Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background

Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies.

Methods

In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality.

Findings

Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H₂O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001).

Interpretation

Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status.

Funding

No funding.

A survey on the practices and capabilities in the management of respiratory failure in South East England

Introduction

The variability of acute respiratory distress syndrome management may affect the referral practice to severe respiratory failure centres. We described the management of acute respiratory distress syndrome in our catchment area.

Methods

An electronic survey was administered to 42 intensive care units in South-East England.

Results

Response rate was 71.4%. High-flow nasal oxygen and non-invasive ventilation were used 'often' in moderate-acute respiratory distress syndrome by 46.7% and 60%. During invasive ventilation, 90% preferred pressure control, targeting tidal volumes of 6-8 ml/kg (53.3%) or 4-6 ml/kg (46.7%). Positive end-expiratory pressure was selected by positive end-expiratory pressure/inspiratory fraction of oxygen tables (50%) or decremental positive end-expiratory pressure trials (20%). Neuro-muscular blockers were widely used, although routinely by only 3.3%. High-frequency oscillatory ventilation (10%) and inhaled nitric oxide (13.3%) were rarely used. None used oesophageal manometry. Recruitment manoeuvres were used 'often' by 26.7%. Equipment (90%) and protocols (80%) for prone position were common, with sessions mostly lasting 12-18 h.

Conclusions

Although variable, practice well reflected the available evidence. Proning was widely practiced with good availability of educational resources and protocolised care.

COVID-19-related organ dysfunction and management strategies on the intensive care unit: a narrative review

The coronavirus disease 2019 (COVID-19) pandemic has resulted in a significant surge of critically ill patients and an unprecedented demand on intensive care services. The rapidly evolving understanding of pathogenesis, limited disease specific evidence, and demand-resource imbalances have posed significant challenges for intensive care clinicians. COVID-19 is a complex multisystem inflammatory vasculopathy with a significant mortality implication for those admitted to intensive care. Institutional strategic preparation and meticulous intensive care support are essential to maximising outcomes during the pandemic. The significant mortality variation observed between institutions and internationally, despite a single aetiology and uniform presentation, highlights the potential influence of management strategies on outcome. Given that optimal organ support and adjunctive therapies for COVID-19 have not yet been well defined by trial-based outcomes, strategies are predicated on existing literature and experiential learning. This review outlines the relevant pathophysiology and management strategies for critically ill patients with COVID-19, and shares some of the collective learning accumulated in a high volume severe respiratory failure centre in London.

Veno-venous extracorporeal membrane oxygenation in coronavirus disease 2019: a case series

Background

The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in severe hypoxaemic respiratory failure from coronavirus disease 2019 (COVID-19) has been described, but reported utilisation and outcomes are variable, and detailed information on patient characteristics is lacking. We aim to report clinical characteristics, management and outcomes of COVID-19 patients requiring VV-ECMO, admitted over 2 months to a high-volume centre in the UK.

Methods

Patient information, including baseline characteristics and clinical parameters, was collected retrospectively from electronic health records for COVID-19 VV-ECMO admissions between 3 March and 2 May 2020. Clinical management is described. Data are reported for survivors and nonsurvivors.

Results

We describe 43 consecutive patients with COVID-19 who received VV-ECMO. Median age was 46 years (interquartile range 35.5–52.5) and 76.7% were male. Median time from symptom onset to VV-ECMO was 14 days (interquartile range 11–17.5). All patients underwent computed tomography imaging, revealing extensive pulmonary consolidation in 95.3%, and pulmonary embolus in 27.9%. Overall, 79.1% received immunomodulation with methylprednisolone for persistent maladaptive hyperinflammatory state. Vasopressors were used in 86%, and 44.2% received renal replacement therapy. Median duration on VV-ECMO was 13 days (interquartile range 8–20). 14 patients died (32.6%) and 29 survived (67.4%) to hospital discharge. Nonsurvivors had significantly higher d-dimer (38.2 versus 9.5 mg·L⁻¹, fibrinogen equivalent units; p=0.035) and creatinine (169 versus 73 μmol·L⁻¹; p=0.022) at commencement of VV-ECMO.

Conclusions

Our data support the use of VV-ECMO in selected COVID-19 patients. The cohort was characterised by high degree of alveolar consolidation, systemic inflammation and intravascular thrombosis.

VV-ECMO, when offered to #COVID19 patients in refractory respiratory failure, can be associated with favourable outcomes. This is a detailed case series of 43 COVID-19 patients requiring VV-ECMO from a UK centre. 67.4% survived to hospital discharge.https://bit.ly/3ko9Ucu

Safety of Percutaneous Dilatational Tracheostomy During Veno-Venous Extracorporeal Membrane Oxygenation Support in Adults With Severe Respiratory Failure

OBJECTIVES

To investigate the safety of percutaneous dilatational tracheostomy in severe respiratory failure patients during veno-venous extracorporeal membrane oxygenation support.

DESIGN

A single-center, retrospective, observational cohort study.

SETTING

Tertiary referral severe respiratory failure center, university teaching hospital.

PATIENTS

Severe respiratory failure patients consecutively admitted and supported with veno-venous extracorporeal membrane oxygenation between January 2010 and December 2015.

INTERVENTION

A bronchoscopy-guided percutaneous dilatational tracheostomy was performed in all cases.

MEASUREMENTS AND MAIN RESULTS

Sixty-five veno-venous extracorporeal membrane oxygenation patients (median [interquartile range] age, 47 yr [interquartile range, 35-59 yr]; 39 males; Acute Physiology and Chronic Health Evaluation-II score, 18 [interquartile range, 17-22] Sequential Organ Failure Assessment score, 10 [interquartile range, 7-16]) underwent percutaneous dilatational tracheostomy. Ten patients (15%) developed one or more major complications. Of these, seven (11%) had major bleeding, and three of these also required circuit change due to extracorporeal membrane oxygenation circuit dysfunction. Two more patients (3.1%) presented with isolated extracorporeal membrane oxygenation circuit dysfunction requiring circuit change, and one developed bilateral pneumothoraces (1.5%) requiring intercostal drain insertion. Patients who developed complications had significantly lower extracorporeal membrane oxygenation postoxygenator PO2 prior to percutaneous dilatational tracheostomy (45.8 kPa [interquartile range, 36.9-56.5 kPa] vs 57.9 kPa [interquartile range, 45.1-64.2 kPa]; p = 0.019]. On multivariate analysis, including demographic, clinical, biochemical, hematologic variables, and extracorporeal membrane oxygenation circuit functional variables, extracorporeal membrane oxygenation postoxygenator PO2 was the only independent variable associated with major complications following percutaneous dilatational tracheostomy (beta = -0.09; odds ratio, 0.9; 95% CI, 0.84-0.99; p = 0.03).

CONCLUSIONS

Percutaneous dilatational tracheostomy is associated with a considerable complication rate in veno-venous extracorporeal membrane oxygenation patients. Preprocedure circuit performance as indicated by extracorporeal membrane oxygenation postoxygenator PO2 is an independent predictor of major complications following percutaneous dilatational tracheostomy.

The use of extracorporeal membrane oxygenation in HIV-positive patients with severe respiratory failure: a retrospective observational case series

The objective is to describe the outcomes of patients with human immunodeficiency virus (HIV) infection who received extracorporeal membrane oxygenation (ECMO) for severe respiratory failure (SRF). The design and setting was a single centre retrospective observational case series, from January 2012 to June 2017, at a tertiary university hospital and regional referral centre for ECMO in the United Kingdom. The participants were all patients referred with SRF and HIV infection. The main outcome measure was patient 90-day survival. Twenty-four patients were referred, of whom nine received ECMO. Six out of nine (67%) of patients were alive at 90 days. Median duration of ECMO was 18 days. There were no identified differences between survivors and non-survivors. ECMO can be used successfully in selected patients with HIV and SRF, including those with poor HIV control and high illness severity. HIV status alone should not exclude patients from treatment with extracorporeal therapy.

Veno-arterio-venous ECMO for septic cardiomyopathy: a single-centre experience

INTRODUCTION

The role of extracorporeal support for patients with septic shock remains unclear.

METHODS

We conducted a retrospective analysis of our single-centre experience with veno-arterio-venous extracorporeal membrane oxygenation (VAV ECMO) in adult patients with severe respiratory failure and septic cardiomyopathy. Clinical data was extracted from electronic medical records including a dedicated ECMO referral and follow-up database.

RESULTS

Twelve patients were commenced on VAV ECMO for septic cardiomyopathy for a median of four days (IQR 3.0 to 5.3) between 01/2014 and 12/2017. Five patients (41.7%) had a cardiac arrest prior to initiation of ECMO support. At baseline, median left ventricular ejection fraction was 16.25% (IQR 13.13 to 17.5) and median PaO₂/FiO₂ ratio was 9 kPa (IQR 6.5 to 12.0) [67.50 mmHg (IQR 48.75 to 90.00)]. The survival rate to hospital discharge for VAV ECMO was 75% in this cohort. None of the surviving patients died within the follow-up period (median six month).

CONCLUSION

VAV ECMO is a feasible rescue strategy for a small proportion of patients with combined respiratory and cardiac failure secondary to septic shock with septic cardiomyopathy. We provide a detailed report of our experience with this technique. Further research is required comparing the different extracorporeal strategies directly to conventional resuscitation and against each other.

Refractory septic shock: our pragmatic approach

Despite timely intervention, there exists a small subgroup of patients with septic shock who develop progressive multi-organ failure. Seemingly refractory to conventional therapy, they exhibit a very high mortality. Such patients are often poorly represented in large clinical trials. Consequently, good evidence for effective treatment strategies is lacking. In this article, we describe a pragmatic, multi-faceted approach to managing patients with refractory septic shock based on our experience of toxin-mediated sepsis in a specialist referral centre. Many components of this strategy are inexpensive and widely accessible, and so may offer an opportunity to improve outcomes in these critically ill patients.

International survey on the management of mechanical ventilation during ECMO in adults with severe respiratory failure

BACKGROUND

No consensus exists on the optimal settings of mechanical ventilation during veno-venous extracorporeal membrane oxygenation (ECMO). Our aim was to describe how mechanical ventilation and related interventions are managed by adult ECMO centres.

METHODS

A cross-sectional, multi-centre, international survey of 173 adult respiratory ECMO centres. The survey was generated through an iterative process and assessed for clarity, content and face validity.

RESULTS

One hundred thirty-three centres responded (76.8%). Pressure control was the most commonly used mechanical ventilation mode (64.4%). Although the median PEEP was 10 cmH2O, 22.6% set PEEP <10 cmH2O and 15.5% used 15-20 cmH2O. In 63% of centres PEEP was fixed and not titrated. Recruitment maneuvres, were never used in 34.1% of centres, or used daily in 13.2%. Centres reported using either a "lung rest" (45.7%), or an "open lung" strategy (44.2%). Only 24.8% used chest CT to guide mechanical ventilation. Adjunctive treatments were never or occasionally used. Only 10% of centres extubated patients on ECMO, mainly in more experienced centres. 71.3% of centres performed tracheostomy on ECMO, with large variability in timing (most frequent on days 6-10). Only 27.1% of ECMO centres had a protocol for mechanical ventilation on ECMO.

CONCLUSION

We found large variability in ventilatory practices during ECMO. The clinicians' training background and the centres' experience had no influence on the approach to ventilation. This survey shows that well conducted studies are necessary to determine the best practice of mechanical ventilation during ECMO and its impact on patient outcome.

CRITICAL CARE ECHO ROUNDS: Extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is an advanced form of organ support indicated in selected cases of severe cardiovascular and respiratory failure. Echocardiography is an invaluable diagnostic and monitoring tool in all aspects of ECMO support. The unique nature of ECMO, and its distinct effects upon cardio-respiratory physiology, requires the echocardiographer to have a sound understanding of the technology and its interaction with the patient. In this article, we introduce the key concepts underpinning commonly used modes of ECMO and discuss the role of echocardiography.

Capabilities of a mobile extracorporeal membrane oxygenation service for severe respiratory failure delivered by intensive care specialists

We conducted a single-centre observational study of retrievals for severe respiratory failure over 12 months. Our intensivist-delivered retrieval service has mobile extracorporeal membrane oxygenation capabilities. Sixty patients were analysed: 34 (57%) were female and the mean (SD) age was 44.1 (13.6) years. The mean (SD) PaO2 /FI O2 ratio at referral was 10.2 (4.1) kPa and median (IQR [range]) Murray score was 3.25 (3.0-3.5 [1.5-4.0]). Forty-eight patients (80%) required veno-venous extracorporeal membrane oxygenation at the referring centre. There were no cannulation or extracorporeal membrane oxygenation-related complications. The median (IQR [range]) retrieval distance was 47.2 (14.9-77.0 [2.3-342.0]) miles. There were no major adverse events during retrieval. Thirty-seven patients (77%) who received extracorporeal membrane oxygenation survived to discharge from the intensive care unit and 36 patients (75%) were alive after six months. Senior intensivist-initiated and delivered mobile extracorporeal membrane oxygenation is safe and associated with a high incidence of survival.

Extracorporeal Carbon Dioxide Removal as an Alternative to Endotracheal Intubation for Non-Invasive Ventilation Failure in Acute Exacerbation of COPD

Extracorporeal carbon dioxide removal (ECCO2R) is an efficient technique used in the management of hypercapnic respiratory failure. Its application in mechanically ventilated patients has been studied for over 30 years. We describe a case of severe, acute exacerbation of chronic obstructive pulmonary disease (AECOPD) unresponsive to non-invasive ventilation (NIV), where initiation of ECCO2R was used effectively to prevent endotracheal intubation.

RET proto-oncogene mutations are restricted to codon 618 in Cypriot families with multiple endocrine neoplasia 2

BACKGROUND

RET germline mutations predispose to the development of inherited cancer syndrome multiple endocrine neoplasia type 2 (MEN2). Several variants of the RET proto-oncogene including G691S and S904S have been suggested to act as genetic modifiers at the age of onset ofMEN2.

AIM

The aim of this study is to characterize clinically and molecularly 7 Cypriot patients with familial medullary thyroid carcinoma (FMTC) and 1 with MEN2A and also to determine the allelic frequencies of the RET variants G691S and S904S.

SUBJECTS AND METHODS

Seven probands from FMTC families and 1 from MEN2A were screened for the presence of RET mutations and the G691S and S904S variants. Additionally, 226 healthy Cypriots, who served as controls were analysed in an attempt to compare the frequencies of G691S and S904S RET variants to those observed in the 8 patients.

RESULTS

The clinical diagnosis of the probands was based on clinical presentation and supported with biochemical findings. The germline C618R mutation of exon 10 was identified in all 8 probands and in 15 relatives from 7 different families. No significant difference in the G691S/S904S variants allele frequencies between patients (4/16 or 25%) and controls (124/452 or 27.4%) was found.

CONCLUSIONS

Mutational screening of the RET gene identified a common mutation (C618R) in all 8 (7 FMTC and 1 MEN2A) unrelated Cypriot patients which may be explained by a founder effect. Additionally, no association of the G691S/S904S variants was linked with the disease.

Anti-tumour activity of afatinib, an irreversible ErbB family blocker, in human pancreatic tumour cells

BACKGROUND

The combination of the reversible epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) erlotinib with gemcitabine obtained FDA approval for treating patients with pancreatic cancer. However, duration of response is often limited and there is currently no reliable predictive marker.

METHODS

We determined the sensitivity of a panel of human pancreatic tumour cell lines to treatment with afatinib, erlotinib, monoclonal antibody (mAb) ICR62, and gemcitabine, using the Sulforhodamine B colorimetric assay. The effect of these agents on cell signalling and cell-cycle distribution was determined by western blot and flow cytometry, respectively.

RESULTS

At 200 nM, ICR62 had no effect on growth of these tumour cells with the exception of BxPC-3 cells. BxPC-3 cells were also sensitive to treatment with afatinib and erlotinib with respective IC(50) values of 11 and 1200 nM. Compared with erlotinib, afatinib was also more effective in inhibiting the growth of the other human pancreatic tumour cell lines and in blocking the EGF-induced phosphorylation of tyrosine, EGFR, MAPK, and AKT. When tested in BxPC-3 xenografts, afatinib induced significant delay in tumour growth.

CONCLUSION

The superiority of afatinib in this study encourages further investigation on the therapeutic potential of afatinib as a single agent or in combination with gemcitabine in pancreatic cancer.

A real-time PCR assay to differentiate the B and Q biotypes of the Bemisia tabaci complex in Cyprus

A real-time PCR assay based on TaqMan technology was developed and evaluated for the rapid detection of the B and Q biotypes of Bemisia tabaci (Gennadius) (Hemiptera: Aleyrodidae). A survey was conducted during 2005-2007 in order to identify the distribution and prevalence of B. tabaci biotypes in Cyprus using the real-time PCR assay. More than 700 adult whiteflies collected from 35 cultivated and weed plant species were individually haplotyped using TaqMan PCR, and the results of the assay were validated by restriction fragment length polymorphism analysis and DNA sequencing of the mitochondrial cytochrome oxidase I (mtCOI) gene. Two biotypes, B and Q, were identified in the collected plant species on the island. The real-time PCR and RFLP assay consistently yielded the same results, although the real-time assay was more sensitive and less time consuming. Phylogenetic analysis of the mtCOI DNA sequences corroborated the identity of the B and Q biotypes 100% of the time and by phylogenetic analysis the haplotypes grouped, as expected, in the major North African-Mediterranean-Middle Eastern clade of the B. tabaci complex.

Open subintimal angioplasty of the superficial femoral and distal arteries

PURPOSE

To describe an open approach to subintimal angioplasty.

TECHNIQUE

Through a subinguinal incision and arteriotomy over the superficial femoral artery origin, the opening of a subintimal channel is created surgically. The subintimal plane is advanced distally with a guidewire, and this neolumen is expanded with sequential balloon dilations. The atherosclerotic core is dissected proximally in the common femoral artery and tacked down to ensure inflow. A patch graft closes the arteriotomy.

CONCLUSIONS

Open subintimal angioplasty is a simple, minimally invasive alternative treatment for complete SFA occlusion. Long-term follow-up in a large group of patients will be necessary to determine the durability of the false arterial lumen.

Concurrent multivessel stenting in a patient with multifocal arterial disease

PURPOSE

To report the concurrent endovascular treatment of multiple stenoses in different vascular territories.

METHODS AND RESULTS

A 45-year-old male presented with an aortic arch syndrome, renovascular hypertension, and Leriche syndrome. Intra-arterial digital arteriography disclosed occlusion of the left subclavian artery and stenoses in the left common carotid artery (CCA), the right CCA at the bifurcation, the left renal artery, and both iliac arteries. In a single procedure, the patient received 5 stents in 2 carotid, 1 renal, and 2 iliac arteries. At 3-month follow-up, color flow duplex imaging confirmed continued patency of all stented arteries.

CONCLUSIONS

This case illustrates the feasibility, safety, and cost effectiveness of treating multivessel stenoses using a single-session endovascular approach executed by experienced interventionists.

Determination of glutamate by high-performance liquid chromatography with fluorescence detection in superfusates of rat brain preparations

A method is described for the determination of glutamate in superfusates of cortical or hippocampal rat brain slices. This method is based on the precolumn derivatization of amino acids with orthopthaldialdehyde and mercaptopropionic acid, separation by high-performance liquid chromatography, and detection by fluorescence. By adjusting the concentrations of reagents and with the minimum dilution of the sample, it was possible to reproducibly measure the Ca2+-dependent K+-evoked release of neurotransmitter glutamate in superfusates of brain slices.

Surgical treatment of spontaneous internal carotid dissection

Spontaneous dissection of the internal carotid artery is rarely submitted to surgery. We report a case successfully operated on with complete restoration of the cerebral blood flow. A 43-year-old male was admitted to our hospital 10 days after an episode of amaurosis fugax of the left eye, left sided headache and paresis of the right arm of a few hours duration. A diagnosis of dissection of the left internal carotid artery was made by duplex and triplex ultrasound examination and was confirmed by cerebral arteriography in contrast to magnetic resonance angiography which was misleading. Due to the slow arterial flow from the right to the left cerebral hemisphere through only the posterior communicating arteries we envisaged the possibility of a cerebral infarction if the dissection were to be extended. For this reason a surgical procedure was performed by excising the dissected segment and inserting a venous graft for the re-establishment of the arterial flow. Surgical treatment of spontaneous internal carotid dissection should be considered very carefully when the clinical and laboratory findings suggest the possibility of an impending stroke.

Fatalities from non-use of seat belts and helmets in Greece: a nationwide appraisal. Hellenic Road Traffic Police

It has been established that seat belt use by car occupants and helmet use by motorcycle riders substantially reduces the risk of serious and fatal injuries following accidents. No study, however, has evaluated the motor vehicle deaths that could be prevented in Greece by general use of these devices, even though this country has the highest mortality from motor vehicle accidents in the European Union. We have estimated the odds ratios (OR) for death rather than injury in a motor vehicle accident by seat belt use among occupants of passenger cars or helmet use among motorcycle riders, using a nationwide database in which persons killed or injured in road traffic accidents in 1985 and 1994 were recorded. The study base included 910 dead and 19,511 injured persons for 1985 and 1203 dead and 22,186 injured persons for 1994. The OR and 95% confidence intervals (CI) for death rather than injury was 0.69 (CI: 0.58 to 0.81, p < 10(-5)) for seat belt users versus non-users and 0.64 (CI: 0.51 to 0.81; p < 10(-3)) for helmet users versus non-users. There was evidence that the protective effect of these passive safety devices increased from 1985 to 1994 probably reflecting technological improvements. The proportion of all deaths that could have been avoided if all car occupants used seat belts was estimated to 27%, whereas 38% of motorcycle deaths could have been avoided if all motorcycle riders used helmets. These proportions translate to about 500 deaths per year, mostly deaths among young men.

Is cerebral arteriography necessary for decision making in carotid endarterectomy?

The development of ultrasonic diagnostic imaging technics has recently been a competitive diagnostic method in cerebral arteriography. Many vascular surgeons, based on the high specificity and sensitivity of the ultrasonic imaging technics in carotid artery disease, have been performing carotid endarterectomy without arteriography with satisfactory results. In the last four years we have performed in our Department 62 carotid endarterectomies on 57 patients without using cerebral arteriography. In this paper diagnostic ultrasonic imaging and transcranial Doppler technics are presented and the immediate results of carotid endarterectomy in the above series of patients are reported. From our and other authors' experience it is concluded that carotid endarterectomy in patients with carotid artery disease is a safe procedure. Larger series of patients are needed with a longer follow-up in order that carotid endarterectomy without arteriography be accepted by the medical profession as a safe procedure.

Ruptured abdominal aortic aneurysms. Clinical and surgical considerations

Rupture of abdominal aortic aneurysms (AAA) is a life-threatening condition and a leading cause of death in various countries. In spite of increased awareness of most physicians for an early diagnosis of the rupture, the performance of surgery in an early stage and special care in the Intensive Care Unit, postoperative mortality is still high in most medical centers as well as in our Clinic. Two series of patients operated in our Clinic during the last 17 years are analysed. The applied surgical technics are presented and morbidity and mortality are analysed. A distinction between the general mortality was made based on all the inhospital deaths and the postoperative mortality rate including only the deaths after the operation during the postoperative period. Among the other conclusions it is also stressed that a real improvement in the mortality rate depends on elective surgery of all the disclosed AAA larger than 4 cm in diameter.

Somatostatin as adjuvant therapy in the management of obstructive ileus

The adjuvant use of somatostatin in the clinical management of obstructive ileus was studied prospectively. Fifty-four consecutive patients suffering from total obstructive ileus were managed over a period of one year. A double-blind clinical trial involving the administration of somatostatin for two days was carried out. Twenty-seven non-selected patients received somatostatin, while the other twenty-seven did not. Of the 27 patients who did not receive somatostatin, 12 (44%) were operated on, while only 6 (22%) of those who had received the agent required surgery. As little as 16% of the patients who received somatostatin pre-operatively exhibited severe dilatation and necrosis of the intestine proximal to the area of destruction as compared with 83% of those patients who did not receive somatostatin before the operation. It was concluded that while the administration of somatostatin to patients suffering from obstructive ileus may not be directly related to a reduction in surgery, it does reduce the effects of intestinal dilatation on the healthy gut proximal to the area of destruction.

The effective treatment of multifocal atrial tachycardia with amiodarone

Multifocal atrial tachycardia (MAT) was observed in 9 patients aged 60-85 (mean 72.1 +/- 8.6) years during exacerbation of their chronic lung and/or cardiac disease. Four, in whom the rapid heart rate caused symptoms of pulmonary congestion, were treated with intravenous amiodarone (450-900 mg over 2 hours) with restoration of sinus rhythm soon after the termination of the drug infusion. In 1, with recurrence of MAT, the same intravenous dosage was repeated for 2 consecutive days, with final achievement of stable sinus rhythm. Five patients, apart from the conventional management of their underlying disease (digitalis, diuretics, aminophylline) were treated with oral amiodarone (600 mg/day). Sinus rhythm was restored in all and remained stable during their hospitalization, under alpha maintenance dosage of 200-400 mg daily. Amiodarone may be the drug of choice for the treatment of MAT, for which up to now no effective therapy has been established.