Ocular complications in acquired partial lipodystrophy.
Explore the source record for details and available documents.
Adult↗
Biomedical subjects
B Page
Publications and source records attributed to B Page.
Prospective study on the presentation and outcome of patients with an acute hernia.
Recent advances in hernia surgery should help to make operation more acceptable to patients and their doctors. The aim of this study was to prospectively assess the presentation and management of patients with an acute hernia in light of these changes. Data on all patients admitted with an acute hernia between March 2001 and February 2004 was entered on a prospective database. During the 3 year study period, of the 91 patients admitted with an acute hernia, 41 were ventral, 24 femoral, 24 inguinal and 2 parastomal. Forty-six had a previous medical assessment, 18 of these had been declared unfit for operation at that assessment; ten were ASA4 (ASA, American Society of Anaesthesiology), five ASA3 and three ASA2. Eleven patients were on the waiting list for operation, three of whom had a previous acute hospital admission. For 30 patients this hospital admission was the first indication that they had a hernia while the remaining were aware that they had a hernia but did not seek medical advice. Of the five patients who died, two while being assessed for operation and three postoperatively, three were ASA4 and had a ventral hernia while two were ASA3 with a femoral hernia. Despite advances in hernia surgery there is still room for improvement in preoperative assessment of patients presenting with an acute hernia.
Acute Disease↗
Does radio-opaque contrast improve radiographic localisation of percutaneous central venous lines?
BACKGROUND: Percutaneous central venous lines (long lines) are commonly used in neonatal practice. The position of these lines is important, because incorrect placement may be associated with complications. AIMS: To determine whether the addition of radio-opaque contrast material improves the localisation of long line tips over plain radiography. METHODS: Radiographs taken to identify long line position were identified in two periods; 106 radiographs without contrast taken between October 1999 and August 2000, and 96 radiographs with contrast between September 2001 and July 2002. Two observers independently reviewed each radiograph to identify the position of the line tip. The formal radiology report was recorded as a third observer. RESULTS: The use of contrast increased the proportion of radiographs in which all observers reported they could see the long line tip (53 (55%) v 41 (39%)). It also increased the proportion where they agreed on anatomical position (57 (59%) v 39 (37%)) and there was a higher kappa coefficient for agreement (0.56 v 0.33). CONCLUSIONS: The use of contrast while taking radiographs for the localisation of long line position improves the likelihood that an observer can see a long line tip and reduces inter-observer variability. Even using contrast, precise localisation of a long line tip can be difficult.
Catheterization, Central Venous↗
Pain from primary inguinal hernia and the effect of repair on pain.
BACKGROUND: No previous study has attempted to quantify pain from a primary inguinal hernia. The aim of this study was to quantify patients' pain from inguinal hernia at rest and on moving, and to assess the effect of hernia repair on the pain. METHODS: Linear analogue pain scores at rest and on moving were recorded before operation and at 1 year after surgery in a consecutive series of patients undergoing elective repair of a primary inguinal hernia. RESULTS: During the study period 323 patients underwent inguinal hernia repair. Eighty-six patients (26.6 per cent) recorded no pain at rest from the hernia, and 174 (53.9 per cent) had mild pain only (score less than 10). On moving, 53 patients (16.4 per cent) had no pain and 137 (42.4 per cent) had mild pain on moving. Only 1.5 per cent experienced severe pain (score greater than 50) at rest, and 10.2 per cent had severe pain on moving. There was no association between pain and hernia type, direct or indirect, or patient occupation. One year after operation only 24.5 per cent of patients had no pain from the hernia repair site at rest, and 21.6 per cent had no pain from the site on moving. Overall there was a significant reduction in pain score at rest (mean(s.e.m.) decrease from baseline - 2.9(1.2), P = 0.019) and on moving (- 9.2(1.8), P = 0.001) compared with preoperative values, and this was due mainly to the large effect observed in patients with high preoperative values. Patients who had no pain at rest before operation had significant pain scores at rest at 1 year (P = 0.001). CONCLUSION: Clinical trials are required to evaluate hernia repair in patients with an asymptomatic inguinal hernia. Results from such trials should help to determine whether repair is the treatment of choice for these patients.
Adult↗
The Internal jugular veins are asymmetric. Usefulness of ultrasound before catheterization.
OBJECTIVE: To demonstrate an asymmetry of the internal jugular veins, a finding which will have consequences for catheterization. DESIGN: Prospective study. SETTING: The medical ICU of a university-affiliated teaching hospital. PATIENTS: Eighty critically ill consecutive patients. INTERVENTION: Measurement of the cross-sectional area of the internal jugular veins. Search for an asymmetry, defined as an area at least twice that of the contralateral vein. RESULTS: An asymmetry was noted in 62.5% of the patients. The dominant vein was the right in only 68 % of these cases. In addition, 23% of the 160 jugular internal veins had an area of 0.4 cm2 or less. CONCLUSIONS: Using a simple technique, ultrasound identifies the dominant internal jugular vein, thus indicating the safer side before blind catheterization.
Catheterization, Central Venous↗
Acute cor pulmonale in massive pulmonary embolism: incidence, echocardiographic pattern, clinical implications and recovery rate.
OBJECTIVE: The indications for the use of thrombolytic agents in massive pulmonary embolism (MPE) remain controversial and it has been suggested that transthoracic echocardiographic (TTE) examination, which is able to detect an associated right ventricular dysfunction, may cast light on this question. The goal of this study was to examine the incidence of acute cor pulmonale (ACP) in MPE, diagnosed on the basis of TTE criteria, its clinical implications and its resolution rate. DESIGN: Ten-year retrospective clinical study. SETTING: A medical and a coronary intensive care unit, university hospital. PATIENTS: One hundred sixty-one patients with proven MPE. INTERVENTIONS: Acute cor pulmonale was defined as right ventricular end-diastolic area / left ventricular end-diastolic area (RVEDA/LVEDA) ratio in the long axis greater than 0.6 associated with septal dyskinesia in the short axis. ACP patients were divided into three groups according to circulatory status: 32 patients without circulatory failure constituted group 1, 32 patients with circulatory failure requiring inotropic support, but free of metabolic acidosis, constituted group 2 and 34 patients in whom circulatory failure was associated with metabolic acidosis (defined by a base deficit >5 mEq/l) constituted group 3. RESULTS: Acute cor pulmonale was present in 61% of patients with MPE and carried a 23% mortality, but this mortality was very different in stable patients (groups 1 and 2, 64 patients, 3% mortality) and in unstable patients (group 3, 34 patients, 59% mortality). A multivariate logistic regression analysis showed that the TTE results were not predictive of the risk of death. Conversely, the same analysis showed that the presence of metabolic acidosis was a powerful predictor of death. CONCLUSION: Because none of the TTE measurements in ACP could be used to stratify the severity of MPE, TTE was of no help in deciding on medical thrombolysis. However, depending on its severity, metabolic acidosis could justify a large cooperative study to assess the impact of thrombolytic therapy on mortality rate in this specific group.
Acidosis↗
Effect of routine use of a multiplex PCR for detection of vanA- and vanB- mediated enterococcal resistance on accuracy, costs and earlier reporting.
A multiplex PCR (MPCR) for detection of vanA-and vanB-mediated resistance to vancomycin was optimized and adapted for use in the routine microbiology laboratory. Consecutive specimens (1196) submitted for vancomycin resistant Enterococci (VRE) surveillance were processed by clinical technologists on Bile Esculin Azide Agar containing 6 mg/L vancomycin (BEAA/Vanco6) plates and 466 showing black colony growth were processed by conventional biochemical testing (CBT) and by MPCR. CBT identified 208 VRE positives. MPCR detected 205 of the CBT- positives plus an additional 10. Analysis of the discordant specimens determined that 5 CBT- negative/MPCR-positive specimens also contained Enterococci with vanC resistance, 3 CBT-positive/MPCR-negative specimens were true positives, and 5 CBT-negative/MPCR-positive specimens occurred due to technical error. The sensitivity and specificity of MPCR were 98.4% and 96.1%. MPCR identifications of VRE were achieved approximately 48 h earlier than CBT and at 60% of the costs.
Bacterial Proteins↗
Percutaneous intravenous central catheters.
Explore the source record for details and available documents.
Catheterization, Central Venous↗
Early preload adaptation in septic shock? A transesophageal echocardiographic study.
BACKGROUND: An accepted concept in septic shock is that preload adaptation by acute left ventricular dilatation, when occurring spontaneously or with the aid of volume loading, permits maintenance of an adequate cardiac output, leading to final recovery. From a physiologic point of view, this concept appears debatable because a normal pericardium exerts a restraining action on a normal heart. METHODS: During a 26-month period, the authors investigated, by transesophageal echocardiography, 40 patients hospitalized in their unit for an episode of septic shock. Transesophageal echocardiography was performed in the first hours after admission, proceeded by correction of any hypovolemia, and stabilization of arterial pressure by vasoactive agent infusion if necessary. Left ventricular dimensions were obtained in long- and short-axis views, permitting calculation of left ventricular ejection fraction (long axis) and fractional area contraction (short axis). Stroke index was simultaneously measured by the Doppler technique. RESULTS: Stroke index was strongly correlated with both echocardiographic left ventricle ejection fraction (r = 0.75; P < 0.0001) and left ventricle fractional area contraction (r = 0.76; P < 0.0001), whereas it was independent of echocardiographic left ventricle diastolic dimensions. CONCLUSIONS: The transesophageal echocardiography study was unable to confirm the reality of the concept of early preload adaptation by left ventricular dilatation in septic shock. Conversely, because left ventricular volume always remained in a normal range after correcting hypovolemia, systolic function was the unique determinant of stroke index in septic shock.
Adult↗
Influence of superior vena caval zone condition on cyclic changes in right ventricular outflow during respiratory support.
BACKGROUND: Adequate fluid resuscitation in critically ill patients undergoing mechanical ventilation remains a difficult challenge, and diastolic and systolic right ventricular (RV) changes produced by positive airway pressure are important to consider in an individual patient with inadequate circulatory adaptation during respiratory support. We hypothesized that insufficient thoracic vena cava filling, predisposing to inspiratory collapse (zone 2 condition), may transiently affect RV outflow. METHODS: We measured beat-to-beat superior vena caval diameter and Doppler RV outflow during a routine transesophageal echocardiographic examination in 22 patients undergoing mechanical ventilation, all of whom required hemodynamic monitoring, and we calculated a collapsibility index for the superior vena cava as maximal expiratory diameter minus minimal inspiratory diameter, divided by maximal expiratory diameter. RESULTS: In 15 patients (group 1), the collapsibility index was low (17 +/- 7%) and was associated with a moderate inspiratory decrease in RV outflow (25 +/- 17%). However, in seven patients (group 2), we observed a high collapsibility index (71 +/- 7%), which was associated with a major inspiratory decrease in RV outflow (69 +/- 14%) combined with a reduced pulmonary artery flow period. A rapid volume expansion, only performed on group 2, markedly and significantly reduced both the collapsibility index (15 +/- 12%) and the inspiratory decrease in RV outflow (31 +/- 20%). CONCLUSION: A major inspiratory decrease in RV outflow associated with a reduced pulmonary artery flow period in a patient undergoing mechanical ventilation reflected a high collapsibility index of the thoracic vena cava, suggesting a zone 2 condition, and may be corrected by blood volume expansion.
Aged↗
Positive end-expiratory pressure titration in acute respiratory distress syndrome patients: impact on right ventricular outflow impedance evaluated by pulmonary artery Doppler flow velocity measurements.
OBJECTIVE: Positive end-expiratory pressure (PEEP) titration in acute respiratory distress syndrome patients remains debatable. We used two mechanical approaches, calculation of the compliance of the respiratory system and determination of the lower inflexion point of the pressure-volume curve of the respiratory system, to identify specific PEEPs (PEEPS and PEEPA) whose impact on right ventricular (RV) outflow was compared with Doppler analysis of pulmonary artery flow velocity. DESIGN: Prospective, open, clinical study. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Sixteen consecutive ventilator-dependent acute respiratory distress syndrome patients. INTERVENTIONS: Two PEEPs were determined: PEEPS was the highest PEEP associated with the highest value of respiratory compliance, and PEEPA was the coordinate of the lower inflexion point of the inspiratory pressure-volume curve on the pressure axis plus 2 cm H2O. MEASUREMENTS AND MAIN RESULTS: We observed a large difference between the two PEEPs, with PEEPA (13 + 4 cm H2O) > PEEPS (6 + 3 cm H2O). Changes in RV outflow impedance produced by tidal ventilation with zero end-expiratory pressure (ZEEP) and after application of these two PEEPs were assessed by Doppler study of pulmonary artery flow velocity obtained by a transesophageal approach, with particular reference to the end-expiratory and end-inspiratory pulmonary artery velocity-time integral, as reflecting RV stroke output, and mean acceleration as reflecting RV outflow impedance during an unchanged flow period. A significant inspiratory reduction in pulmonary artery velocity-time integral (from 11.8 + 0.3 to 10.0 + 0.3 cm) and mean acceleration (from 11.9 + 0.9 to 8.0 + 0.9 m/sec2) was observed with ZEEP, showing a reduction in RV stroke index (from 29.0 + 0.9 to 26.0 + 0.6 cm3/m2) by a sudden increase in outflow impedance during tidal ventilation. Application of PEEPA, which improved Pao2 (102 + 40 vs. 65 + 18 torr with ZEEP), worsened the inspiratory drop in RV stroke index (21.6 + 0.8 cm3/m2), resulting in a significant reduction in cardiac index compared with ZEEP (from 3.0 + 1.0 to 2.7 + 1.1). Application of PEEPS, which also significantly improved Pao2 (81 + 21 torr), was associated with a lesser impact on RV outflow impedance (inspiratory mean acceleration: 9.5 + 1 m/sec2) and cardiac index (3.2 + 1.0) than PEEPA. CONCLUSION: RV outflow impedance evaluated by the Doppler technique appeared sensitive to PEEP titration. Application of PEEPA worsened RV systolic function impairment produced by tidal ventilation. Conversely, application of PEEPS reduced RV systolic function impairment, suggesting an association with a lower pulmonary vascular resistance.
Analysis of Variance↗
Acute cor pulmonale in acute respiratory distress syndrome submitted to protective ventilation: incidence, clinical implications, and prognosis.
CONTEXT: The incidence of acute cor pulmonale (ACP), a frequent and usually lethal complication of acute respiratory distress syndrome (ARDS) during traditional respiratory support, has never been re-evaluated since protective ventilation gained acceptance. OBJECTIVE: We performed a longitudinal transesophageal echocardiographic (TEE) study to determine whether this incidence, and its severe implications for prognosis, might have changed in our unit as we altered respiratory strategy. DESIGN: Prospective open clinical study. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Seventy-five consecutive ARDS patients given respiratory support with airway pressure limitation (plateau pressure < or =30 cm H2O). INTERVENTIONS: ACP was defined as a ratio of right ventricular end-diastolic area to left ventricular end-diastolic area in the long axis >0.6 associated with septal dyskinesia in the short axis during TEE examination. RESULTS: Normal right ventricular function was present in 56 patients, whereas right ventricular dysfunction was observed in 19 patients after 2 days of respiratory support. ACP was associated with pulmonary artery hypertension, increased heart rate, and decreased stroke index. Significant impairment of left ventricular diastolic function was also seen. All echo-Doppler abnormalities were reversible in patients who recovered, and the mortality rate was the same in both groups (32%). However, ACP patients who recovered required a longer period of respiratory support. A multivariate analysis individualized Paco2 level as the sole factor independently associated with ACP, suggesting that ACP development in ARDS is influenced by the severity of lung damage and/or the respiratory strategy. CONCLUSION: Evaluation of right ventricular function by TEE in a group of 75 ARDS patients submitted to protective ventilation revealed the persistence of a 25% incidence of ACP, resulting in detrimental hemodynamic consequences associated with tachycardia. However, ACP was reversible in patients who recovered and did not increase mortality.
APACHE↗
Hyaluronic acid serum levels in fibromyalgia, nonspecific arm disorder, and controls.
Explore the source record for details and available documents.
Arm↗
Older bull elephants control young males.
Explore the source record for details and available documents.
Aging↗
Questions about results reported with potent antiretroviral therapy for human immunodeficiency virus type 1 infection.
Explore the source record for details and available documents.
Anti-HIV Agents↗
Echocardiographic evaluation of left ventricular function in critically ill patients: dynamic loading challenge using medical antishock trousers.
STUDY OBJECTIVE: We hypothesized that a dynamic left ventricular (LV) evaluation during a loading challenge might enhance diagnostic capabilities of routine transesophageal echocardiography in critically ill patients and selection of therapeutic options against circulatory failure, particularly the choice between volume expansion and vasoactive agent infusion. DESIGN: Prospective clinical study in a group of 26 patients requiring hemodynamic support by vasoactive infusion because of low systemic arterial pressure (< 90 mm Hg by invasive monitoring) during mechanical ventilation. SETTING: University hospital ICU. PATIENTS: Patients required respiratory support for an episode of acute respiratory failure of various causes or for an episode of coma. They were studied by transesophageal echocardiography during mechanical ventilation in the controlled mode, before and during a loading challenge made using the legs compartment of medical antishock trousers inflated at 80 mm Hg. MEASUREMENTS: A short-axis view of the left ventricle was obtained by a transgastric approach, and end-diastolic and end-systolic areas were measured. LV stroke area (LVSA) and LV fractional area contraction (LVFAC) were calculated. RESULTS: Changes in LV echocardiographic measurements permitted separation of the patients into two groups. In nine patients (group 1), LVSA, used as an index of stroke output, was significantly increased during the challenge, together with a significant increase in LV end-diastolic area, suggesting preload improvement by the challenge. Conversely, in 17 patients (group 2), LVSA was significantly reduced by the challenge, together with a significant decrease in LVFAC, suggesting a negative effect of increased afterload by the challenge. CONCLUSION: Study of the changes in LV dimensions during loading challenge in hemodynamically unstable patients was used to evaluate the balance between the adequacy of preload and the ability of the heart to pump against an increased load, and might thus guide hemodynamic support.
Critical Illness↗
Preliminary evaluation of two new rapid immunoturbidimetric D-dimer assays in patients with clinically suspected venous thromboembolism (VTE).
The practical utility and diagnostic accuracy of two new rapid, automated and quantitative immunoturbidimetric D-dimer methods have been evaluated in a population of 123 randomly selected patients with suspected VTE. The STA Liatest D-dimer and MDA D-dimer methods are based on the photo-optical measurement of the rate of agglutination of antibody-coated latex particles. The VIDAS D-dimer automated Elisa was used as the reference method. Diagnosis was confirmed in 51 patients (29 PE, 19 DVT, 3 DVT+PE). The immunoturbidimetric methods compared favorably with the VIDAS Elisa as judged from the correlation coefficients of linear regression lines (r = 0.82, MDA vs VIDAS; r = 0.75, STA vs VIDAS) and areas under the curve of ROC plots (VIDAS 0.83; STA 0.83; MDA 0.81). At a discriminant value of 500 ng/mL, all three D-dimer assays showed high sensitivity (96-98%), high NPV (93-97%) and moderate specificity (39-42%). Reproducibility of results around the cut-off is an important aspect of the diagnostic utility of D-dimer assays. CV's of duplicate determinations in this critical zone showed average values of 5.4% and 17.0% for MDA and STA, respectively. These data demonstrate that such rapid and automated latex-based methods for the quantitative measurement of D-dimer hold promise as reliable and cost-efficient approaches for the exclusion of VTE. Prospective patient management studies will be required to confirm this.
Adult↗
Improved prognosis of acute respiratory distress syndrome 15 years on.
OBJECTIVE: Evaluation of the impact of low-volume, pressure-limited ventilation on the recovery rate of acute respiratory distress syndrome (ARDS). DESIGN: Prospective observational clinical study with historical control. SETTING: University hospital intensive care unit (ICU). PATIENTS: We studied two groups of, respectively, 33 and 37 ARDS patients separated by 15 years ("historical", June 1978-April 1981, and "recent", October 1993-June 1996). METHOD: ARDS was defined as the presence of bilateral chest infiltrates and a PaO(2)/FIO(2) ratio of less than 200 mmHg under controlled ventilation regardless of PEEP level. Any cardiac participation was excluded by right heart catheterization in the "historical" group and by echo-Doppler examination in the "recent" group. The origin of ARDS was principally pulmonary (ARDS(p)) in both groups (26/33 and 29/37, respectively), and secondarily extrapulmonary (ARDS(exp)) (7/33 and 8/37, respectively). In the "historical" group, normocapnia was the major goal for respiratory support and was achieved in all patients regardless of airway pressure levels. In contrast, end-inspiratory plateau pressure in the "recent" group was limited to 30 cmH(2)O under respiratory support, regardless of PaCO(2) level. The "historical" and "recent" ARDS groups were compared with regard to therapeutic procedure and outcome. RESULTS: Normalization of PaCO(2) (36 +/- 6 mmHg) in the "historical" group required high airway pressure (end-inspiratory plateau pressure at 39 +/- 4 cmH(2)O) and high tidal volume (13 ml/kg). Respiratory support used in the "recent" group was less aggressive, with lower airway pressure (end-inspiratory plateau pressure 25 +/- 4 cmH(2)O) and tidal volume (9 ml/kg) resulting in "permissive" hypercapnia (51 +/- 10 mmHg). Mortality rates significantly decreased from 64 % in the "historical" group to 32 % in the "recent" group (p < 0.01). This decrease concerned only ARDS(p), which was markedly predominant in both groups. CONCLUSION: Mortality due to ARDS of pulmonary origin has declined in our unit over the last 15 years. Low-volume, pressure-limited (protective) ventilation seems the most likely reason for improved survival, despite hypercapnia.
Adult↗