Quantitative endoscopy: precise computerized measurement of metaplastic epithelial surface area in Barrett's esophagus

BACKGROUND/AIMS

The inability to precisely measure the area of Barrett's metaplasia has impaired the study of its natural history and response to therapy. This study used a novel computer program that creates two-dimensional maps of the esophagus allowing for calculation of the area of Barrett's metaplasia.

METHODS

Endoscopic photographs of Barrett's models and patients were obtained by independent endoscopists. The program transformed the photographs into maps, and the area of Barrett's metaplasia was calculated.

RESULTS

Using models, calculated areas correlated with actual areas (r = 0.96) with an overall error of 5.2%. Color, size, shape, diameter of the model, or endoscopist's experience did not affect the accuracy. Accuracy did improve by decreasing the interval between photographs from 4 cm (10.0% error) to 2 cm (4.8% error). In patients, area calculations from maps created by independent technicians correlated precisely (r = 0.99) at 1-cm (n = 22) and 2-cm (n = 40) intervals. Independent endoscopists correlated precisely in producing photographs for map construction (r = 0.99; n = 20).

CONCLUSIONS

This novel computer technology produces two-dimensional maps of Barrett's metaplasia that can be used to accurately calculate area. Minimal interobserver variability in obtaining photographs is found.

Characterization of domains of herpes simplex virus type 1 glycoprotein E involved in Fc binding activity for immunoglobulin G aggregates

Herpes simplex virus type 1 glycoproteins gE and gI form receptors for the Fc domain of immunoglobulin G (IgG) which are expressed on the surface of infected cells and on the virion envelope and which protect the virus from immune attack. Glycoprotein gE-1 is a low-affinity Fc receptor (FcR) that binds IgG aggregates, while gE-1 and gI-1 form a complex which serves as a higher-affinity FcR capable of binding IgG monomers. In this study, we describe two approaches used to map an Fc binding domain on gE-1 for IgG aggregates. First, we constructed nine plasmids encoding gE-1/gD-1 fusions proteins, each containing a large gE-1 peptide inserted into the ectodomain of gD-1. Fusion proteins were tested for FcR activity with IgG-sensitized erythrocytes in a rosetting assay. Three of the fusion proteins containing overlapping gE-1 peptides demonstrated FcR activity; the smallest peptide that retained Fc binding activity includes gE-1 amino acids 183 to 402. These results indicate that an Fc binding domain is located between gE-1 amino acids 183 and 402. To more precisely map the Fc binding domain, we tested a panel of 21 gE-1 linker insertion mutants. Ten mutants with insertions between gE-1 amino acids 235 and 380 failed to bind IgG-sensitized erythrocytes, while each of the remaining mutants demonstrated wild-type Fc binding activity. Taken together, these results indicate that the region of gE-1 between amino acids 235 and 380 forms an FcR domain. A computer-assisted analysis of the amino acid sequence of gE-1 demonstrates an immunoglobulin-like domain contained within this region (residues 322 to 359) which shares homology with mammalian FcRs.

Accurate placement of central venous catheters: a prospective, randomized, multicenter trial

OBJECTIVES

a) To define the frequency of dangerous (intracardiac) central venous catheter placement in a multicenter study of large community hospital intensive care units (ICUs) and to evaluate physician responses to this finding. b) To validate right atrial electrocardiography as a technique to assure adherence with recent Food and Drug Administration (FDA) guidelines regarding the location of central venous catheter tips. c) To conduct a literature review of vascular cannulation and its associated potentially lethal complications.

DESIGN

Prospective, randomized, blinded, multicenter study.

SETTING

Multidisciplinary ICUs in five large community teaching hospitals.

PATIENTS

Consecutive patients (n = 112) who required a central venous catheter by either internal jugular vein or subclavian vein at four separate hospitals were assessed using 30-cm catheters. Consecutive patients (n = 50) in a fifth hospital who subsequently required a central venous catheter via the internal jugular vein or subclavian vein route were prospectively randomized to receive a 20-cm central venous catheter with either conventional surface-landmark guidance, or with the right atrial electrocardiography-guided technique.

MAIN OUTCOME MEASURES

a) Occurrence rate of malpositioned central venous catheters. b) Ability of right atrial electrocardiography to aid in the accurate placement of central venous catheters.

RESULTS

a) Using conventional placement techniques with a 30-cm catheter, 53 (47%) of 112 initial central venous catheter placements resulted in location of the catheter tip within the heart. Catheter tips were not repositioned to locations outside the right atrium after this finding was identified on initial post-procedure films. b) Using the right atrial electrocardiography technique to place 20-cm central venous catheters resulted in no catheter tip locations within the heart (0/25) vs. 14 (56%) of 25 (p < .0001) intracardiac placements using conventional techniques. c) The literature suggests that serious mechanical complications of central venous catheterization, although uncommon, are associated with a high mortality rate. Deaths are associated with intracardiac placement.

CONCLUSIONS

a) The FDA guidelines regarding catheter tip location (catheter tip should not be in the right atrium) have not been widely publicized. b) The average safe insertion depth for a central venous catheter from the left or right internal jugular vein or subclavian vein is 16.5 cm for the majority of adult patients; a central venous catheter should not be routinely inserted to a depth of > 20 cm. Catheters longer than this size are rarely needed, and potentially dangerous. Catheter tip location is important to document following central venous catheter insertion. Thirty-centimeter central venous catheters should not be used when accessing the central circulation via internal jugular or subclavian veins. c) Right atrial electrocardiography is a technique that assures initial tip position outside the heart in accordance with FDA guidelines. This technique would virtually eliminate the major risk of death (i.e., cardiac perforation) associated with this procedure. d) Recently available, 15- and 16-cm central venous catheters have significant potential to minimize intracardiac placement of central venous catheters by either the internal jugular or subclavian vein route and may become the standard of care.

Effects of clinical maneuvers on sonographically determined internal jugular vein size during venous cannulation

We sought to define variations in internal jugular vein (IJV) anatomy and the effect of recommended cannulation maneuvers on a population of ICU patients. Maneuvers that decreased IJV lumen cross-sectional area were carotid artery palpation (1.48 to 0.82 cm2, p less than .05) and advancement of the needle (1.57 to 0.75 cm2, p less than .001). The head-down (modified Trendelenburg) position increased IJV lumen cross-sectional area (1.18 to 1.62 cm2, p less than .05). There was wide variability in IJV anatomic features, although most patients had patent veins.

Detection of renal blood flow abnormalities in septic and critically ill patients using a newly designed indwelling thermodilution renal vein catheter

To evaluate alterations in renal blood flow in sepsis-induced renal failure, we developed and studied a percutaneously placed thermodilution renal blood flow catheter in eight critically ill patients. Para-aminohippurate extraction coefficients were decreased, supporting the need for renal vein sampling to determine CPAH in sepsis. Thermodilution and CPAH methods correlated strongly, confirming the reliability of this thermodilution method. Renal vascular resistance, an indicator of renal vascular function, remained unchanged throughout the bouts of sepsis. The fraction of total body arterial blood flow going to the kidneys rose significantly during recovery from sepsis. Glomerular filtration rate, which was reduced in four of seven septic patients, correlated with the fraction of total blood flow going to the kidneys. These results suggest that renal vascular abnormalities may be occurring during septic shock. Our study demonstrates that sepsis-induced renal dysfunction may occur despite normal ranges of total renal blood flow during shock.

Ultrasound guidance improves the success rate of internal jugular vein cannulation. A prospective, randomized trial

STUDY OBJECTIVE

To compare conventional versus ultrasound-guided internal jugular vein cannulation techniques.

DESIGN

Patients were randomly assigned to receive either conventional or two-dimensional ultrasound-guided internal jugular vein cannulation. Patients who could not be cannulated with five or fewer passes by either technique, were crossed over to the other technique.

SETTING

Clinical research unit in a tertiary care center.

PATIENTS

All consecutive patients who required urgent or urgent-elective internal jugular vein cannulation during the study period.

INTERVENTIONS

The two-dimensional ultrasound transducer imaged all cannulation attempts. For patients randomized to ultrasound guidance, the operator viewed two-dimensional ultrasound images, and received verbal guidance from the ultrasound technician. For patients randomized to the conventional arm, two-dimensional ultrasound images were recorded without visual or verbal feedback.

MEASUREMENTS AND MAIN RESULTS

Two-dimensional ultrasound was significantly better than conventional guidance in reducing the number of failed site cannulations from 6/17 (35 percent), to 0/12 (0 percent), p less than 0.05. Two-dimensional ultrasound also reduced the mean number of passes required to cannulate the vein from 3.12 to 1.75 (p less than .05), and was also successful in six/six (100) of patients who failed cannulation by conventional means (p less than 0.05).

CONCLUSIONS

Intensivists can increase successful internal jugular vein cannulation using ultrasound guidance. Two-dimensional ultrasound should be considered for patients difficult to cannulate or those at high risk of cannulation complications.

Cardiovascular effects and safety of intravenous and intramuscular pentamidine isethionate

Intramuscular (im) pentamidine isethionate can cause substantial local pain and inflammation at the injection site. This drug is being used more frequently in recent years to treat Pneumocystis pneumonia, particularly in patients with acquired immunodeficiency syndrome. Clinicians began administering it iv despite warnings that iv administration might cause severe hypotension. We investigated the safety of im and iv pentamidine, monitoring hemodynamics after each dose in 11 patients with intra-arterial lines. Results showed only a small (but statistically significant) fall in mean arterial pressure after both im and slow (60 min) iv administration. A concomitant decrease in pulse occurred, but no change in cardiac output, pulmonary capillary occlusion pressure or systemic vascular resistance was noted. These results suggest that it may be safe to infuse pentamidine slowly intravenously. This route is more comfortable to patients than im administration.