the study. Fifty patients suffered from brain injury, whereas 26 had no intracranial pathology and served as control individuals. Initially, brain-injured patients were evaluated clinically (Glasgow Coma Scale) and using a semiquantitative (I to VI) neuroimaging scale (Marshall Scale). Thereafter, the patients were divided into those with moderate (Marshall Scale = I and Glasgow Coma Scale > 8 [n = 18]) and severe (Marshall Scale = II to VI and Glasgow Coma Scale < or =8 [n = 32]) brain injury. All patients underwent noninvasive measurement of the ICP (estimated ICP) by transcranial Doppler sonography, and synchronous ONSD measurements by optic nerve sonography. Finally, invasive ICP measurement using an intraparenchymal catheter was performed in patients with severe brain injury. RESULTS: ONSD and estimated ICP were both significantly increased (6.1 +/- 0.7 mm and 26.2 +/- 8.7 mmHg, respectively; P < 0.0001) in patients with severe brain injury as compared with patients with moderate brain injury (4.2 +/- 1.2 mm and 12.0 +/- 3.6 mmHg) and compared with control individuals (3.6 +/- 0.6 mm and 10.3 +/- 3.1 mmHg). Furthermore, in patients with severe brain injury the ONSD measurements were strongly correlated with estimated ICP values (r = 0.80, P < 0.0001) as well as with the neuroimaging scale results (r = 0.82, P < 0.001). In the patients with severe brain injury, ONSD measurements correlated with invasive ICP values (r = 0.68, P = 0.002). The best cut-off value of ONSD for predicting elevated ICP was 5.7 mm (sensitivity = 74.1% and specificity = 100%). CONCLUSION: ONSD measurements correlate with noninvasive and invasive measurements of the ICP, and with head computed tomography scan findings in brain-injured adults. Hence, optic nerve sonography may serve as an additional diagnostic tool that could alert clinicians to the presence of elevated ICP, whenever invasive ICP evaluation is contraindicated and/or is not available. This trial is International Standard Randomised Controlled Trial Number registered (ISRCTN 91941687).
Abstract: INTRODUCTION: We conducted an ultrasound study to investigate echocardiographic artifacts in mechanically ventilated patients with lung pathology. METHODS: A total of 205 mechanically ventilated patients who exhibited lung atelectasis and/or pleural effusion were included in this 36-month study. The patients underwent lung echography and transthoracic echocardiography, with a linear 5 to 10 MHz and with a 1.5 to 3.6 MHz wide-angle phased-array transducer, respectively. Patients were examined by two experienced observers who were blinded to each other's interpretation. RESULTS: A total of 124 patients (60,48%) were hospitalized because of multiple trauma; 60 patients (29,26%) because of respiratory insufficiency, and 21 (10,24%) because of recent postoperative surgery. The mean duration ( +/- standard deviation) of hospitalization was 35 +/- 27 days. An intracardiac artifact was documented in 17 out of 205 patients (8.29%) by echocardiography. It was visible only in the apical views, whereas subsequent transesophageal echocardiography revealed no abnormalities. The artifact consisted of a mobile component that exhibited, on M-mode, a pattern of respiratory variation similar to the lung 'sinusoid sign'. Lung echography revealed lung atelectasis and/or pleural effusion adjacent to the heart, and a similar M-mode pattern was observed. The artifact was recorded within the left cardiac chambers in 11 cases and within the right cardiac chambers in six. CONCLUSIONS: Lung atelectasis and/or pleural effusion may create a mirror image, intracardiac artifact in mechanically ventilated patients. The latter was named the 'cardiac-lung mass' artifact to underline the important diagnostic role of both echocardiography and lung echography in these patients. TRIAL REGISTRATION: This trial is ISRCTN registered: ISRCTN 49216096.
Abstract: INTRODUCTION: Sclerosing mesenteritis is a rare disease resembling a mesenteric tumour. We present here a case of sclerosing mesenteritis that affected both the large and the small intestine of the patient. Therapeutic and diagnostic issues are discussed. CASE PRESENTATION: A 62-year-old man with a history of non-Hodgkin lymphoma presented with fatigue, a palpable tender abdominal mass and clinical signs of progressing intestinal obstruction. The preoperative evaluation failed to prove recurrence of the lymphoma or any other definite diagnosis. A laparotomy was performed through a midline incision. The mesentery resembled a tumour-like thickened and fibrotic mass. Abundant, rigid intestinal loop adhesions were observed. Diffuse fibrotic infiltration of the ileum and of the sigmoid colon, which obviously affected the intestinal vascular supply, were identified. A right colectomy and partial sigmoidectomy were performed. Pathological evaluation revealed extensive myofibroblastic reaction of the mesentery with accompanying loci of fat necrosis and areas of inflammation. A diffuse fibrotic infiltration that focally showed a ground-glass appearance was observed. The post-operative course was complicated by respiratory insufficiency and infections and the patient died 2 months after the operation. CONCLUSION: Sclerosing mesenteritis that affects both the small and the large intestine is extremely rare. The disease is characterized by myofibroblastic reaction, fat necrosis and diffuse fibrosis of the mesentery. Pathological confirmation may be required for definite diagnosis. If the disease is characterized by severe and diffuse fibrosis, then the application of surgical therapy may be problematic.
Abstract: Post-surgical meningitis and/or ventriculitis caused by Gram-negative bacteria may be difficult to treat due to the emergence of multiresistant strains. Two patients with multiresistant Acinetobacter baumannii central nervous system infection, successfully treated with either intravenous and/or intraventricular colistin are presented. Unresolved issues such as dose and duration of intraventricular colistin are discussed.
Abstract: BACKGROUND: In a prospective study, we evaluated the blood perfusion and the blood flow of anterolateral thigh (ALT) flap by both near-infrared spectroscopy and color Doppler ultrasonography. Moreover, we assessed the ability of the perforator flap to reconstruct infected wounds of the lower extremity in 11 patients. METHODS: Near-infrared spectroscopy showed excellent oxygen saturation, and Doppler ultrasonography documented excellent blood flow and decreased vascular resistance in the ALT flap postoperatively. RESULTS: All flaps were successful and all wounds healed uneventfully within 2 weeks without any signs of recurrences or persistent infection. All patients achieved acceptable gait function after rehabilitation. CONCLUSIONS: Apart from the mandatory role of thorough debridement, our results indicate that the ALT flap offers rich blood supply to the recipient area, thus contributing to the sterilization and healing of an infected wound within a short time period.
Abstract: AIM: We examined the relationship between proximal aortic stiffness and left ventricular (LV) diastolic function in patients with end-stage renal disease (ESRD). PATIENTS AND METHODS: We studied 99 patients with ESRD with preserved LV ejection fraction greater than 50% and 83 controls. We assessed the aorta stiffness by measuring the pulse wave velocity (PWV) in the proximal aorta (PWVr) using a novel echo application and in the descending aorta (PWVcf) using a foot-to-foot method. Patients were classified according to LV diastolic filling pattern into normal, delayed relaxation, pseudonormal, and restrictive filing pattern groups. RESULTS: Patients with ESRD had increased PWVr, PWVcf, and LV mass index (LVMI) compared with controls (all P < .0001). Patients with advanced diastolic dysfunction showed increased PWVr (P < .001) and PWVcf (P = .007) compared with those with mild diastolic dysfunction. PWVr was correlated to PWVcf (r = 0.74, P < .001) in patients with ESRD. Multivariate linear regression analysis revealed that PWVr was independently correlated to both LVMI and LV diastolic filling pattern. CONCLUSIONS: Increased LVMI, advanced LV diastolic dysfunction, and generalized aortic stiffening were observed in patients with ESRD. Proximal aorta stiffness is associated with both increased LVMI and advanced LV diastolic dysfunction in those patients.
Abstract: The co-administration of lidocaine and propranolol leads to significant drug-drug interactions. Beta-blockers decrease liver perfusion and inhibit the activity of hepatic microsomal lidocaine metabolizing enzymes of the P450_2D subfamily. Hence, there is a resulting reduction in the hepatic breakdown of lidocaine and an increase in its serum concentrations. In this study the ability of propranolol to displace lidocaine from its binding sites in liver tissue has been examined through an in vitro model. Rat liver slices were incubated together with propranolol and/or lidocaine in human serum and the percentage of the bound fraction of lidocaine in the experimental mixture was assessed. The present results indicate that propranolol significantly decreases the binding process of lidocaine in liver tissue. This effect develops only when blood is used as incubation medium and the incubation period lasts 60 min. In conclusion, propranolol can displace lidocaine from liver proteins and therefore the co-administration of the two drugs may increase the free fraction of lidocaine excreted by the liver. However, this result arises from an in virro model and thus further investigation is needed.
Abstract: Peripheral artery stiffness is altered in diabetic patients with end-stage renal disease (ESRD), whereas few data exist to confirm this trend for proximal aortic stiffness. The pulse wave velocity of the proximal aorta (PWVr) and of the carotid-to-femoral aortic segment (PWVcf) were determined by ultrasound imaging in 160 patients with ESRD (70 diabetic) and in 160 matched control subjects. Also, plasma levels of endothelin, homocysteine, and high-sensitivity C-reactive protein were determined in both groups. Patients with ESRD had increased pulse pressure, left ventricular (LV) end-diastolic diameter, LV mass index, PWVr, and PWVcf compared with control subjects (p < 0.05). Diabetic patients had increased LV mass index, PWVr, and PWVcf compared with nondiabetic patients with ESRD (p < 0.05). Endothelin levels exhibited a strong relation with PWVr (r = 0.32, p < 0.001) and PWVcf (r = 0.33, p < 0.001) measurements in ESRD patients. Multivariate linear regression analysis revealed that age, diabetes, and plasma levels of endothelin were major determinants of increased PWVr measurements in the total ESRD population. After adjustment for age, body surface area, time on dialysis, systolic blood pressure, history of hypertension, and plasma endothelin levels, diabetes was an independent factor associated with PWVr in ESRD subjects. Diabetic patients with ESRD had significantly increased proximal aortic stiffness and significantly altered plasma levels of endothelin as compared with the nondiabetic.
Abstract: BACKGROUND: Hemodialysis patients experience a variety of hemodynamic abnormalities that contribute to cardiovascular disease mortality which is the leading cause of death in these patients. Impedance cardiography has been utilized in order to monitor cardiac hemodynamics with lower cost and inconvenience, but it has not been appropriately validated in the hemodialysis population. AIM: We repeatedly used impedance cardiography to assess short- (48 hours) and long-term (15 days) reproducibility of cardiac output measurements and we compared baseline impedance cardiography measurements with echocardiographic measurements. PATIENTS AND METHODS: We studied 109 stable hemodialysis patients, aged 59.70 +/- 11.97 years being on hemodialysis for 67.59 +/- 40.15 months, on a non-dialysis day. Cardiac output was obtained with the BioZ impedance cardiography system (Cardiodynamics, San Diego, Ca, USA). Baseline echocardiography was performed using a Hewlett-Packard Sonos 2500 (Andover, Mass., USA). RESULTS: The values of impedance cardiography derived cardiac output were 5.28 +/- 0.79, 5.27 +/- 0.75 and 5.25 +/- 0.74 l/min at baseline (107 patients), 48 hours (107 patients) and 15 days (98 patients) respectively, showing high reproducibility. Bland and Altman analysis estimated that bias at 48 hours and at 15 days were: -0.013 (95% confidence intervals = -0.045 to 0.019) and 0.028, (95% confidence intervals = -0.044 to 0.101), respectively. In addition baseline impedance cardiography derived cardiac output was significantly correlated with the echocardiographic derived cardiac output (r = 0.9, p < 0.0001). CONCLUSION: Impedance cardiography is a simple non invasive technique for cardiac output estimation in hemodialysis patients which has high reproducibility when performed under controlled conditions, and is closely correlated with echocardiographic measurements of cardiac output.
Abstract: OBJECTIVES AND METHODS: Altered plasma high-sensitivity C-reactive protein (hs-CRP) and adiponectin (ADP) may contribute to increased vascular inflammation and accelerated atherosclerosis in patients with end-stage renal disease (ESRD) and co-morbid diabetes. Common carotid artery intima-media thickness (CCA-IMT) and atherosclerotic plaque occurrence, left-ventricular mass index (LVMI), and pulse wave velocity of the proximal aorta (PWVr) were determined by ultrasound imaging in 120 ESRD (55 diabetic) patients, and 83 age-, sex-, and blood pressure-matched controls. Also, plasma levels of ADP and hs-CRP were determined and their relationships with the above cardiovascular alterations were analyzed. RESULTS: LVMI, PWVr, CCA-IMT and atherosclerotic plaque occurrence were all increased in ESRD patients compared to controls (all p < 0.001). LVMI (p < 0.05), PWVr (p < 0.001), CCA-IMT (p < 0.001) and atherosclerotic plaque occurrence (p < 0.001) were increased in diabetic compared to nondiabetic ESRD patients. Hs-CRP levels were increased and ADP levels were decreased in diabetic compared to nondiabetic ESRD patients (both p < 0.001). ADP levels correlated inversely with hs-CRP (r = -0.473, p < 0.0001) in ESRD patients. Hs-CRP was positively correlated with LVMI (r = 0.365, p < 0.0001), PWVr (r = 0.42, p < 0.0001) and CCA-IMT (r = 0.18, p = 0.047) while ADP inversely correlated with PWVr (r = -0.263, p = 0.0035) and CCA-IMT (r = -0.207, p = 0.022) in ESRD patients. CONCLUSION: The present results indicate diabetic disease-specific alterations in the biochemical parameters of hs-CRP and ADP in ESRD patients. The above biochemical parameters were intimately linked to the cardiovascular measurements of LVMI, PWVr and CCA-IMT in patients with ESRD and co-morbid diabetes mellitus.
Abstract: OBJECTIVE: Cerebral blood flow tests have increasingly been advocated for the confirmation of brain death (BD). Angiography has been considered the gold standard in the diagnosis of BD but is invasive. We validated transcranial color Doppler ultrasonography (TCD) to confirm BD by comparing it to angiography. PATIENTS AND METHODS: Forty patients experienced the clinical diagnosis of brain death due to head injury in 19 cases (47.5%), cerebral hemorrhage in 11 (27.5%), subarachnoid hemorrhage in 7 (17.5%), and cerebral infarction in 3 (7.5%). Blood pressure, heart rate, SPO2, and PCO2 were monitored throughout the study. Patients were excluded if episodes of hypoxia, arrhythmia, and hypotension occurred during examinations, or if the TCD was not technically feasible. RESULTS: Both angiography and TCD confirmed BD in all patients. The agreement between the above methods to confirm BD was 100%. Angiography showed the absence of filling of intracranial arteries, while TCD revealed: (1) brief systolic forward flow or systolic spikes and diastolic reversed flow (50%); (2) brief systolic forward flow or systolic spikes and no diastolic flow (25%); (3) no demonstrable flow in a patient in whom flow had been clearly documented on a previous TCD examination (12.5%). Five patients required repeated TCD examinations, because of initial detection of a diastolic to-and-fro flow pattern. BD was confirmed by TCD in the above patients after 30 hours of clinical BD. CONCLUSION: TCD was a sensitive tool to diagnose BD, affording a reliable alternative examination to standard angiography.
Abstract: OBJECTIVE: To present a novel, non-invasive echocardiographic application to assess the structural and functional properties of the complex composition of the proximal aorta in patients with end stage renal disease (ESRD). METHODS: 71 haemodialysis patients (mean (SD) age 61.3 (9.3) years, dialysis duration 79.2 (51.6) months) and 62 age matched controls were studied. From the suprasternal view, the distance between ascending and descending aorta was measured with two dimensional ultrasound. The aortic flow wave transit time was measured with pulsed wave Doppler. M mode echocardiography, with simultaneous blood pressure estimates, was used to assess the diameters of the aortic annulus and of the ascending aorta. Pulse pressure, pulse wave velocity (PWV), pressure strain elastic modulus, characteristic impedance, and beta index were calculated. RESULTS: Patients had increased pulse pressure (68.0 (7.2) v 51.4 (5.0) mm Hg, p < 0.001), PWV (6.1 (1.1) v 3.9 (0.6) m/s, p < 0.001), characteristic impedance (174 (58) v 111 (31) m/s.cm2, p < 0.001), pressure strain elastic modulus (872 (254) v 541 (140) mm Hg, p < 0.001), and beta index (8.9 (3.4) v 5.5 (1.4), p < 0.001) compared with controls. In patients PWV was correlated with age and time on haemodialysis (r = 0.44, p < 0.001, and r = 0.51, p < 0.001, respectively). CONCLUSION: A novel application of duplex ultrasound of the proximal aorta showed that patients with ESRD have impaired proximal aortic function compared with controls. The data indicate that these non-invasive measurements can be used to describe status and change in aortic biophysical properties and may be used as a marker for cardiovascular disease risk.
Abstract: OBJECTIVE: We investigated whether alterations in the optic nerve diameter (OND) correlated with brain computed tomography (CT) imaging results among patients with brain injury and whether monitoring of OND could predict brain death. PATIENTS AND METHODS: We enrolled 54 patients with brain injury (Glasgow Coma Scale < 8) and 53 controls. OND measurements were performed 3 mm posterior to the papillae by means of transorbital sonography. The severity of the injury was classified according to a semiquantitative CT neuroimaging scale (1 to 4). All patients underwent 3 repeated evaluations of OND combined with synchronous CT scans. RESULTS: Twenty-two patients progressed to brain death, while 32 patients showed gradual clinical improvement. Upon admission, the patients showed significantly increased OND (4.84 +/- 1.2 mm) compared with the controls (3.49 +/- 1.1 mm; P < .001). The median intraobserver variation of OND was 0.2 mm (95% confidence intervals [CI]: 0.1-0.7). The median interobserver variation of OND was 0.3 mm (95% CI: 0.1-0.9). Alterations in the OND were significantly correlated with the neuroimaging scale on 3 repeated evaluations: r = .65, r = .70, and r = .73 (all P < .001). An OND greater than 5.9 mm (specificity = 65% and sensitivity = 74%; P < .01) and a 2.5 mm increased OND between repeated measurements (specificity = 70% and sensitivity = 81%; P < .01) were associated with a poor prognosis. CONCLUSIONS: Alterations in OND strongly correlated with neuroimaging results among patients with brain injury. However, monitoring of OND exhibited a low predictive value for brain death.
Abstract: OBJECTIVES AND METHODS: Two thirds of men with end-stage kidney disease (ESKD) have serum testosterone levels in the hypogonadal range. We examined if low serum testosterone levels were correlated with measures of endothelial dysfunction in ESKD. Bilateral common carotid artery (CCA) intima-media thickness (IMT) and atherosclerotic plaque occurrence, left ventricular mass index, flow- (FMD) and nitrate-mediated vasodilatation (NMD) of the brachial artery were determined by ultrasound imaging in 100 nondiabetic men with ESKD (50 men exhibited androgen deficiency; serum testosterone concentrations <300 ng/dl). RESULTS: Left-ventricular mass index, CCA diameter, CCA-IMT and atherosclerotic plaque occurrence were all significantly increased in ESKD patients with androgen deficiency compared with patients without androgen deficiency (p < 0.05). Also, FMD and NMD measurements were significantly reduced in the former compared with the latter (p < 0.05). Testosterone levels were inversely correlated with age and duration of hemodialysis therapy (r = -0.44 and r = -0.55; p < 0.001). Testosterone levels were negatively correlated to CCA-IMT and atherosclerotic plaque occurrence in patients with androgen deficiency (r = -0.32, p < 0.003, and r = -0.23, p < 0.04, respectively). FMD and NMD measurements were positively correlated to total (r = 0.65 and r = 0.61; both p < 0.0001) and free (r = 0.52 and r = 0.48; both p < 0.001) testosterone levels in patients with low androgenicity. CONCLUSION: The present results indicated that ESKD patients with androgen deficiency had increased CCA-IMT, atherosclerotic plaque occurrence and reduced FMD and NMD compared with patients without androgen deficiency. Testosterone serum levels were negatively correlated to CCA-IMT and positively correlated to endothelium-dependent vasodilatation in ESKD patients with androgen deficiency.
Abstract: The blood flow and the blood perfusion of pedicled anterolateral thigh (ALT) flap was evaluated in 11 patients with skin and soft tissue defects by means of color Doppler ultrasonography and of near-infrared spectroscopy, respectively. Also, the authors assessed the ability of the pedicled perforator flap to cover the above defects. A proximally based flap was used to cover defects at the lower abdominal wall (two patients), the suprapubic area, the penis (two patients), the greater trochanter (two patients), the lateral gluteal area, and the ischial tuberosity. A distally based flap was used to cover the exposed knee joint (two patients). Near-infrared spectroscopy revealed excellent oxygen saturation and Doppler ultrasonography documented increased blood flow and decreased vascular resistance in the pedicled ALT flap, postoperatively. All flaps survived completely and the wounds healed uneventfully, resulting in excellent esthetic and functional results. The vascular anatomy of ALT flap facilitates the design of versatile pedicled flaps with tremendous vascularity, two pivot points and large arc of rotation, able to cover defects from the lower abdominal wall to the knee joint.
Abstract: INTRODUCTION: Central venous cannulation is crucial in the management of the critical care patient. This study was designed to evaluate whether real-time ultrasound-guided cannulation of the internal jugular vein is superior to the standard landmark method. METHODS: In this randomised study, 450 critical care patients who underwent real-time ultrasound-guided cannulation of the internal jugular vein were prospectively compared with 450 critical care patients in whom the landmark technique was used. Randomisation was performed by means of a computer-generated random-numbers table, and patients were stratified with regard to age, gender, and body mass index. RESULTS: There were no significant differences in gender, age, body mass index, or side of cannulation (left or right) or in the presence of risk factors for difficult venous cannulation such as prior catheterisation, limited sites for access attempts, previous difficulties during catheterisation, previous mechanical complication, known vascular abnormality, untreated coagulopathy, skeletal deformity, and cannulation during cardiac arrest between the two groups of patients. Furthermore, the physicians who performed the procedures had comparable experience in the placement of central venous catheters (p = non-significant). Cannulation of the internal jugular vein was achieved in all patients by using ultrasound and in 425 of the patients (94.4%) by using the landmark technique (p < 0.001). Average access time (skin to vein) and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < 0.001). In the landmark group, puncture of the carotid artery occurred in 10.6% of patients, haematoma in 8.4%, haemothorax in 1.7%, pneumothorax in 2.4%, and central venous catheter-associated blood stream infection in 16%, which were all significantly increased compared with the ultrasound group (p < 0.001). CONCLUSION: The present data suggest that ultrasound-guided catheterisation of the internal jugular vein in critical care patients is superior to the landmark technique and therefore should be the method of choice in these patients.
Abstract: OBJECTIVE: To review the results of the surgical treatment of all types of hyperthyroidism (Graves' disease, toxic nodular goitre, and toxic solitary adenoma). DESIGN: Retrospective study. SETTING: University hospital and private hospital, Greece. SUBJECTS: 400 Consecutive patients who were operated on between 1982 and 1991. INTERVENTION: Near total/total thyroidectomy in 226 patients with toxic nodular goitre and 87 patients with Graves' disease. Subtotal thyroidectomy in 25 patients with Graves' disease (early period of the study); lobectomy with resection of the isthmus of the thyroid in 62 patients with a solitary toxic adenoma. MAIN OUTCOME MEASURES: Mortality, morbidity and patients' self assessment of the results of operation (symptoms, scar, ophthalmopathy). RESULTS: There was no mortality. Morbidity included 2 postoperative bleeds that required reoperation; 2 patients developed permanent unilateral vocal cord paralysis and 2 had permanent hypoparathyroidism. In 27 of the 400 patients (7%) a thyroid carcinoma was found in the resected specimen. No patient had persistent or recurrent hyperthyroidism 2 to 10 years after operation. Of the 49 patients with Graves' disease and opthalmopathy at the time of operation, 35 (71%) reported improvement in their ophthalmopathy and 14 (29%) reported no improvement. No patient had worsening of their exophthalmos; 388 (97%) were satisfied with their incision; and 360 (90%) reported a significant improvement in their preoperative symptoms (tachycardia, weakness, anxiety, and pressure in the neck). CONCLUSIONS: We suggest that the primary treatment of all types of hyperthyroidism should be surgical.
