Volumetric evaluation of hepatic tumors: multi-vendor,multi-reader liver phantom study

Purpose

To compare liver lesion volume measurement on multiple 3D software platforms using a liver phantom.

Methods

An anthropomorphic phantom constructed with ten liver lesions of varying size, attenuation, and shape with known volume and long axis measurement was scanned (120 kV_p, 80–440 smart mA, NI 12). DICOM data were uploaded to five commercially available 3D visualization systems and manual tumor volume was obtained by three-independent readers. Accuracy and reproducibility of linear and volume measurements were compared. The two most promising systems were then compared with an additional prototype system by two readers using both manual and semi-automated measurement with similar comparison between linear and volume measures. Measurements were performed on 5- and 1.25-mm data sets. Inter- and intra-observer variability was also assessed.

Results

Overall mean % volume error on the five commercially available software systems (averaging all ten liver lesions among all three readers) was 8.0% ± 7.5%, 13.7% ± 11.2%, 14.2% ± 15.2%, 16.4% ± 14.8 %, and 16.9% ± 13.8%, varying almost twofold across vendor. Moderate inter-observer variability was present. Volume measurement was slightly more accurate than linear measurement, but linear measurement was more reproducible across readers and systems. On the two “best” systems, the manual measurement method was more accurate than the automated method (p = 0.001). The prototype system demonstrated superior semi-automated assessment, with a mean % volume error of 5.3% ± 4.1% (vs. 17.8% ± 11.1% and 31.5% ± 19.7%, p < 0.001), with improved inter- and intra-observer variability.

Conclusions

Accuracy and reproducibility of volume assessment of liver lesions varies significantly by vendor, which has important implications for clinical use.     

Volumetric analysis of pelvic hematomas after blunt trauma using semi-automated seeded region growing segmentation: a method validation study

Objective

Manually segmented traumatic pelvic hematoma volumes are strongly predictive of active bleeding at conventional angiography, but the method is time intensive, limiting its clinical applicability. We compared volumetric analysis using semi-automated region growing segmentation to manual segmentation and diameter-based size estimates in patients with pelvic hematomas after blunt pelvic trauma.

Materials and methods

A 14-patient cohort was selected in an anonymous randomized fashion from a dataset of patients with pelvic binders at MDCT, collected retrospectively as part of a HIPAA-compliant IRB-approved study from January 2008 to December 2013. To evaluate intermethod differences, one reader (R1) performed three volume measurements using the manual technique and three volume measurements using the semi-automated technique. To evaluate interobserver differences for semi-automated segmentation, a second reader (R2) performed three semi-automated measurements. One-way analysis of variance was used to compare differences in mean volumes. Time effort was also compared. Correlation between the two methods as well as two shorthand appraisals (greatest diameter, and the ABC/2 method for estimating ellipsoid volumes) was assessed with Spearman’s rho (r).

Results

Intraobserver variability was lower for semi-automated compared to manual segmentation, with standard deviations ranging between ±5–32 mL and ±17–84 mL, respectively (p = 0.0003). There was no significant difference in mean volumes between the two readers’ semi-automated measurements (p = 0.83); however, means were lower for the semi-automated compared with the manual technique (manual: mean and SD 309.6 ± 139 mL; R1 semi-auto: 229.6 ± 88.2 mL, p = 0.004; R2 semi-auto: 243.79 ± 99.7 mL, p = 0.021). Despite differences in means, the correlation between the two methods was very strong and highly significant (r = 0.91, p < 0.001). Correlations with diameter-based methods were only moderate and nonsignificant. Mean semi-automated segmentation time effort was 2 min and 6 s and 2 min and 35 s for R1 and R2, respectively, vs. 22 min and 8 s for manual segmentation.

Conclusion

Semi-automated pelvic hematoma volumes correlate strongly with manually segmented volumes. Since semi-automated segmentation can be performed reliably and efficiently, volumetric analysis of traumatic pelvic hematomas is potentially valuable at the point-of-care.

     

Total and viable residual splenic volume measurement after partial splenic embolization by three-dimensional ultrasound

Purpose

We prospectively evaluated the validity of total and viable residual splenic volume after partial splenic embolization (PSE) with three-dimensional (3D) ultrasound (US) measurement.

Methods

Twenty patients with splenomegaly were included. All splenic volumes were measured with transabdominal US using virtual organ computer-aided analysis (VOCAL). The viable residual splenic volume after PSE was estimated by using contrast-enhanced (CE) US with VOCAL. The agreement of the measurements from VOCAL and computed tomography (CT) was confirmed using interclass correlation coefficients (ICCs) and Bland–Altman plots.

Results

Mean volume was 503 ± 250 ml for total spleen and 209 ± 108 ml for viable residual volume. Regarding total volume, there was a high correlation and agreement (ICCs = 0.90) between 3D US and CT volumetry. Regarding viable residual volume, although there was a moderate correlation between 3D CEUS and CT volumetry, mean ICCs of 0.617 indicated poor agreement. With Bland–Altman plots, a narrow 95 % limit of agreement was observed among patients with a total volume under 1000 ml.

Conclusion

The total splenic volume could be accurately estimated with 3D US. However, estimation of viable residual splenic volume should be limited in cases with total splenic volume under 1000 ml.     

Kosteneffizienzvergleich von Physiotherapie, manueller Therapie und hausärztlicher Therapie in der Behandlung von Nackenschmerzen

Objective

To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neckpain.

Design

Economic evaluation alongside a randomized controlled trial.

Setting

Primary care.

Participants

A total of183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilization), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counseling, education, and drugs).

Main outcome measures

Clinical outcomes were perceived: recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques.

Results

The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow-up at 52 weeks. The total costs of manual therapy (447 EUR) were around one third of the costs of physiotherapy (1297 EUR) and general practitioner care (1379 EUR). These differences were significant: p<0.01 for manual therapy vs. physiotherapy and manual therapy vs. general practitioner care, and p=0.55 for general practitioner care vs. physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care.

Conclusions

Manual therapy (spinal mobilization) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.     

Automated sedation outperforms manual administration of propofol and remifentanil in critically ill patients with deep sedation: a randomized phase II trial

Purpose

To compare automated administration of propofol and remifentanil guided by the Bispectral index (BIS) versus manual administration of short-acting drugs in critical care patients requiring deep sedation. The primary outcome was the percentage of BIS values between 40 and 60 (BIS_40–60).

Methods

This randomized controlled phase II trial in the intensive care unit (ICU) was conducted in adults with multiorgan failure. Thirty-one patients were assigned to receive sedation with propofol or remifentanil either by an automated or a manual system, both targeting BIS_40–60. Performance and feasibility of an automated administration were assessed.

Results

The study groups were well balanced in terms of demographic characteristics. Study duration averaged 18 [8–24] h in the automated group and 14 [9–21] h in the manual group (p = 0.81). Adequate sedation (BIS_40–60) was significantly more frequent in the automated group 77 [59–82] % than in the manual group 36 [22–56] %, with p = 0.001. Propofol consumption was reduced by a factor of 2 in the automated group with a median change of infusion rates of 39 ± 9 times per hour. In contrast, there were only 2 ± 1 propofol and 1 ± 1 remifentanil dose changes per hour in the manual group compared to 40 ± 9 for remifentanil in the automated group (p < 0.001). Vasopressors were more often discontinued or reduced in the automated group than in the manual control group (36 [6–40] vs. 12 [4–20] modifications, p = 0.03).

Conclusions

Continuous titration of propofol and remifentanil sedation with an automatic controller maintains deep sedation better than manual control in severely ill patients. It is associated with reduced sedative and vasopressor use.     

Pancreatic retention cyst: multi-modality imaging findings and review of the literature

Purpose

To investigate the multi-modality imaging presentation of the pancreatic retention cyst (PRC) with pathologic correlation.

Methods

Imaging data including CT, MRI, endoscopic ultrasonography (EUS) and EUS guided fine needle aspiration (EUS-FNA), and endoscopic retrograde cholangiopancreatography (ERCP) in fifteen patients (five males and ten females; mean age, 44.5 years) with pathologically proven PRC were analyzed retrospectively, and imaging features were correlated with pathological findings.

Results

Sixteen PRCs of 15 patients were included in this study. The mean size of PRCs was 4.4 × 4.6 cm (range 0.5 × 0.6–8.1 × 10.1 cm). PRC were round (n = 11), oval (n = 2), or lobular (n = 3). Punctiform calcification of the wall on CT (n = 2), thin septa (n = 4), thin wall (n = 3), and dilation of upstream pancreatic duct (n = 6; mean diameter, 4.3 mm) were detected. Dilation of upstream pancreatic duct was smooth in five PRCs and irregular in one PRC with pancreatic duct with punctiform calcification. Communication of PRCs with pancreatic duct was seen in two patients (one on CT, one on ERCP). Pancreatic inflammation and neoplasm were detected in four and two patients, respectively.

Conclusions

PRC typically presents as a well-defined, round cystic lesion, and different associated pathologic conditions including pancreatic inflammation and neoplasm may be detected in some patients on the multi-modality imaging examinations. Smooth dilation of upstream pancreatic duct with uncommon communication to the cyst may be helpful for the differentiation. Combination of a variety of imaging modalities could contribute to improve the diagnosis.     

MRI manifestations of adult choledochal cysts associated with biliary malignancy: a report of ten cases

Background

To retrospectively review the MRI imaging features of adult choledochal cysts associated with biliary malignancy.

Patients and methods

Ten out of 72 cases of adult choledochal cysts were found to be associated with biliary malignancy between January 1, 2003 and April 1, 2011 in our hospital database. The following MRI findings of these ten patients were retrospectively reviewed: the type of choledochal cysts, the presence of anomalous union of the pancreaticobiliary duct (AUPBD), manifestations of biliary malignancy, and concomitant findings.

Results

Among the ten patients, there were five type I and five type IVA choledochal cysts. AUPBD was noted in four cases. The biliary malignancy was diagnosed as cholangiocarcinoma in seven cases (70.0%) and as gallbladder cancer in three cases. Cholangiocarcinoma manifested with irregularly thickened cyst wall (n = 2), mass with irregularly thickened cyst wall (n = 4), or multiple papillary nodules without thickened cyst wall (n = 1). Most of them showed mark enhancement (n = 4) after contrast administration. Gallbladder cancer appeared as mass with irregular thickening of the gallbladder wall with inhomogeneous enhancement. Concomitant findings included liver invasion or metastases in five cases, lymph node metastases in two cases, cholangitis and/or hepatic abscess in two cases, biliary stones in three cases. The type of choledochal cysts and the extent of malignant tumor invasion revealed by MRI were consistent with the surgical findings.

Conclusion

Most malignancies associated with choledochal cysts are cholangiocarcinoma and gallbladder cancer. MRI is a reliable method for the detection of choledochal cysts with biliary malignant changes. MR features such as irregular thickening of the gallbladder wall or cyst wall, mass or papillary nodules are suggestive of biliary malignant changes.     

The influence of age and BMI on intervertebral disc height and oropharyngeal airway in Japanese men and women

Objective

Intervetebral disc height changes with both age and increasing body mass index (BMI), known risk factors for obstructive sleep apnea (OSA). We studied the relationship of body mass index (BMI) and aging in the neck structures to disc compression and oropharyngeal airway size and shape.

Materials and methods

The intervertebral disc (IVD), neck and airway volumes were measured at the C2 level only from Computerized Tomography scans using a semi-automatic segmentation tool. The change of intervertebral disc height/volume with age and BMI were examined in 38 consecutive Japanese patients (Male: 19, Female: 19), group matched for age (men: 52.2 ± 15.36 years; women: 52.4 ± 17.37) and BMI (men: 23.1 ± 2.97 m/kg²; women: 21.6 ± 4.03 m/kg²).

Results

In this study, the intervertebral disc volume as a percent of neck volume was larger in men than in women (P = 0.039), and the intervertebral disc volume (r = ?0.588; P = 0.013) and height (r = ?0.510; P = 0.037) decreased with increasing age-adjusted BMI in males only. Age was not significantly correlated with any of the volumes. The intervertebral airway volume significantly decreased with increasing age-adjusted BMI in our female subjects (r = ?0.588; P = 0.013).

Conclusion

In our Japanese volunteer population, the intervertebral disc is compressed vertically with the increase of BMI in males only, and the oropharyngeal airway volume decreases with increasing BMI in females only. These results may be useful in assessment of OSA risk.     

Cardiac volumetry in patients with heart failure and reduced ejection fraction: a comparative study correlating multi-slice computed tomography and magnetic resonance tomography. Reasons for intermodal disagreement

Background

In humans with normal hearts multi-slice computed tomography (MSCT) based volumetry was shown to correlate well with the gold standard, cardiac magnetic resonance imaging (CMR). We correlated both techniques in patients with various degrees of heart failure and reduced ejection fraction (HFREF) resulting from cardiac dilatation.

Methods

Twenty-four patients with a left ventricular end-diastolic volume (LV-EDV) of ≥ 150 ml measured by angiography underwent MSCT and CMR scanning for left and right ventricular (LV, RV) volumetry. MSCT based short cardiac axis views were obtained beginning at the cardiac base advancing to the apex. These were reconstructed in 20 different time windows of the RR-interval (0–95%) serving for identification of enddiastole (ED) and end-systole (ES) and for planimetry. ED and ES volumes and the ejection fraction (EF) were calculated for LV and RV. MSCT based volumetry was compared with CMR.

Results

MSCT based LV volumetry significantly correlates with CMR as follows: LV-EDV r = 0.94, LV-ESV r = 0.98 and LV-EF r = 0.93, but significantly overestimates LV-EDV and LV-ESV and underestimates EF (P < 0.0001). MSCT based RV volumetry significantly correlates with CMR as follows: RV-EDV r = 0.79, RV-ESV r = 0.78 and RV-EF r = 0.73, but again significantly overestimates RV-EDV and RV-ESV and underestimates RV-EF (P < 0.0001).

Conclusion

When compared with CMR a continuous overestimation of volumes and underestimation of EF needs to be considered when applying MSCT in HFREF patients.     

Non-invasive quantification of right ventricular systolic function by echocardiography: a new semi-automated approach

Background

Right ventricular (RV) function determines long-term outcome in many cardiopulmonary diseases. However, the assessment of RV function is time-consuming and surrogate parameters derived from two-dimensional (2D) or Doppler echocardiography show poor consistency.

Methods

Forty consecutive patients were examined within 30 min after magnetic resonance imaging (MRI) with comprehensive echocardiography, including strain imaging and real-time three-dimensional echocardiography. A new parameter, the RV automated systolic index (RV-ASI), was obtained from the apical four-chamber view using semi-automated border detection.

Results

RV-ASI could be assessed by 2D echocardiography in 38 of 40 patients. RV ejection fraction assessed by MRI was 48 ± 9 %, while RV-ASI was 52 ± 11 % (r = 0.74, SEE = 6 %, p < 0.0001). Intra- and inter-observer variabilities were 7.5 and 8.9 %, respectively. An RV-ASI cut-off value of 52 % in this cohort was able to differentiate between normal and impaired RV function (AUC 0.92, sensitivity 87 %, specificity 93 %).

Conclusions

In this study, the RV-ASI showed to be an easy, rapid to assess and reliable tool for quantification of right ventricular function. Furthermore, this index can complement the assessment of right ventricular mechanics by 2D strain imaging for efficient and comprehensive non-invasive evaluation of right ventricular function.     

Normal values of liver elasticity measured by real-time tissue elastography (RTE) in healthy infants and children

Purpose

To define normal values of liver elasticity measured by real-time tissue elastography (RTE) in healthy infants and children.

Methods

RTE was performed on 91 children and adolescents by two experienced observers (female, n = 43; male, n = 48) and in two age groups (0–10 years, n = 45; 11–20 years, n = 46). Hepatopathies were excluded clinically by extensive laboratory testing and by ultrasound. RTE provides a histogram from a region of interest (ROI) in the liver representing the degree of stiffness of the liver. The distribution of the colors in the histogram corresponds to organ elasticity. By calculating the mean of stiffness values, a numerical value is expressed in arbitrary units (a.u.) representing the mean elasticity of the liver (MEAN). Additionally, the percentage values of relatively stiffer areas (color coded in blue) in the ROI can be calculated (%AREA). A Mann–Whitney U test was performed for these two parameters according to gender. The reproducibility of these values was determined with an intraclass correlation coefficient (ICC) test on another group of 18 healthy volunteers.

Results

The median elasticity was 106 a.u. Gender did not have an influence on the parameters (MEAN: p = 0.052; %AREA: p = 0.051). Age-specific analyses did not yield any significant difference between the two age groups for either of the two analyzed parameters (MEAN: p = 0.059; %AREA: p = 0.058). The ICC test demonstrated a moderate agreement for MEAN (ICC = 0.582) and %AREA (ICC = 0.659).

Conclusion

Real-time elastography is a new sonography-based method and may be used as a supportive analysis to assess liver parenchyma elasticity in children, especially when fibrosis is suspected. We measured RTE normal values in children as reference data.     

Comparison of two repositioning schedules for the prevention of pressure ulcers in patients on mechanical ventilation with alternating pressure air mattresses

Purpose

The objective was to compare the effectiveness of repositioning every 2 or 4 h for preventing pressure ulcer development in patients in intensive care unit under mechanical ventilation (MV).

Methods

This was a pragmatic, open-label randomized clinical trial in consecutive patients on an alternating pressure air mattress (APAM) requiring invasive MV for at least 24 h in a university hospital in Spain. Eligible participants were randomly assigned to groups for repositioning every 2 (n = 165) or 4 (n = 164) h. The primary outcome was the incidence of a pressure ulcer of at least grade II during ICU stay.

Results

A pressure ulcer of at least grade II developed in 10.3 % (17/165) of patients turned every 2 h versus 13.4 % (22/164) of those turned every 4 h (hazard ratio [HR] 0.89, 95 % confidence interval [CI] 0.46–1.71, P = 0.73). The composite end point of device-related adverse events was recorded in 47.9 versus 36.6 % (HR 1.50, CI 95 % 1.06–2.11, P = 0.02), unplanned extubation in 11.5 versus 6.7 % (HR 1.77, 95 % CI 0.84–3.75, P = 0. 13), and endotracheal tube obstruction in 36.4 versus 30.5 %, respectively (HR 1.44, 95 % CI 0.98–2.12, P = 0.065). The median (interquartile range) daily nursing workload for manual repositioning was 21 (14–27) versus 11 min/patient (8–15) (P < 0.001).

Conclusions

A strategy aimed at increasing repositioning frequency (2 versus 4 h) in patients under MV and on an APAM did not reduce the incidence of pressure ulcers. However, it did increase device-related adverse events and daily nursing workload.     

Effect of β-Glucan on Drain Fluid and Amount of Drainage Following Modified Radical Mastectomy

Introduction

To reduce the seroma formation following mastectomy and axillary dissection, many different techniques and drugs have been investigated. The aim of this study is to evaluate the effects of oral β-glucan on drain fluid and efficacy of daily drainage and drain removal day in mastectomy patients.

Methods

One hundred and thirty breast cancer patients of Ankara Oncology Training and Research Hospital were divided into 2 groups by consecutive randomization (n = 65 each). β-glucan 10 mg capsules were administered to Group 1 twice a day for 10 days. Group 2 took placebos in the same manner. Age, menarche age, menopause, parity, history of oral contraceptives, comorbidities, postoperative daily drainage volumes and drain removal days were recorded and compared. Seroma samples during the first and second day of drainage were taken for analysis of Interleukin-6 (IL-6) and Tumor Necrosis Factor (TNF-α).

Results

There was no difference between groups in terms of age, menarche age, menopause period, parity, oral contraceptive use and comorbidities. Group 1 showed significantly lower daily drainage volumes between days 2 and 8. Mean drain removal day was 7.16 ± 1.72 in Group 1 and 8.59 ± 2.27 in Group 2. The difference was significant (p < 0.001). TNF-α and IL-6 levels on days 1 and 2 in Group 1 were significantly lower (p < 0.001). In addition, β-glucan significantly shortened the number of days required for the drain removal in patients who have comorbidities (p = 0.018). The earliest removal was in patients without comorbidity and who received β-glucan (p = 0.002).

Conclusion

β-glucan decreased drain discharges after mastectomy. The drains were removed earlier in β-glucan administered patients.     

Early diffusion-weighted magnetic resonance imaging in children after cardiac arrest may provide valuable prognostic information on clinical outcome

Objective

We examined whether early diffusion-weighted magnetic resonance imaging (DW-MRI) abnormalities of the brain and variation of apparent diffusion coefficient (ADC) values can provide prognostic information on clinical outcome in children following cardiac arrest (CA).

Design

Retrospective study.

Setting

A 12-bed paediatric intensive care unit (PICU).

Patients

Children aged between 1 month and 18 years who had DW-MRI with ADC measurement within the first week following CA. Neurological outcomes were assessed using the Pediatric Cerebral Performance Category Scale (PCPC). Differences between the favourable (PCPC ≤3) and unfavourable (PCPC ≥4) groups were analysed with regard to clinical data, electrophysiological patterns as well as qualitative and quantitative DW-MRI abnormalities.

Results

Twenty children with a median age of 20 months (1.5–185) and a male/female sex ratio of 1.5 underwent DW-MRI after CA with a median delay of 3 days (1–7). Aetiologies of CA were (i) asphyxia (n = 10), (ii) haemodynamic (n = 5) or (iii) unknown (n = 5). With regard to DW-MRI findings, the unfavourable outcome group (n = 8) was associated with cerebral cortex (p = 0.02) and basal ganglia (p = 0.005) lesions, with a larger number of injured brain regions (p = 0.001) and a global decrease in measured ADC signal (p = 0.008). Normal DW-MRI (n = 5) was exclusively associated with the favourable outcome group (n = 12).

Conclusion

Qualitative, topographic and quantitative analysis of early DW-MRI with ADC measurement in children following CA may provide valuable prognostic information on neurological outcomes.     

3-D Ultrasound Segmentation of the Placenta Using the Random Walker Algorithm: Reliability and Agreement

Volumetric segmentation of the placenta using 3-D ultrasound is currently performed clinically to investigate correlation between organ volume and fetal outcome or pathology. Previously, interpolative or semi-automatic contour-based methodologies were used to provide volumetric results. We describe the validation of an original random walker (RW)-based algorithm against manual segmentation and an existing semi-automated method, virtual organ computer-aided analysis (VOCAL), using initialization time, inter- and intra-observer variability of volumetric measurements and quantification accuracy (with respect to manual segmentation) as metrics of success. Both semi-automatic methods require initialization. Therefore, the first experiment compared initialization times. Initialization was timed by one observer using 20 subjects. This revealed significant differences (p < 0.001) in time taken to initialize the VOCAL method compared with the RW method. In the second experiment, 10 subjects were used to analyze intra-/inter-observer variability between two observers. Bland–Altman plots were used to analyze variability combined with intra- and inter-observer variability measured by intra-class correlation coefficients, which were reported for all three methods. Intra-class correlation coefficient values for intra-observer variability were higher for the RW method than for VOCAL, and both were similar to manual segmentation. Inter-observer variability was 0.94 (0.88, 0.97), 0.91 (0.81, 0.95) and 0.80 (0.61, 0.90) for manual, RW and VOCAL, respectively. Finally, a third observer with no prior ultrasound experience was introduced and volumetric differences from manual segmentation were reported. Dice similarity coefficients for observers 1, 2 and 3 were respectively 0.84 ± 0.12, 0.94 ± 0.08 and 0.84 ± 0.11, and the mean was 0.87 ± 0.13. The RW algorithm was found to provide results concordant with those for manual segmentation and to outperform VOCAL in aspects of observer reliability. The training of an additional untrained observer was investigated, and results revealed that with the appropriate initialization protocol, results for observers with varying levels of experience were concordant. We found that with appropriate training, the RW method can be used for fast, repeatable 3-D measurement of placental volume.     

Dorsal acoustic windows may ameliorate liver ultrasound in patients with chronic liver disease and meteorism/obesity/ascites

Purpose

To identify dorsal acoustic windows (DAWs) for the study of the liver and to investigate whether they could improve the visualization of the liver in patients with chronic liver disease and ascites, meteorism, and/or obesity.

Methods

The study was based on a single ultrasound examination and divided into three successive stages. Firstly, we performed a preliminary study involving 10 cirrhotic patients to identify new DAWs. Inter-observer reproducibility of measurements obtained through the DAWs was then assessed in another 29 cirrhotic patients. Finally, in 50 patients with chronic hepatitis/cirrhosis, we employed the DAWs when ascites, meteorism or obesity hampered the conventional ultrasound examination.

Results

With patients sitting, we found three new DAWs, by the combined use of which it was possible to explore the liver, spleen, and their vascular structures, and which provided reproducible measurements. In the clinical setting, we found 11 of 50 patients in whom the addition of the new DAWs led to better results in terms of successful visualization/Doppler measurements for portal vein (ratio = 100 % vs 27 %, p = 0.001), hepatic artery (ratio = 90 % vs 27 %, p = 0.004), and hepatic veins (mean number = 2.4 ± 0.2 vs 1.0 ± 0.2, p = 0.01). Among these 11 patients, in one case the addition of DAWs led to visualization of hepatic focal lesions in the right lobe, not previously displayed through conventional ultrasound.

Conclusion

These DAWs may be an additional tool that improves the accuracy of ultrasound examinations in patients with meteorism, ascites, or obesity.     

A randomized trial of intravenous glutamine supplementation in trauma ICU patients

Purpose

To evaluate the effect of the intravenous (i.v.) l-alanyl-l-glutamine dipeptide supplementation during 5 days on clinical outcome in trauma patients admitted to the intensive care unit (ICU).

Methods

This was a prospective, randomized, double-blind, multicenter trial. Glutamine was not given as a component of nutrition but as an extra infusion. The primary outcome variable was the number of new infections within the first 14 days.

Results

We included 142 patients. There were no differences between groups in baseline characteristics. Up to 62 % of the patients in the placebo group and 63 % in the treatment group presented confirmed infections (p = 0.86). ICU length of stay was 14 days in both groups (p = 0.54). Hospital length of stay was 27 days in the placebo group and 29 in the treatment group (p = 0.88). ICU mortality was 4.2 % in both groups (p = 1). Sixty percent of the patients presented low glutamine levels before randomization. At the end of the treatment (6th day), 48 % of the patients maintained low glutamine levels (39 % of treated patients vs. 57 % in the placebo group). Patients with low glutamine levels at day 6 had more number of infections (58.8 vs. 80.9 %; p = 0.032) and longer ICU (9 vs. 20 days; p < 0.01) and hospital length of stay (24 vs. 41 days; p = 0.01).

Conclusions

There was no benefit with i.v. l-alanyl-l-glutamine dipeptide supplementation (0.5 g/kg body weight/day of the dipeptide) during 5 days in trauma patients admitted to the ICU. The i.v. glutamine supplementation was not enough to normalize the plasma glutamine levels in all patients. Low plasma glutamine levels at day 6 were associated with a worse outcome.     

Ultrasound assessment of gastric volume in critically ill patients

Purpose

To assess the feasibility and validity of ultrasonographic measurement of gastric antral cross-sectional area (usCSA) in critically ill patients to predict gastric volume and the use of computed tomography (CT) as a reference to measure gastric volume.

Method

This single-center, prospective, cross-sectional study included 55 critically ill patients who had an abdominal CT scan. usCSA measurements were performed within the hour preceding the CT scan. Gastric volumes were measured on the CT scan using semiautomatic software. The feasibility rate, performing conditions (% “good” and “poor”), internal and external validity of antral usCSA measurements, performed by an ICU physician, were assessed to predict gastric volume.

Results

Antral usCSA measurements were feasible in 95 % of cases and were positively correlated with gastric volume measured by the CT scan when performed in “good” conditions (65 %) (r = 0.43). There was good reproducibility of measurements (intraclass correlation coefficient of 0.97, CI 95 % 0.96–0.99) and there was clinically acceptable agreement between measurements performed by radiologists and intensivists (bias ?0.12 cm²). The receiver operating characteristic curve identified a cutoff value of 3.6 cm² that discriminated an “at-risk stomach” (volume >0.8 mL/kg) at a sensitivity of 76 % and a specificity of 78 %.

Conclusions

Ultrasonographic measurement of antral CSA is feasible and reliable in the majority of critically ill patients. This technique could be useful to manage critically ill patients at risk of aspiration or with enteral feeding.     

Comparison of cardiac output and blood volumes in intrathoracic compartments measured by ultrasound dilution and transpulmonary thermodilution methods

Purpose

To compare cardiac output (CO) and blood volumes measured by COstatus^® (Transonic Systems Inc., NY, USA) versus PiCCO (Philips IntelliVue MP40 with PiCCO-technology module M3012A#10, Netherlands) in adult ICU patients.

Methods

This was a prospective single-center study. Each of the 30 patients studied received a 5-Fr Pulsiocath femoral arterial and a standard central venous catheter. Twenty ml of iced 5% dextrose solution was injected for PiCCO measurements. For COstatus measurements, an extracorporeal arteriovenous loop, with two sensors placed on it, was connected between the Pulsiocath femoral arterial and central venous catheters. Blood was circulated through this loop at 12 ml/min for 5–8 min using a pump. Twenty ml of warm saline was injected into the venous side for measurements. For each method, three injections were averaged for comparison.

Results

A good agreement for measured CO (range 3.65–16.3 l/min) with a percentage error of 20% was observed, with r = 0.95, bias = ?0.037 l/min. PiCCO’s global end-diastolic volume (GEDV) was 2.5 times larger than the analogous COstatus’s total end-diastolic volume (TEDV) [TEDV = 0.28 × GEDV + 176 ml]. PiCCO’s intrathoracic blood volume (ITBV) was larger than the analogous COstatus’s central blood volume (CBV) [CBV = 0.73 × (ITBV) +78 ml].

Conclusions

CO measured by COstatus was found to be equivalent and hence interchangeable with PiCCO in this study population. COstatus blood volumes were found to be within the expected physiological range whilst PiCCO blood volumes were significantly higher, which was also observed in other studies. Future studies using 3D echo/MRI are required to validate these blood volumes.     

Use of strain ratio in evaluating superficial soft tissue tumors on ultrasonic elastography

Object

The aim of this study was to describe the strain ratio in histopathologically confirmed superficial soft tissue tumors using ultrasonic elastography (USE).

Methods

From March to August 2012, 94 soft tissue tumors in 79 consecutive patients (age range 19–70 years) were examined using USE for palpable masses. Among them, 39 lesions in 36 patients were histopathologically confirmed. Thirty-four lesions in 31 patients with lipoma, ganglion, epidermal inclusion cyst, and pilomatricoma were included: 34 histopathologically confirmed mature lipomas (n = 19), ganglia (n = 6), epidermal inclusion cysts (n = 5), and pilomatricomas (n = 4). Ultrasonographic features of margins, echogenicity, walls, ultrasonic transmission, and vascular flow via Doppler ultrasonography were evaluated. The strain ratios were calculated from the USE strain measured within the lesion and in adjacent tissue. Intraclass correlation (ICC) with Cohen’s kappa was used to determine intraobserver agreement, and the strain ratios of the three groups were compared using Mann–Whitney U tests. All statistical analyses were performed using R package statistical software, and p values <0.05 were considered to be statistically significant.

Results

On USE, repeated measurements of the strain ratios showed excellent intraobserver agreement [ICC value = 0.952 (CI 0.905–0.977), p < 0.05]. The strain ratios of lipomas (median ± standard error 0.83 ± 0.18) were statistically different (p < 0.05) from those of ganglia, epidermal inclusion cysts, and pilomatricomas. The strain ratios of ganglia (2.78 ± 0.48) were also statistically different (p < 0.05) from those of epidermal inclusion cysts and pilomatricomas. The strain ratios of epidermal inclusion cysts (0.17 ± 0.21) were not statistically different (p > 0.05) from that of pilomatricomas (0.13 ± 0.02).

Conclusion

Strain ratios determined by USE help to differentiate lipomas and ganglia from other superficial soft tissue tumors. Our results suggest that USE could be used in addition to traditional ultrasound techniques to obtain diagnostic clues in the evaluation of superficial soft tissue tumors.