Characteristics of sepsis-induced cardiac dysfunction using speckle-tracking echocardiography: a feasibility study

Septic cardiomyopathy is commonly encountered in patients with severe sepsis and septic shock. This study explores whether novel global and segmental echocardiographic markers of myocardial deformation, using two-dimensional speckle tracking, are associated with adverse sepsis outcomes. We conducted a retrospective observational feasibility study, at a tertiary care centre, of patients admitted to the ICU with a diagnosis of sepsis who underwent an echocardiogram within the first week of sepsis diagnosis. Data were collected on chamber dimensions, systolic and diastolic function, demographics, haemodynamics, and laboratory parameters. Global and segmental left ventricular longitudinal strain (LVLS) and tissue mitral annular displacement (TMAD) were assessed on 12 left ventricular segments and six mitral annulus segments in apical views, respectively. We explored associations of abnormal LVLS and TMAD with duration of mechanical ventilation, hospital length of stay, and mortality. Fifty-four patients were included. Global LVLS was not associated with any of the primary study endpoints. However, reduced systolic LVLS of the basal anterior segment was associated with in-hospital mortality. There was a suggestion that patients with a reduced global TMAD were associated with an increased risk of mortality and a short length of hospital stay but these associations were not statistically significant. Reduced global LVLS was associated with lower ejection fraction. Reduced global TMAD was associated with reduced global and segmental LVLS, reduced left ventricular ejection fraction, and increased left ventricular end-systolic and end-diastolic volumes. Speckle-tracking echocardiography can be performed feasibly in patients in sepsis. Global and segmental left ventricular deformation indices are associated with ejection fraction. Further studies need to evaluate the ability of these new indices to predict sepsis outcomes.

Diabetes care in rest homes in Christchurch, New Zealand

AIM

To determine the prevalence and describe the management of known diabetes in a group of New Zealand rest homes.

METHODS

A random sample of 54 rest homes in Christchurch were studied. Residents with known diabetes were identified by rest home staff and interviewed. Selected staff members of all rest homes were also interviewed using structured questionnaires. The medical and nursing records and laboratory results of all residents with known diabetes were reviewed and all information pertaining to diabetes management recorded.

RESULTS

The prevalence of known diabetes in Christchurch rest homes was 11.7%. Residents with known diabetes had a mean of five other comorbidities and were prescribed a mean of 7.5 medications. Of residents with diabetes, 45% were taking oral glucose-lowering agents, 28% were on a diet alone and 27% on insulin treatment. The mean blood pressure was 134/73 mmHg. The mean HbA(1c) was 7.3%. Routine blood glucose monitoring was performed often but residents with possible hypoglycaemic episodes frequently did not have their blood glucose level checked.

CONCLUSIONS

The prevalence of known diabetes in Christchurch rest homes is similar to that found in British studies but less than that found in studies from the USA. Indicators of quality of care in residents with diabetes in this study appeared to be satisfactory, in contrast to other studies. There was poor recognition by staff of the necessity of checking acutely blood glucose levels in residents with diabetes who became unwell.

Echocardiographic Assessment of Dyssynchrony for Predicting a Favorable Response to Cardiac Resynchronization Therapy

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A 28 year old woman with ventricular tachycardia and an abnormal chest radiograph

A 28 year old white woman with no medical history presented to the emergency room with symptomatic non-sustained ventricular tachycardia. She was asymptomatic up to a few days before presentation. Her physical examination was essentially normal and hence did not help with the differential diagnosis of the problem. Bronchoscopic transbronchial biopsy led to the final diagnosis of cardiac sarcoidosis.

Prevalence and diagnostic value of precordial murmurs for valvular regurgitation in obese patients treated with dexfenfluramine

Echocardiography is recommended for the detection of valvular regurgitation in asymptomatic users of anorexigens with a heart murmur. To determine the prevalence and diagnostic value of heart murmurs for valvular regurgitation, 223 patients receiving dexfenfluramine therapy for 6.9 months and 189 matched controls underwent history and cardiac auscultation by experienced noncardiologists unaware of echocardiography. Color Doppler echocardiograms were interpreted by 3 observers unaware of patients' clinical data. The frequency of at least mild regurgitation of any valve and abnormal regurgitation (moderate mitral or tricuspid or mild aortic regurgitation) were determined. Heart murmurs heard in 31 dexfenfluramine users (14%) and in 20 controls (11%) were all systolic and of grade I to II/VI intensity. Mild or worse regurgitation of any valve showed a trend in patients (18% vs 11.6% in controls, odds ratio [OR] 1.66, confidence interval [CI] 0.95 to 2.9, p = 0.08), but abnormal regurgitation (includes Food and Drug Administration grade regurgitation) was more common in patients (9% vs 3% in controls, OR 3.0, CI 1.18 to 7.65, p = 0.02). In dexfenfluramine users, heart murmurs were associated with at least mild or abnormal regurgitation (OR 3.1 and 3.05, 95% CI 1.34 to 7.13 and 1.1 to 8.67; p = 0.008 and 0.036, respectively), had a specificity of 89% and 88%, negative predictive value of 85% and 93%, but sensitivity of 37% and 30%, and positive predictive value of 35% and 19%, respectively. Most valves missed by cardiac auscultation had normal morphology and mild regurgitation. Finally, heart murmurs had better diagnostic value for either type of valvular regurgitation than heart murmurs and clinical variables or clinical variables alone. In summary, in dexfenfluramine users the prevalence of heart murmurs was low and their absence predicted absence of mild or worse regurgitation of any valve or abnormal valvular regurgitation. Therefore, cardiac auscultation should be the screening method of choice for detecting valvular regurgitation in users of anorexigens.

Prevalence and determinants of valvulopathy in patients treated with dexfenfluramine

BACKGROUND

Valve regurgitation has been associated with dexfenfluramine, but its prevalence and severity are uncertain. Additional factors that may contribute to valve regurgitation in patients exposed to this drug are poorly understood.

METHODS AND RESULTS

Echocardiography was performed on subjects recruited from 26 prescribing sites in 15 states. The total sample of 412 subjects included 172 dexfenfluramine patients and 172 unexposed controls matched for age, sex, and body mass index and 68 unmatched subjects meeting the same entry criteria (51 dexfenfluramine patients and 17 controls). Mean treatment duration was 6.9 months; mean interval from treatment discontinuation to echocardiogram was 8.5 months. Each echocardiogram was interpreted independently by 3 echocardiographers. FDA-grade regurgitation (at least mild aortic regurgitation or at least moderate mitral regurgitation) was significantly more frequent in dexfenfluramine patients (7.6% versus 2.1% for controls; P=0.01; odds ratio, 3.82). This difference was primarily due to more frequent mild aortic regurgitation in dexfenfluramine patients (6.3% versus 1.6% in controls; P<0.02; odds ratio, 4.15). No differences were found in sclerosis or mobility for either the aortic or mitral valve. Factors independently related to FDA-grade regurgitation or any grade of aortic regurgitation were older age, higher diastolic blood pressure at the time of echocardiography, and shorter time from drug discontinuation to echocardiogram.

CONCLUSIONS

Dexfenfluramine use is associated with an increase in the prevalence of abnormal valve regurgitation. Age and blood pressure may also affect the prevalence of regurgitation. Dexfenfluramine-related valve regurgitation may regress after drug discontinuation.

Reversal of left ventricular hypertrophy with angiotensin converting enzyme inhibition in hypertensive patients with autosomal dominant polycystic kidney disease

BACKGROUND

Hypertension occurs commonly and early in the natural history of autosomal dominant polycystic kidney disease (ADPKD), affecting both renal and patient outcome. Activation of the renin angiotensin aldosterone system due to cyst expansion and local renal ischaemia plays an important role in the development of ADPKD related hypertension and left ventricular hypertrophy (LVH), a known important risk factor for cardiovascular morbidity and mortality. The aim of this study was to investigate the effects of an angiotensin converting enzyme (ACE) inhibitor, enalapril, on renal function, blood pressure and LVH in hypertensive ADPKD patients.

METHODS

Fourteen hypertensive ADPKD patients (11 men, 3 women; mean age: 40 years) were included in the study. All patients had LVH and creatinine clearance (Cer) greater than 50 ml/min/1.73 m2. The patients were followed for 7 years on enalapril therapy. The effects of enalapril on renal function, blood pressure and LVH were investigated.

RESULTS

Baseline measurements of mean arterial pressure (MAP), Ccr and left ventricular mass index (LVMI) were 110 +/- 2 mmHg, 84 +/- 6 ml/min/1.73 m2 and 146 +/- 4 g/m2, respectively. After one year of enalapril therapy there was a significant decrease in MAP (94 +/- 3 mmHg, P < 0.005) which remained stable until the end of the study at 7 years (94 +/- 1 mmHg, P < 0.005 vs baseline). There was also a significant decrease in LVMI (131 +/- 6 g/m2, P < 0.05) after year 1 which continued to decrease until the end of the study reaching 98 +/- 6 g/m2 (P < 0.01 vs year 1 and baseline). Although Ccr remained stable after year 1, a significant decrease was observed after 7 years of follow-up (59 +/- 6 ml/min, P < 0.001 vs year 1 and baseline).

CONCLUSIONS

ACE inhibition in hypertensive ADPKD patients provided long-term reversal of LVH in association with a mean 3.6 ml/min/year decline of Ccr. These preliminary results have potential important implications for cardiovascular and renal protection in ADPKD.

Effects of carvedilol on left ventricular mass, chamber geometry, and mitral regurgitation in chronic heart failure

We and others have previously shown that carvedilol improves left ventricular (LV) function and symptoms in chronic heart failure. This improvement in LV function has also been shown to be associated with an improvement in survival. This study evaluates the effect of carvedilol on LV mass, geometry, and degree of mitral regurgitation (MR). In 59 patients with symptomatic heart failure and LV ejection fraction <0.35, previously randomized to either treatment with carvedilol or placebo, we evaluated LV mass, geometry, and degree of MR over the time period of carvedilol treatment. LV mass decreased as early as 4 months into the treatment protocol and continued to decrease over a period of 1 year. LV geometry, defined by the length/diameter ratio, and severity of MR also improved with 4 months of therapy. Thus, compared with placebo treatment, carvedilol decreases LV mass while improving cardiac geometry and decreasing MR in patients with chronic heart failure. These changes occur in association with an improvement in LV systolic function. This process begins by 4 months of treatment and continues for 12 months.

Bacterial lipopolysaccharide induces endothelial cells to synthesize a degranulating factor for neutrophils

Enzymes and other factors secreted by degranulating neutrophils (polymorphonuclear leukocytes, PMNs) mediate endothelial injury, thrombosis, and vascular remodeling. In bacteremia and sepsis syndrome and their consequent complications (including acute respiratory distress syndrome and systemic ischemia-reperfusion resulting from septic shock), neutrophil degranulation is an important mechanism of injury. In related studies, we found that human endothelial cells regulate neutrophil degranulation and that inflammatory cytokines induce synthesis of degranulating factors by human endothelial cells. Here we show that lipopolysaccharides (LPS) from gram-negative bacteria were the most potent agonists for release of degranulating activity by endothelial cells when compared to several cytokines and stimulatory factors. LPS also induced the release of degranulating signals for PMNs from a human endothelial cell line, EA.hy 926. Interleukin 8 (IL-8) is synthesized by endothelial and EA.hy 926 cells in response to LPS and induces neutrophil degranulation. However, complementary strategies using receptor desensitization, translation of messenger RNA by Xenopus laevis oocytes, and purification and analysis of factors from conditioned supernatants demonstrated that degranulating factors distinct from IL8 are generated in response to LPS. The characteristics of a partially purified degranulating factor isolated from conditioned supernatants distinguished it from known chemokines and other factors that induce PMN degranulation and are generated by endothelial cells in response to LPS. Thus, cultured human endothelial cells and endothelial cell lines synthesize several unique signaling molecules that can trigger neutrophil granular secretion. If produced in vivo in response to LPS or other pathologic agonists, these degranulating signals may activate PMNs in combination or in sequence, initiating or propagating vascular damage.

Utility of three-dimensional ultrasound Doppler flow reconstruction of the proximal jet to quantify effective orifice area: in vitro steady and pulsatile flow studies

We examined the utility of three-dimensional (3D) reconstruction of two-dimensional color Doppler images of the proximal jet to quantify the effective area of an orifice in an in vitro model. Steady and pulsatile flows were directed through various orifices; orifice vena contracta areas were quantified with laser flow visualization, thus providing gold standard effective orifice areas. Three-dimensional areas followed vena contracta areas well, although variations in color Doppler gain and 3D gray levels for thresholding produced significant changes in reconstructed images. These variations were minimized by using minimum color gain and 50% gray level threshold. At these settings, 3D areas still overestimated vena contracta areas by approximately 25% because of the poor lateral resolution of the color Doppler system, which caused bleeding of the flow signal past the edges of the proximal jet. Nevertheless, 3D flow images provided a superior format for qualitative and quantitative appreciation of proximal jet shape and dimensions.

Diverse presentation of aberrant origin of the right subclavian artery: two case reports

Aberrant origin of the right subclavian artery occurs in up to 1% of the population and can result in a wide range of symptoms. In this report, two cases of this anomaly are presented. In the first case, a patient developed fatal group A streptococcal aortitis. In the second case, the patient complained of chronic cough and intermittent dyspnea. The embryologic genesis of this abnormality is discussed and the current literature is summarized. Although relatively uncommon, it is important to consider this vascular anomaly in the differential diagnosis of patients with dysphagia, dyspnea, chest pain, fever, or mediastinal widening evidenced on chest roentgenography.

Current concepts in aortic stenosis

Noninvasive cardiac imaging techniques now make it possible to determine the morphologic and hemodynamic status of patients with aortic stenosis, even in early asymptomatic stages of the disease. This is particularly important since the prognosis is generally poor once symptoms are apparent and since replacement of the aortic valve is usually the only recourse when stenosis is severe.

An oligosaccharide sialyl-Lewis(x) analogue does not reduce myocardial infarct size after ischemia and reperfusion in dogs

BACKGROUND

Polymorphonuclear leukocytes, particularly neutrophils, are important mediators of ischemia/reperfusion-induced myocardial and coronary vascular injury. The selectin family of glycoprotein receptors mediates neutrophil "rolling," a loose, transient adhesion to the coronary endothelium that precedes the firmer adhesion associated with cardiovascular injury. The oligosaccharide sialyl-Lewis(x) (SLe(x)) is the probable neutrophil counterligand for endothelial E- and P-selectin. Administration of analogues of SLe(x) could potentially prevent neutrophil rolling by competing for the selectin-adhesion sites. We investigated the effects of treatment with an analogue of SLe(x) in a chronic canine model of ischemia/reperfusion.

METHODS AND RESULTS

Anesthetized mongrel dogs were subjected to 90 minutes of ischemia through occlusion of the left anterior descending coronary artery and 48 hours of reperfusion. Five minutes before the onset of reperfusion, dogs received either the SLe(x) analogue CY-1503 at a dose of 20 mg/kg or normal saline. Myocardial infarct size was measured through triphenyltetrazolium chloride staining, and polymorphonuclear leukocyte accumulation was evaluated through measurement of cardiac myeloperoxidase activity. After adjustment for blood flow, the mean infarct size of control dogs (44.7 +/- 4.2%) was not different from that of treated dogs (33.4 +/- 4.0%, P = .06), although there was a trend toward a slightly lower value in the treated dogs. Myeloperoxidase activity was not different in the infarcted myocardium of the treated group compared with that of the control group (2.7 +/- 0.71 treated versus 1.08 +/- 0.41 units/mg protein control, P = .06).

CONCLUSIONS

We conclude that CY-1503 does not substantially or consistently reduce myocardial infarct size or neutrophil accumulation in dogs subjected to ischemia followed by a prolonged period (48 hours) of reperfusion.

Anterior shoulder dislocation. A simple and rapid method for reduction

Anterior shoulder dislocation is a common skiing injury. Several methods are available for reduction of shoulder dislocations. We evaluated a method for reduction of anterior shoulder dislocation that has not previously appeared in the literature. This method is performed with the patient seated in a chair with the chair used as countertraction. The physician applies traction to the affected shoulder using downward pressure on a loop of stockinette wrapped around the patient's forearm. Our method was successful in 97% of 118 anterior dislocations with no complications. Ninety-three percent were performed without the use of narcotic analgesia.

Left ventricular mass increases during cardiac allograft vascular rejection

OBJECTIVES

This study evaluated whether left ventricular mass increases during cellular or vascular (humoral) cardiac allograft rejection.

BACKGROUND

An increase in left ventricular mass during cellular cardiac allograft rejection has been described by other investigators, although controversy has existed over the validity of these findings. Left ventricular mass changes have not been evaluated in the setting of vascular (humoral) cardiac allograft rejection.

METHODS

To determine the effect of allograft rejection on left ventricular mass, we retrospectively reviewed endomyocardial biopsy results and corresponding echocardiograms in 41 cardiac transplant recipients undergoing treatment for allograft rejection. Left ventricular mass was assessed by two-dimensional echocardiography using the method of Schiller. Maintenance immunosuppression included cyclosporine in all patients.

RESULTS

Although significant changes in left ventricular wall thickness, mass and dimensions were not observed in patients experiencing moderate or severe cellular allograft rejection (International Society for Heart and Lung Transplantation grades III and IV, n = 27), marked changes were noted in patients with vascular (humoral) rejection (n = 14). Patients with vascular rejection demonstrated an echocardiographic mean (+/- SEM) increase in left ventricular wall mass (from 109 +/- 17 to 151 +/- 17 g), and left ventricular wall thickness (from 1.3 +/- 0.1 to 1.6 +/- 0.1 cm) during the rejection episode. Additionally, vascular rejection was associated with a trend toward an increase in left ventricular systolic dimension (from 2.6 +/- 0.1 to 3.0 +/- 0.2 cm) and a decrease in left ventricular fractional shortening and increased incidence of hemodynamic compromise with rejection (50% for vascular vs. 11% for cellular rejection).

CONCLUSIONS

Left ventricular mass increases during episodes of vascular (humoral) rejection, but there is no significant change in left ventricular mass during cellular cardiac allograft rejection.

The Churg-Strauss syndrome. A case report with angiographically documented coronary involvement and a review of the literature

The Churg-Strauss syndrome (CSS) is an unusual disease that presents as a systemic vasculitis and peripheral eosinophilia in a patient with chronic atopic disease. Although often not prominent on initial presentation, cardiac involvement is a major cause of morbidity and mortality in patients with CSS. We report a case of a young woman with CSS who had a myocardial infarction. Coronary arteriography was performed for recurrent chest pain and demonstrated diffuse vasculopathy consistent with vasculitis in CSS. We have also included a review of the literature on cardiac involvement in CSS.

Primary sternal osteomyelitis

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Resuscitative thoracotomy in children and adolescents

Accidental injury continues as the leading cause of mortality in children and adolescents. With the recent push for improvement in emergency medical services and specialized trauma centers for this age group, more moribund patients can be expected to reach these centers. Multiple reports document the efficacy of resuscitative thoracotomy in the moribund adult trauma victim, but published reports of this technique in children and adolescents are lacking. From January 1981 to July 1986, 19 patients ranging in age from 4 to 18 years (mean 14) underwent resuscitative thoracotomy. Eleven patients sustained penetrating trauma while eight sustained injuries from blunt trauma. Five patients survived and were discharged from the hospital (26%). There were no survivors in the 0-15 year age group in five penetrating injuries and four blunt trauma victims. This review confirms the efficacy of resuscitative thoracotomy in the patient with penetrating trauma. Salvage in the blunt trauma victim is possible, but less than in penetrating injuries (12.5% versus 36%). Further studies in this age group will be necessary to establish appropriate guidelines for the use of RT in children and adolescents.

Slipped capital femoral epiphysis

Slippage of the capital femoral epiphysis typically presents as hip pain in a child. Radiographic examination demonstrates translocation of the upper femoral epiphysis away from its normal anatomic position on the neck of the femur. Slipped capital femoral epiphysis can result in permanent deformity if it is not promptly corrected. Closed pinning is the treatment for acute slips, but treatment options are complex when the condition is chronic.