[Brain natriuretic peptide for postoperative monitoring of the fluid balance in a cardiac surgery patient]

Brain natriuretic peptide is a neurohormone used for estimation of left ventricular wall tension and volume overload. We describe the use of this parameter in a postoperative cardiac surgery patient for detection and monitoring of left ventricular failure in a postoperative intensive care unit at a tertiary care center. Left ventricular failure was detected by brain natriuretic peptide levels, while x-ray and values obtained by the pulmonary artery catheter were inconclusive.

Tissue/dose compensation to reduce toxicity from combined radiation and chemotherapy for advanced head and neck cancers

This study was undertaken to quantify the reduction in normal tissue complications resulting from the aggressive management of advanced head and neck cancers (AHNCs) utilizing tissue/dose compensation (TDC). Thirty-nine patients with AHNC were treated on an intensive chemotherapy + radiation regimen. Eighteen of 39 patients were treated using TDC; the remaining 21 patients were radiated without TDC (NTDC). Acute and chronic toxicities, swallowing, speech function, and quality of life were assessed. The TDC group had a smaller radiation dose gradient across the entire treatment volume. Unscheduled treatment breaks were required in 11% of TDC patients as compared with 43% of the NTDC group (P = 0.04). The TDC group had fewer Grade 3 or 4 acute and chronic toxicities and lower SOMA scores. At 3 months posttreatment, patients in the TDC group had better oral intake, lower pharyngeal residue, and better oropharyngeal swallowing efficiency and were able to swallow more bolus types. Patients in the TDC group also had better articulation. Use of TDC resulted in reduced treatment-related interruptions, decreased acute and chronic toxicities, and better speech and swallowing functions. Techniques to improve radiation dose conformality around the target tissues while decreasing the radiation dose to the normal tissues should be an integral part of aggressive combined modality therapy.

[Ventricular arrhythmia in patients with chronic renal failure treated with hemodialysis]

From the group of 66 patients (pts) treated with in-hospital haemodialysis (HD), 30 pts were selected for 48 hrs monitoring of heart rhythm to register arrhythmias using Holter method. Cardiovascular complications were observed in 24 pts (80%) of the studied group; ischemic heart disease in 10 pts (33%), chronic cardiac failure in 8 pts (27%), left ventricular hypertrophy in 16 pts (53%) and hypertension in 24 pts. During 48 hrs of heart rhythm monitoring ventricular heart arrhythmias (VHA) were registered in 23 pts. 8 pts of this group had more then 100 additional ventricular beats for 24 hrs. VHA were registered before HD in 14 pts, during HD in 15 pts and after in 15 pts. The frequency of VHA pt/one hour of monitoring increased during and immediately after HD. There were no statistically significant differences between 23 pts with VHA and 7 pts without VHA with respect to the following parameters measured before HD: blood pressure, urea, calcium, kalium and magnesium blood concentrations. We found statistically significant difference between both groups of pts for creatinine values (p < 0.02); respectively 899.7 mmol/l SD 152 mmol/l versus 767 mmol/l SD 95.3 mmol/l and for interdialytic body weight increase (p < 0.012); respectively 2.65 kg SD 0.8 kg versus 2.04 kg SD 0.46 kg. Our initial results indicate that VHA appears in the majority of hemodialysed pts and that HD intensifies arrhythmogenic influence of irreversible renal failure on heart. It is also possible that non-adequate HD might be responsible for induction of ventricular heart arrhythmias during and after dialysis.

Fractionated stereotactic radiotherapy for pediatric brain tumors: the Chicago children's experience

Thirty-three children with a total of 35 benign/malignant brain and eye neoplasms were treated with fractionated stereotactic radiotherapy. In the first 11 children immobilization for treatment was achieved with plaster of Paris casts or aquaplast masks. In the remaining 22 children the Laitinen stereoadapter was used. Radiation was delivered with noncoplanar static or rotational beams. The dose fractionation used was 50.4-60 Gy in 28-30 fractions in patients receiving treatment with curative intent, and 10-32 Gy at 2-4 Gy/fraction for reirradiation. The accuracy of daily treatment was < 2 mm. After a median follow-up of 27 months, 22 of the 25 children treated with curative intent achieved local control. One child had progressive brain necrosis following 54 Gy in 30 fractions for a pontine astrocytoma. The exact etiology of this complication is unknown. This series demonstrates that in children fractionated stereotactic radiotherapy using the Laitinen stereoadapter is well tolerated and accurate and results in good local control.

Transesophageal echocardiographic assessment of right heart hemodynamics during high-frequency jet ventilation

STUDY OBJECTIVE

To evaluate right ventricular dimensions and function by echocardiography in anesthetized patients during superimposed high-frequency jet ventilation (HFJV).

DESIGN

Prospective clinical study.

SETTING

University hospital operating room.

PATIENTS

20 ASA physical status I patients undergoing elective minor otorhinolaryngological surgery, and undergoing conventional mechanical ventilation with subsequent superimposed HFJV.

INTERVENTIONS

Two-dimensional transesophageal echocardiography with a 5-MHz multiplane transducer to determine right ventricular dimensions and function from a mid-esophageal view. Insertion of a radial artery catheter for monitoring blood pressure and blood gases.

MEASUREMENTS AND MAIN RESULTS

Heart rate, mean arterial blood pressure, and right ventricular end-diastolic and end-systolic volumes determined by echocardiography, stroke volume, and ejection fraction. Measurements were performed after 10 minutes of conventional positive pressure ventilation (control) and after 10 minutes of subsequent superimposed HFJV at similar peak and positive end-expiratory airway pressures. Right ventricular systolic and diastolic volumes, stroke volume, and ejection fraction did not reveal statistical significant differences after transition to HFJV. Interventricular septum did not show any abnormalities in motion. In contrast, interatrial septum demonstrated momentary mid-systolic bows toward the left atrium in 9 of 17 patients (53%) during conventional ventilation, but in 15 of 17 patients (88%) during jet ventilation. Heart rate and mean arterial blood pressure remained unchanged, but arterial oxygen tension values were higher and arterial carbon dioxide tension values lower during HFJV.

CONCLUSION

Transesophageal echocardiographic evaluation of right heart hemodynamics did not show any significant difference after transition of ventilation to superimposed HFJV applying similar airway pressures. Furthermore, superimposed HFJV was safe and effective, it improved oxygenation, and it facilitated carbon dioxide elimination.

[SHFJV. Jet-adapter for application of superimposed high-frequency jet ventilation (SHFJV) via a tube in intensive care: a new technique]

Despite advances and technical developments in the area of intensive care medicine it has not been possible to lower the mortality of patients with pulmonary insufficiency. Therefore, alternative ventilation strategies have been developed and applied. One of these ventilation techniques is superimposed high-frequency jet ventilation (SHFJV). For optimal application of SHFJV we designed a special jet-adapter.

METHODS

This jet-adapter made of plastic consists of a T-piece and four central, small-bore cannulas and can be connected to any commercially available endotracheal tube. Therefore, it does not require reintubation with an endotracheal jet tube when beginning SHFJV. The simultaneous high-frequency and low-frequency jet ventilation is performed over two jet-nozzles that have been designed according to optimal flow dynamic measurements. Two further cannulas are used for continuous airway pressure monitoring and humidification of the applied gases. A pre-warmed and humidified bias flow with exactly defined oxygen concentration is led through the cross-part of the T-piece for gas entrainment. Additionally, the cross-part contains a port that can be opened for endotracheal suctioning or bronchoscopy and makes disconnection of the jet adapter from the endotracheal tube for either purpose unnecessary.

CONCLUSION

The jet adapter can be used: (1) to apply SHFJV; (2) to measure airway pressures continuously; (3) to humidify and warm inspired gases; (4) to administer medications or add nitrous oxide by the inspiratory route, enabling combination with new therapeutic possibilities in the management of patients with severe ARDS.

Classical and anaplastic seminoma: difference in survival

Classical and anaplastic seminoma are traditionally treated with radiation therapy and are said to have the same prognosis. A retrospective study was undertaken of 90 seminoma patients treated with radiation therapy between 1961 and 1985. The classical group consisted of 71 patients of whom 50 had stage I and 21 had stage II disease. The anaplastic group consisted of 19 patients of whom ten had stage I and nine had stage II disease. The median follow-up time was 64 months for the entire group. The 10-year relapse-free survival rate for the classical group was 94% and for the anaplastic group was 70% (P less than .05). For patients with classical stage I disease, the relapse-free actuarial survival rate was 98%; for patients with anaplastic stage I disease, it was 64% (P less than .02). For the classical stage II disease group, the relapse-free actuarial survival rate was 84% and for the anaplastic stage II disease group, 75% (P less than .70). Four patients in the classical group (6%) had relapses; of these, one patient had local recurrence of tumor, and three had distant metastases. In the anaplastic group, four patients (21%) had relapses; two patients had local recurrence of tumor, and two had distant metastases. Therefore the data suggest a difference in survival and relapse rates between classical and anaplastic seminoma.

Uterine contractility data processing system

A versatile system has been developed for off-line computerized quantitation of uterine contractility. It includes tabulation and display of intensity, frequency, resting tone, uterine activity, cumulative area below the pressure curve, and average intrauterine pressure. Its advantages and drawbacks are compared with the conventional method and with an automated on-line labor surveillance system.