0649 Ultrasound Assessment of Tongue Movement as a Predictor of Response to Hypoglossal Nerve Stimulation (HGNS)

Introduction

HGNS is an approved therapy for obstructive sleep apnea (OSA). Initial setting of HGNS voltage is based on observation of anterior tongue movement, which may not reflect opening of the retroglossal airway. We developed an ultrasonographic (US) technique to assess tongue movement with HGNS. We correlated US measures of tongue movement at the initial HGNS voltage setting with the AHI determined by PSG/HSAT on HGNS therapy.

Methods

Eleven subjects implanted with INSPIRE™ (HGNS) were enrolled at least one month post-implantation. Initial HGNS voltage was determined while awake and semi-recumbent and set to achieve visualized anterior tongue protrusion at a tolerable stimulation voltage. A curvilinear probe (5-2MHz) was placed longitudinally in the submental region at the midline with the indicator pointed anteriorly. Hyoid bone excursion (HBE) with stimulation was used as a marker of base of tongue movement. PSG or HSAT was performed to determine AHI with HGNS. Responders were defined as those with a reduction in AHI ≥50% and an AHI <20 events/hr.

Results

N=11, 6M, 5F, Age=66.5 ±18.4 years, BMI=27.9±2.7 kg/m2. Pre-treatment AHI=38.8±13.4/hr, T-90%=10.5±16.7%. Mean HBE in responders=1.02±0.17cm vs 0.76±0.20cm in non-responders (p=0.006). Best subsets regression analysis performed using post-treatment AHI as the dependent variable and age, BMI, baseline AHI, HBE and HGNS voltage as independent variables showed that HBE (coef. -29.1, p=0.038) and BMI (coef. 2.6, p=0.018) were independent predictors of response.

Conclusion

We demonstrated that ultrasound assessment of HBE during HGNS may be a useful tool to predict response to therapy and guide HGNS settings. HBE, rather than voltage, predicted post-treatment AHI.

Support

None.

Systematic review and literature appraisal on methodology of conducting and reporting critical-care echocardiography studies: a report from the European Society of Intensive Care Medicine PRICES expert panel

Background

The echocardiography working group of the European Society of Intensive Care Medicine recognized the need to provide structured guidance for future CCE research methodology and reporting based on a systematic appraisal of the current literature. Here is reported this systematic appraisal.

Methods

We conducted a systematic review, registered on the Prospero database. A total of 43 items of common interest to all echocardiography studies were initially listed by the experts, and other “topic-specific” items were separated into five main categories of interest (left ventricular systolic function, LVSF n = 15, right ventricular function, RVF n = 18, left ventricular diastolic function, LVDF n = 15, fluid management, FM n = 7, and advanced echocardiography techniques, AET n = 17). We evaluated the percentage of items reported per study and the fraction of studies reporting a single item.

Results

From January 2000 till December 2017 a total of 209 articles were included after systematic search and screening, 97 for LVSF, 48 for RVF, 51 for LVDF, 36 for FM and 24 for AET. Shock and ARDS were relatively common among LVSF articles (both around 15%) while ARDS comprised 25% of RVF articles. Transthoracic echocardiography was the main echocardiography mode, in 87% of the articles for AET topic, followed by 81% for FM, 78% for LVDF, 70% for LVSF and 63% for RVF. The percentage of items per study as well as the fraction of study reporting an item was low or very low, except for FM. As an illustration, the left ventricular size was only reported by 56% of studies in the LVSF topic, and half studies assessing RVF reported data on pulmonary artery systolic pressure.

Conclusion

This analysis confirmed sub-optimal reporting of several items listed by an expert panel. The analysis will help the experts in the development of guidelines for CCE study design and reporting.

Correction to: A decade of progress in critical care echocardiography: a narrative review

The original version of this article unfortunately contained a mistake.

A Biologically Active Analog of the Sex Pheromone of the Emerald Ash Borer, Agrilus planipennis

The emerald ash borer, Agrilus planipennis (Coleoptera: Buprestidae) (EAB), is an invasive species causing unprecedented levels of mortality to ash trees in its introduced range. The female-produced sex pheromone of EAB has been shown to contain the macrocyclic lactone (3Z)-dodecen-12-olide. This compound and its geometrical isomer, (3E)-dodecen-12-olide, have been demonstrated previously to be EAG active and, in combination with a host-derived green leaf volatile, (3Z)-hexenol, to be attractive to male EAB in green prism traps deployed in the ash tree canopy. In the current study, we show that the saturated analog, dodecan-12-olide, is similarly active, eliciting an antennal response and significant attraction of EAB in both olfactometer and trapping bioassays in green traps with (3Z)-hexenol. Conformational modeling of the three lactones reveals that their energies and shapes are very similar, suggesting they might share a common receptor in EAB antennae. These findings provide new insight into the pheromone ecology of this species, highlighting the apparent plasticity in response of adults to the pheromone and its analog. Both of the unsaturated isomers are costly to synthesize, involving multistep, low-yielding processes. The saturated analog can be made cheaply, in high yield, and on large scale via Mitsunobu esterification of a saturated ω-hydroxy acid or more simply by Baeyer-Villiger oxidation of commercially available cyclododecanone. The analog can thus provide an inexpensive option as a lure for detection surveys as well as for possible mitigation purposes, such as mating disruption.

Identification of sex pheromone components of blueberry spanworm Itame argillacearia (Lepidoptera: Geometridae)

Blueberry spanworm, Itame argillacearia (Packard), is an important defoliator of lowbush (syn. 'wild') blueberry, Vaccinium angustifolium Aiton, in north-eastern North America. The goal of the present study was to identify the female I. argillacearia sex pheromone, which could be used in traps for monitoring or mass-trapping this pest. Gas chromatography/mass spectrometry (GC/MS) and electroantennogram (EAG) recordings of sex pheromone gland extracts, in combination with chemical synthesis, a Y-tube olfactometer study and field experiments confirmed (2R,3S)-2-ethyl-3-((Z,Z)-tridecadi-2,5-enyl) oxirane (hereafter (Z,Z)-(3R,4S)-3,4-epoxy-6,9-heptadecadiene) and (Z,Z,Z)-3,6,9-heptadecatriene as female-produced sex pheromone components. (Z,Z)-(3R,4S)-3,4-Epoxy-6,9-heptadecadiene elicited a response from male I. argillacearia antennae during EAG recording, and in the Y-tube olfactometer tests males did not discriminate between a live female and (Z,Z)-(3R,4S)-3,4-epoxy-6,9-heptadecadiene. Field-trapping experiments showed that a blend of (Z,Z)-(3R,4S)-3,4-epoxy-6,9-heptadecadiene and (Z,Z,Z)-3,6,9-heptadecatriene was more attractive to male moths than (Z,Z)-(3R,4S)-3,4-epoxy-6,9-heptadecadiene alone.

Analysis of image quality parameter of conventional and dental radiographic digital images

The image quality obtained by a radiographic equipment is very useful to characterize the physical properties of the image radiographic chain, in a quality control of the radiographic equipment. In the radiographic technique it is necessary that the evaluation of the image can guarantee the constancy of its quality to carry out a suitable diagnosis. In this work we have designed some radiographic phantoms for different radiographic digital devices, as dental, conventional, equipments with computed radiography (phosphor plate) and direct radiography (sensor) technology. Additionally, we have developed a software to analyse the image obtained by the radiographic equipment with digital processing techniques, as edge detector, morphological operators, statistical test for the detected combinations‥ The design of these phantoms let the evaluation of a wide range of operating conditions of voltage, current and time of the digital equipments. Moreover, the image quality analysis by the automatic software, let study it with objective parameters.

Analysis of digital image quality indexes for CIRS SP01 and CDMAM 3.4 mammographic phantoms

Mammographic phantom images are usually used to study the quality of images obtained by determined mammographic equipment. The digital image treatment techniques allow carrying out an automatic analysis of the phantom image. Nowadays, the digital radiographic equipments are replacing the traditional film-screen equipments and it is necessary to update the parameters to guarantee the quality of the process. In this work we apply some techniques of digital image processing to compute a specific image quality indexes for mammographic phantoms, namely CIRS SP01 and CDMAM 3.4. to study the evolution of this parameter with different varying conditions of the mammographic equipment. The indexes are calculated from a scoring system based on a designed algorithm which analyses the phantom image by means of an automatic detection of the test objects in each phantom.

Study of digital mammographic equipments by phantom image quality

Nowadays, the digital radiographic equipments are replacing the traditional film-screen equipments and it is necessary to update the parameters to guarantee the quality of the process. Contrast-detail phantoms are applied to digital radiography to study the threshold contrast-detail sensitivity at operation conditions of the equipment. The phantom that is studied in this work is CDMAM 3.4. One of the most extended indexes to measure the image quality in an objective way is the image quality figure (IQF). The aim of this work is to study the image quality of different images contrast-detail phantom CDMAM 3.4, carrying out the automatic detection of the contrast-detail combination and to establish a parameter which characterize in an objective way the mammographic image quality. This is useful to compare images obtained at different digital mammographic equipments to study the functioning of the equipments that facilitates the evaluation of image contrast and detail resolution.

Nonlinear diffusion, negentropy and restoration of mammographic images

Diffusive iterative filtering may be used to restore mammographic noisy images. Assuming that images are corrupted by additive gaussian noise, the negentropy as a statistical measure of the nongaussianity, can be used to estimate the amount of noise removed from noisy images. In particular, the evolution of the negentropy with the iterations is used to introduce a stopping criterion to end the diffusive filtering process. Because of computational complexity of the negentropy function, it is estimated by using an approximation of the negentropy introduced by Hyvärinen in the context of independent component analysis.

Comparing methods to denoise mammographic images

Digital mammographic image processing often requires a previous application of filters to reduce the noise level of the image while preserving important details. This may improve the quality of digital mammographic images and contribute to an accurate diagnosis. In the literature, one can find a large amount of denoising techniques available for different kinds of images. We have adapted some of the existing denoising algorithms to mammographic images. We compare the effect of different denoising filters acting on digitized mammograms. The considered filters are: a local Wiener filter, a wavelet filter, a filter based on independent component analysis, and finally, a filter based on the diffusion equation. The noise reduction is measured by the mean squared error.

Diffusion equations with negentropy applied to denoise mammographic images

Mammography is a radiographic technique used for the detection of breast lesions. The analysis of the digital image normally requires a previous application of filters as a preprocessing step to reduce the noise level of the image, while preserving important details to carry out a suitable diagnostic. In the literature, there are a large amount of denoising techniques applied to different medical images. In this work we have studied the performance of a diffusive filter with a stopping condition based on the statistical concept of negentropy, applied to denoise mammographic images. The negentropy has been succesfully prove with other denoising methods as independent component analysis by the authors in [1]. We have evaluated the final image quality obtained, measuring a root mean squared error between the noise-free initial image and the final restored image and compared the results obtained by this diffusive filter with those obtained by an adaptative non-linear Wiener filter.

A comparative study of computer assisted assessment of image quality index for mammographic phantom images

Mammographic phantom images are usually used to study the quality of images obtained by dedicated mammographic equipment. The digital image treatment techniques allow us to carry out an automatic analysis of the phantom image. In this work, some techniques of digital image processing are applied to compute a specific image quality index (IQI) for a mammographic phantom, namely CIRS model 11A version SP01. The algorithm designed analyses the phantom image by means of automatic detection of the number of microcalcifications, and the image resolution as the number of line pairs per millimetre. Then, the IQI is calculated from a scoring system. The manner in which the functioning conditions (kV and mAs) of the mammographic equipment and the preprocessing denoising method of the digital image affect the results for the IQI are also studied.

Automatic evaluation of the image quality of a mammographic phantom

In this work a method has been developed to analyse the digital image quality of a mammographic phantom by means of automatic process techniques. The techniques used for the digital image treatment are standard techniques as the image thresholding to detect objects, the regional growing for pixels pooling and the morphological operator application to determine the objects shape and size, etc. This study allows the obtention of information about the phantom characteristics, that due to its small size and lowly contrast can be obtained very difficultly by direct observation. The final aim of this work is to obtain one or more parameters to characterize the reference phantom quality image in an objective way. These parameters will serve to compare images obtained at different mammographic centers and also, to study the temporal evolution of the image quality produced by determined mammographic equipment.

Remote substituent effects on the oxymercuration of 2-substituted norbornenes: an experimental and theoretical study

The effect of a remote substituent on regioselectivity in the oxymercuration of 2-substituted norbornenes has been investigated experimentally and theoretically using density functional theory (DFT). Regioselectivities of 1:1 to 14:1 were observed with various 2-substituted norbornenes. Exo-2-substituted norbornenes always gave greater regioselectivities compared to the corresponding endo-2-substituted norbornenes. The effects of solvents on the regioselectivity have also been examined, and ethereal solvents were found to be the best choice giving the optimal yield and regioselectivity. The relative rate of oxymercuration was estimated by competition experiments. The least reactive substrate (X = OAc) gave the highest regioselectivity. According to DFT predictions, the increased difference between the reaction barriers that results in the greater regioselectivity is correlated directly with the larger polarity of the C=C double bond, which is attacked by the mercury and oxygen. A number of stable exo and endo conformers were predicted. All exo conformers show the same polarity of the double bond, while some endo conformers have a reversal of this polarity. All the conformers except those with the OAc substituent are very close in energy and thus should react. The existence of a mixture of endo conformers with the C=C double bond of opposite polarity clearly explains a decrease in regioselectivity for the endo species. The origin of the greatest regioselectivity for the OAc-2-norbornenes lies in the fact that the conformer with the largest polarity is notably lower in energy than others due to an internal C-H-O hydrogen bond.

Protective effect of BCG in Ahmednagar, India

As part of a series of investigations to determine the effect of sensitisation by environmental mycobacteria on the efficacy of BCG vaccination in India, this study was carried out in Ahmednagar in Maharashtra. A preliminary skin test survey showed that the rate of sensitisation with age was much lower than in Agra, the site of a previous study, and BCG vaccination scars were associated with considerable enhancement in sensitisation to Tuberculin and other reagents. It was possible to set up prospective BCG vaccination studies in pre-school and primary and secondary school children. Follow up with skin tests were carried out 1 and 2 years later. By the second year, results were obtained almost identical with those 10 years after BCG administration in the UK. On this basis it is proposed that the vaccine is likely to provide a considerable level of protection in Ahmednagar. The results of this study also resemble those obtained in the very youngest age group studied in Agra. The marked differences between Indian towns strongly suggest the influence of exposure to mycobacteria in the environment.

Early thoracotomy and decortication for nontuberculous empyema in adults with and without underlying disease. A twenty-five year review

The present review deals with 63 adult patients having acute nontuberculous empyema treated by early thoracotomy and decortication, during the period from 1955 through 1979. Group I (38 patients) had postpneumonic empyema, but no underlying disease. Group II (25 patients) had acute empyema and one or more serious associated diseases. Positive cultures were present in 45 of 63 patients (71.4%). Most surgeons have customarily recommended conservative management, especially for patients in Group II, because of the supposedly "high risk" involved in decortication. Consequently, the mortality is extremely high. The empyema must be cured; a "well drained" or "controlled" empyema will not suffice. The severely ill patient can better withstand the ordeal of a major operation than the deleterious effects of a lingering empyema. The critically ill patient is best managed by the primary procedure of open thoracotomy and decortication. The author's experience confirms that such patients can expect an outlook (8% mortality) approaching the zero mortality of Group I patients.

Spontaneous rupture of the spleen presenting as acute thoracic empyema

Splenic rupture heralded by acute thoracic empyema is rare. A review of 420 cases of spontaneous and delayed splenic rupture failed to list a single such instance. I have reported two unusual cases of spontaneous rupture of the spleen presenting in each instance an acute thoracic empyema without history of trauma.

Spontaneous pneumothorax in the newborn

Spontaneous pneumothorax is more frequent during the newborn period than at any other time in childhood. Intubation, vigorous resuscitation, aspiration of meconium-stained amniotic fluid, and hyaline membrane disease have been associated most often with the occurrence of spontaneous pneumothorax; however, it may occur in the absence of any of these precursors. Most pneumothoraces occur in term babies (64%); however, the premature infant is more susceptible. Signs and symptoms are due chiefly to lung compression and include grunting, tachypnea, cyanosis, and retraction. The accumulation of air serves as an intrathoracic space-occupying lesion, an emergency condition that demands prompt diagnosis and treatment.

Acute empyema in children treated by open thoracotomy and decortication

Acute nontuberculous empyema treated conventionally by thoracentesis, thoracostomy drainage, and antibiotics has an unacceptably high rate of morbidity and mortality. Early open thoracotomy to eliminate the empyema with decortication of the fibrinous peel and reexpansion of the lung has proven safe and effective for 25 years. The goals of treatment of acute nontuberculous empyema are: (1) to save life, (2) to eliminate the empyema, (3) to reexpand the trapped lung, (4) to restore mobility of the chest wall and diaphragm, (5) to return respiratory function to normal, (6) to eliminate complications or chronicity, and (7) to reduce the duration of hospital stay. Our studies confirm the normal values to be expected in patients who have had complete recovery from the acute empyema, and we lay to rest any concern that decortication might, in time, limit pulmonary function. We present the cases of 21 children who had acute and mature empyemas that were treated by open thoracotomy and decortication, with an average follow-up of 18 years, among whom there were no deaths or complications.

Forces during squatting and rising from a deep squat

The joint and muscle forces arising from and generated in the knee during the activity of squatting, and rising from a deep squat have been calculated. The analysis involved the consideration of a two-dimensional model. Data was then collected from each of the subjects performing the activity using: a force platform; a ciné film used in conjunction with the X-rays to describe accurately the configuration of the lower limb; EMG data; anthropometric data. A computer program was developed to analyse the data and compute the forces in the leg. Six subjects were tested and graphs of joint and muscle forces versus knee angle were obtained for each of them. A discussion follows. The results for ascent and descent, and slow and fast activities are compared.

Surgical treatment of anterior diaphragmatic hernia

Of ten patients with anterior diaphragmatic hernia treated by operation, only three had shortness of breath and chest pain. The remainder of the patients were referred to us because of a roentgenographic abnormality. All patients have had follow-up of between six months and 11 years without recurrence. Surgical repair is recommended to prevent incarceration and strangulation.

Middle lobe syndrome: diagnosis and management

Ninety-eight patients with middle lobe syndrome were reviewed. There were 31 male and 67 female patients ranging in age from 4 to 80 years. The most common presenting symptoms were cough, dyspnea, fever, hemoptysis, and chest pain. Diagnostic studies included chest roentgenogram, bronchoscopy, and bronchography. Sixty-five patients had full recovery following intensive medical therapy. Thirty-one patients underwent surgical resection for persistent disease. There were five post-operative complications and 1 death in this series.

Histoplasmosis: clinical manifestations and surgical management

In this retrospective study of 115 cases of histoplasmids, there were 66 male and 49 female patients ranging in age from 2 months to 79 years. The most common presenting symptoms were cough, chest pain, wheezing, weight loss, hemoptysis, and shortness of breath. Thirty-five patients (30%) were asymptomatic. Two patients had manifestations of obstruction of the superior vena cava. Radiologic findings simulated carcinoma, tuberculosis, pneumonia, and viral infections. Sixty-five patients had various operative proceudres, such as lung biopsy, wedge resection, lobectomy, pneumonectomy, resection of lymph node, and bypass of superior vena cava, for diagnosis and treatment. There were two deaths and two postoperative complications. A total of 15 patients received intravenous amphotericin B. Four patients with pneumonic infiltrates developed disseminated histoplasmosis.