To investigate the impact of thoracic ultrasound (TUS) examinations on clinical management in adult ICU patients.
A prospective international observational study.
Four centers in The Netherlands and ...Italy.
Adult ICU patients (> 18 yr) that received a clinically indicated lung ultrasound examination.
None.
Clinicians performing TUS completed a pre- and post-examination case report form. Patient characteristics, TUS, and resulting clinical effects were recorded. First, change of management, defined as a TUS-induced change in clinical impression leading to a change in treatment plan, was reported. Second, execution of intended management changes within 8 hours was verified. Third, change in fluid balance after 8 hours was calculated. A total of 725 TUS performed by 111 operators across 534 patients (mean age 63 ± 15.0, 70% male) were included. Almost half of TUS caused a change in clinical impression, which resulted in change of management in 39% of cases. The remainder of TUS confirmed the clinical impression, while a minority (4%) did not contribute. Eighty-nine percent of management changes indicated by TUS were executed within 8 hours. TUS examinations that led to a change in fluid management also led to distinct and appropriate changes in patient's fluid balance.
In this international observational study in adult ICU patients, use of TUS had a major impact on clinical management. These results provide grounds for future randomized controlled trials to determine if TUS-induced changes in decision-making also lead to improved health outcomes.
Most spontaneous mutations affecting fitness are likely to be deleterious, but the strength of selection acting on them might be impacted by environmental stress. Such stress‐dependent selection ...could expose hidden genetic variation, which in turn might increase the adaptive potential of stressed populations. On the other hand, this variation might represent a genetic load and thus lead to population extinction under stress. Previous studies to determine the link between stress and mutational effects on fitness, however, have produced inconsistent results. Here, we determined the net change in fitness in 29 genotypes of the green algae Chlamydomonas reinhardtii that accumulated mutations in the near absence of selection for approximately 1000 generations across two stress gradients, increasing NaCl and decreasing phosphate. We found mutational effects to be magnified under extremely stressful conditions, but such effects were specific both to the type of stress and to the genetic background. The detection of stress‐dependent fitness effects of mutations depended on accurately scaling relative fitness measures by generation times, thus offering an explanation for the inconsistencies among previous studies.
Extracorporeal membrane oxygenation (ECMO) has been increasingly used in the treatment of refractory cardiac arrest and postarrest cardiogenic shock. We propose a technique for percutaneous ...decannulation of femoral venoarterial ECMO cannulas by using the MANTA vascular closure device, designed to close large-bore arteriotomies. This technique significantly simplifies the decannulation and might diminish the potential complications caused by the standard surgical removal.
On utilise de plus en plus l’oxygénation par membrane extracorporelle (ECMO, de l’anglais extracorporeal membrane oxygenation) dans le traitement de l’arrêt cardiaque réfractaire et du choc cardiogénique post-arrêt cardiaque. Nous proposons une technique percutanée de décanulation des canules de l’ECMO veino-artérielle fémorale à l’aide du dispositif de fermeture vasculaire MANTA, qui est conçu pour fermer les artériotomies des artères de gros calibre. Cette technique simplifie considérablement la décanulation et diminuerait les complications potentielles causées par l’extraction chirurgicale habituelle.
At the SINBAD facility (DESY Hamburg), novel particle acceleration techniques like dielectric laser acceleration (DLA) structures will be tested using the ARES linac. Due to the small size of these ...structures, the accelerated electron beams only have a very low (sub-pC) charge. To determine the energy distribution of these beams, a silicon strip detector for the ARES linac spectrometer is currently under development. This detector fulfils the requirements of high spatial resolution for low charge density beams. The detector consists of two 1 cm × 1 cm silicon strip sensors and readout components. The design of the detector, its components and an estimate of its behaviour for a specific electron beam distribution are presented and discussed.
Background: This study was performed to confirm the presence and significance of a gastroesophageal flap valve.
Methods: The pressure gradient needed to induce reflux across the gastroesophageal ...junction and the level of a high-pressure zone were determined in 13 cadavers. On inspection in the cadavers, a mucosal flap valve at the entrance of the esophagus into the stomach was seen through a gastrostomy. This valve was deficient or absent in cadavers with a hiatal hernia. The valve was inspected in controls and in patients with reflux with a retroflexed endoscope.
Results: In cadavers with no hiatal hernia, a gradient across the gastroesophageal junction was present in nearly all cadavers. The gradient could be increased by surgically accentuating the valve without a concomitant rise in pressure in the high-pressure zone. Reduction of the hiatal hernia in the cadaver and anchoring of the gastroesophageal junction to the normal attachment to the preaortic fascia restored the valve and the gradient as seen through a gastrostomy. Control subjects had a prominent fold of tissue that extended 3 to 4 cm along the lesser curve of the stomach and tightly grasped the shaft of the endoscope. This was diminished or absent in reflux patients. Inspection of the valve in control subjects and subjects with reflux allowed for a grading system with Grades I through IV. This grading system was applied to a cohort of patients with and without reflux. The appearance of the flap valve was a better predictor of the presence or absence of reflux than was lower esophageal sphincter pressure. Endoscopic viewing of the valve during surgery can confirm that a competent valve has been reconstructed.
Conclusions: Grading of the gastroesophageal valve is simple, reproducible, and offers useful information in the evaluation of patients with suspected reflux undergoing endoscopy. (Gastrointest Endosc 1996;44:541-7.)
1 Department of Kinesiology, The College of William & Mary,
Williamsburg, Virginia 23187-8795; and 2 The Human Performance
Laboratory, Department of Kinesiology, The University of Connecticut,
...Storrs, Connecticut 06269-1110
Strength decrements observed after
extended (4-6 wk) periods of muscle unloading are associated with
significant atrophy. Because early (up to 2 wk) strength gains from
resistance exercise are related to improved neural recruitment, we
hypothesized that the loss of strength resulting from 2 wk of muscle
unloading unilateral lower limb suspension (ULLS) was due to
impaired neural activation of the affected muscle. Blood samples,
muscle biopsy specimens, muscle function data, and electromyography
(EMG) recordings were analyzed before and after 14 days of muscle
unloading. Pre- to postunloading data showed significant
( P 0.05) decrements in peak torque and total work
performed by knee extensors and flexors. This was coupled with
decreased EMG activity, but no change in neuromuscular efficiency
(total torque/EMG). Resistance to muscle fatigue was enhanced after
ULLS. The 14-day intervention failed to alter the size or fiber type
distribution of muscle samples. However, resting plasma cortisol levels
were significantly increased after muscle unloading, suggesting an
endocrine environment favorable to muscle atrophy. Our data confirm
that the diminution in muscle function displayed after 2 wk of
unloading is mainly due to neural, rather than contractile, disturbances.
unweighting; neuromuscular; cortisol; adrenocorticotropic hormone; electromyography
The yellow fever virus (YFV) epidemic in Brazil is the largest in decades. The recent discovery of YFV in Brazilian
species mosquitos highlights a need to monitor the risk of reestablishment of urban ...YFV transmission in the Americas. We use a suite of epidemiological, spatial, and genomic approaches to characterize YFV transmission. We show that the age and sex distribution of human cases is characteristic of sylvatic transmission. Analysis of YFV cases combined with genomes generated locally reveals an early phase of sylvatic YFV transmission and spatial expansion toward previously YFV-free areas, followed by a rise in viral spillover to humans in late 2016. Our results establish a framework for monitoring YFV transmission in real time that will contribute to a global strategy to eliminate future YFV epidemics.
This experiment utilized a laterally placed controlled cortical impact model of traumatic brain injury (TBI) to assess changes on spatial learning and memory in the Morris water maze (MWM). Adult ...rats were subjected to one of two different levels of cortical injury, mild (1 mm) or moderate (2 mm) deformation, and subsequently tested for their ability to learn (acquisition) or remember (retention) a spatial task, 7 or 14 days after injury. Results revealed an injury-dependent deficit for experimental animals compared to sham-operated controls. Not only did the TBI result in longer escape latencies, but also significant deficits in search time and relative target visits. Although the moderately injured animals demonstrated significant histopathology in the cortex and hippocampus, mildly injured subjects demonstrated no obvious tissue destruction, but did manifest significant behavioral change. These results demonstrate that a laterally placed controlled cortical impact is capable of producing significant cognitive deficits on both acquisition and retention paradigms utilizing the MWM.
Aspiration is a common complication in acute stroke patients and is strongly associated with a poor outcome. Due to an insufficient sensitivity and specificity of clinical bedside tests, further ...refinements are needed to improve the accuracy of clinical aspiration screening in acute stroke.
To assess the ability of the simple 2-step swallowing provocation test (SPT) to detect aspiration risk in acute stroke patients.
100 consecutive patients with first-ever stroke were examined by SPT and fiberoptic endoscopic evaluation of swallowing (FEES) within 72 hours of stroke onset. Using FEES as an objective instrumental technique to evaluate dysphagia, statistical measures representing the ability of SPT to detect aspiration risk were calculated.
The incidence of endoscopically proven aspiration risk was 81%. The 1st-step SPT had a sensitivity of 74.1% and a specificity of 100%. Although the 2nd-step SPT showed the same 100% specificity, sensitivity was significantly lower. False-negative results of SPT appeared predominantly in subjects exhibiting leakage of liquids to pyriform sinus without a pronounced delay in swallow onset.
In acute stroke patients with an impairment of the pharyngeal phase of swallowing, 1st-step SPT reliably detects aspiration risk. In patients with a sole or predominant impairment of the oral phase of swallowing and a relatively intact pharyngeal phase, SPT fails to detect aspiration risk sufficiently. In the latter group, FEES or additional clinical features more specifically indicating oral-phase pathology should be considered to accurately judge the patient's aspiration risk.
The mechanisms that underlie cholinergic neuronal degeneration in Alzheimer disease (AD) are unclear, but recent data suggest that oxidative stress plays a role. We report that 4-hydroxynonenal ...(HNE), an aldehydic product of lipid peroxidation, damages and kills basal forebrain cholinergic neurons when administered intraparenchymally. Examination of Nisslstained brain sections following unilateral HNE infusion revealed widespread neuronal loss in basal forebrain ipsilateral to the injection, but not on the contralateral side. Levels of choline acetyltransferase activity and immunoreactivity in the ipsilateral basal forebrain and hippocampus were significantly reduced by 60-80% seven days following HNE administration. Performance in Morris water maze tasks of visuospatial memory was severely impaired in a dose-dependent manner seven days following bilateral administration of HNE. Bilateral infusion of FeCl2 (an inducer of membrane lipid peroxidation) into the basal forebrain caused neuron loss and decreased choline acetyltransferease immunoreactivity and deficits in visuospatial memory. Additionally, FeCl2 infusion increased HNE immunoreactivity, implicating HNE in iron-induced oxidative damage. Because recent studies have demonstrated HNE adducts in degenerating neurons in AD brain, the present findings suggest a role for HNE in damage to cholinergic neurons in AD.
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