Abstract Background Controversy persists regarding the management of patients with IPMN. International consensus guidelines stratify patients into high risk, worrisome, and low risk categories. Study ...Design The medical records of 7 institutions were reviewed for patients that underwent surgical management of IPMN between 2000-2015. Results 324 patients were included in the analysis. 60.4% of patients had main-duct / mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, while invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n=136). 68.9% of patients with high risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/ IC. Multivariate analysis demonstrated that only one of three high risk features and two of seven worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI = 0.65-0.94) and 0.69 (95% CI= 0.39-0.91), respectively. In the absence of high risk features, HGD/ IC was still present in 57.4% of patients with two or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/ IC in a linear fashion (OR 1.39, 95% CI=1.08-1.80, p<0.01). Conclusions These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.
The purpose of this retrospective analysis was to define the incidence of severe adverse events after exposure to ultrasound contrast agents.
Data between January 1, 2001, and September 30, 2007, ...were collected using invited responses to an on-line web-based questionnaire from 1 general and 12 cardiac ultrasound laboratories. During a period of 4.5 +/- 2.4 years, a total of 66,164 doses of Definity (Lantheus Medical Imaging, North Billerica, MA) and 12,219 doses of Optison (GE Healthcare, Buckinghamshire, UK) were administered, reflecting contrast use in 5% of transthoracic and 28% of stress echocardiographic procedures. More than 10,000 doses were given to critically ill patients in intensive care unit settings or to patients with acute chest pain of suspected cardiac origin. The median age of patients who received an ultrasound contrast agent was 60 years, 49% were male, and the mean body mass index was 32 +/- 1.4 g/m(-2).
Severe reactions that were considered "probably" related to an ultrasound contrast agent developed in 8 patients (0.01%), all of whom were outpatients, and 4 (0.006%) of these were consistent with anaphylactoid reactions. There were no deaths reported. All patients recovered with treatment. No serious events were seen in inpatients.
This multicenter, retrospective analysis includes the largest number of doses of ultrasound contrast agents ever published and a large number of patients evaluated in a wide variety of settings, including the critically ill. It shows that these agents have a good safety profile in both cardiac and abdominal ultrasound applications. The incidence of severe adverse reactions to ultrasound contrast agents is no greater, and may be lower, than that reported for contrast agents commonly used in other cardiac imaging tests.
Abstract In this case report, ultrasound-guided radial artery catheterization and a modified Allen's test were performed by Emergency Department (ED) physicians to facilitate the management of an ...intubated, critically injured patient. Ultrasound was demonstrated to be a valuable tool in determining collateral circulation and guiding radial artery cannulation in a patient unable to cooperate with the traditional Allen's test. Ultrasound guidance may reduce the risk of radial artery catheterization in severely injured patients.
Although time-domain measures of heart rate variability (HRV) are used to estimate cardiac autonomic tone and disease risk in multiethnic populations, the genetic epidemiology of HRV in ...Hispanics/Latinos has not been characterized.
The purpose of this study was to conduct a genome-wide association study of heart rate (HR) and its variability in the Hispanic Community Health Study/Study of Latinos, Multi-Ethnic Study of Atherosclerosis, and Women's Health Initiative Hispanic SNP-Health Association Resource project (n = 13,767).
We estimated HR (bpm), standard deviation of normal-to-normal interbeat intervals (SDNN, ms), and root mean squared difference in successive, normal-to-normal interbeat intervals (RMSSD, ms) from resting, standard 12-lead ECGs. We estimated associations between each phenotype and 17 million genotyped or imputed single nucleotide polymorphisms (SNPs), accounting for relatedness and adjusting for age, sex, study site, and ancestry. Cohort-specific estimates were combined using fixed-effects, inverse-variance meta-analysis. We investigated replication for select SNPs exceeding genome-wide (P <5 × 10
) or suggestive (P <10
) significance thresholds.
Two genome-wide significant SNPs replicated in a European ancestry cohort, 1 one for RMSSD (rs4963772; chromosome 12) and another for SDNN (rs12982903; chromosome 19). A suggestive SNP for HR (rs236352; chromosome 6) replicated in an African-American cohort. Functional annotation of replicated SNPs in cardiac and neuronal tissues identified potentially causal variants and mechanisms.
This first genome-wide association study of HRV and HR in Hispanics/Latinos underscores the potential for even modestly sized samples of non-European ancestry to inform the genetic epidemiology of complex traits.
Abstract Purpose An initial description of a sonographic finding predictive of intrathoracic chest tube placement. Methods This was a prospective observational study using unembalmed cadaveric ...models. Chest tubes were randomly placed intra- and extrathoracically and evaluated using ultrasound. Chest tube location was confirmed using blunt dissection followed by tactile and visual confirmation. Sonographers were blinded to chest tube position. Sonographic images obtained in a transverse orientation revealed a subcutaneous hyperechoic arc, created by the chest tube, at the insertion site. The path of the hyperechoic arc was followed cephalad. Disappearance of the hyperechoic arc signified intrathoracic chest tube placement. In contrast, continuation of a subcutaneous hyperechoic arc for the full length of the chest tube signified extrathoracic chest tube placement (the Disappearance/Intrathoracic, Continuation/Extrathoracic sign). Results Ultrasound was used to evaluate 48 chest tube placements. All chest tube locations were identified correctly. In differentiating intra- vs extrathoracic chest tube placement, the Disappearance/Intrathoracic, Continuation/Extrathoracic sign revealed a sensitivity of 100% (95% confidence interval, 83%-100%) and a specificity of 100% (95% confidence interval, 83%-100%). Conclusions In this small study, bedside ultrasound appears to be highly sensitive and specific in differentiating intra- versus extrathoracic chest tube placement.
Abstract In this case report, an ultrasound-guided hematoma block was performed in the Emergency Department (ED) for immediate and effective pain control in a patient suffering from a sternal ...fracture. This technique of anesthesia may allow safer and more effective analgesia and a more rapid discharge from the hospital or ED in selected cases.
A 22-year-old man presented to the emergency department (ED) complaining of 2 weeks of unremitting nausea, vomiting, headache, dizziness, as well as neck and back pain. The bone of the superior orbit ...was penetrated, and the needle was directed posteriorly toward the coronal suture and the midline to a depth of 3 cm until clear cerebrospinal fluid was obtained from the dilated anterior horn of the lateral ventricle (Fig. 2).
Abstract Introduction End-tidal carbon dioxide (EtCO2 ) monitoring is standard of care for intubated patients. Sidestream technology also allows EtCO2 monitoring in non-intubated patients. This is ...the first study to evaluate the feasibility of monitoring sidestream EtCO2 on intubated and non-intubated patients during helicopter transport. Setting An air medical transport program serving two level 1 trauma centers. Methods In this prospective observational study, sidestream EtCO2 was monitored in 100 consecutive patients transported by helicopter. Flight nurses rated the difficulty posed by various factors of sidestream monitoring. An experienced flight nurse and a clinical engineer evaluated waveforms and EtCO2 values. Results Only 1 of the 100 transported patients required a change from sidestream to mainstream EtCO2 monitoring. Moisture was noted in the tubing of two patients, and one was changed to mainstream. Eleven patients had occluded nares but were not changed to mainstream monitoring. On a 5-point Likert scale, responses to statements regarding difficulty with length of tubing, patient tolerance, and interference with patient care produced mean scores of 0.5 (range, 0–3). Responses regarding difficulty securing the cannula yielded a mean score of 0.7 (range, 0–3). Of 1,685 (99%) recorded EtCO2 values, 1,668 met pre-established criteria for “consistent.” Alveolar plateaus were identified in 81 of 94 (86%) patient waveforms by the flight nurse and 73 of 94 (78%) patient waveforms by the clinical engineer. Conclusion Sidestream EtCO2 monitoring is feasible during air medical transport of both intubated and non-intubated patients. The mechanism was easy to use, and consistent numeric values and waveforms with alveolar plateaus were obtained in a large majority of readings.
Influenza causes substantial morbidity and mortality despite available treatments. Anecdotal reports suggest that plasma with high antibody titres to influenza might be of benefit in the treatment of ...severe influenza.
In this randomised, open-label, multicentre, phase 2 trial, 29 academic medical centres in the USA assessed the safety and efficacy of anti-influenza plasma with haemagglutination inhibition antibody titres of 1:80 or more to the infecting strain. Hospitalised children and adults (including pregnant women) with severe influenza A or B (defined as the presence of hypoxia or tachypnoea) were randomly assigned to receive either two units (or paediatric equivalent) of anti-influenza plasma plus standard care, versus standard care alone, and were followed up for 28 days. The primary endpoint was time to normalisation of patients' respiratory status (respiratory rate of ≤20 breaths per min for adults or age-defined thresholds of 20-38 breaths per min for children) and a room air oxygen saturation of 93% or more. This study is registered with ClinicalTrials.gov, number NCT01052480.
Between Jan 13, 2011, and March 2, 2015, 113 participants were screened for eligibility and 98 were randomly assigned from 20 out of 29 participating sites. Of the participants with confirmed influenza (by PCR), 28 (67%) of 42 in the plasma plus standard care group normalised their respiratory status by day 28 compared with 24 (53%) of 45 participants on standard care alone (p=0·069). The hazard ratio (HR) comparing plasma plus standard care with standard care alone was 1·71 (95% CI 0·96-3·06). Six participants died, one (2%) from the plasma plus standard care group and five (10%) from the standard care group (HR 0·19 95% CI 0·02-1·65, p=0·093). Participants in the plasma plus standard care group had non-significant reductions in days in hospital (median 6 days IQR 4-16 vs 11 days 5-25, p=0·13) and days on mechanical ventilation (median 0 days IQR 0-6 vs 3 days 0-14, p=0·14). Fewer plasma plus standard care participants had serious adverse events compared with standard care alone recipients (nine 20% of 46 vs 20 38% of 52, p=0·041), the most frequent of which were acute respiratory distress syndrome (one 2% vs two 4% patients) and stroke (one 2% vs two 4% patients).
Although there was no significant effect of plasma treatment on the primary endpoint, the treatment seemed safe and well tolerated. A phase 3 randomised trial is now underway to further assess this intervention.
National Institute of Allergy and Infectious Diseases, US National Institutes of Health.
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