Is there an underestimation of intima‐media thickness based on M‐mode ultrasound technique in the abdominal aorta?

Measuring intima-media thickness (IMT) in the common carotid artery (CCA) is a valuable resource for the evaluation of subclinical atherosclerosis. The main objective of this study was to explore whether a B-mode ultrasound technique, Philips ATL, and an M-mode ultrasound technique, Wall Track System (WTS), show interchangeable results when measured in CCA and the abdominal aorta (AA). A total of 24 healthy, young subjects were examined. IMT and lumen diameter (LD) of the AA and the CCA were measured twice by two skilled ultrasonographers with two different ultrasound equipment B-mode: (Philips, ATL and M-mode: WTS).The intra-observer variability of IMT in CCA and AA using B-mode showed a coefficient of variation 8% and 9%, and with M-mode 11% and 15%, respectively. Interobserver variability of IMT in CCA and AA using B-mode was 6% and 12%, and with M-mode 11% and 18%, respectively. CCA IMT was 0·53 ± 0·07 and 0·53 ± 0·09 mm using B-mode and M-mode, respectively. However, in AA, IMT was 0·61 ± 0·05 and 0·54 ± 0·10 mm using B-mode and M-mode, respectively. Thus, AA IMT was 11·5% thicker using B-mode (P < 0·01). We received adequate IMT readings from the carotid artery as well as the AA using two commonly used B-mode and M-mode techniques. B-mode technique seems to show less variability, especially in the AA. More importantly, the two techniques measured different IMT thickness in the aorta, emphasizing the importance of using similar technique when comparing the impact of absolute values of IMT on cardiovascular disease.     

Is there still gender bias in nursing research? An update

Data from 300 studies published in four research journals in 2010–2011 were analyzed to assess whether nurse researchers continue to oversample females. One‐third of the studies had samples that were 100% female and, on average, 74% of all study participants were female. As was found for studies published 5 years earlier, the bias against male participants was consistent across studies differing in methods, specialty areas, funding, and sample characteristics. Studies with male first authors, however, were significantly less likely to have biased samples. Authors of only 23.6% of studies with mixed‐sex samples provided information about sex differences in outcomes. Because of gender bias, the evidence base for nursing practice may suffer from problems with generalizability. © 2012 Wiley Periodicals, Inc. Res Nurs Health 36:75–83, 2013     

Is there still a role for open cordotomy in cancer pain management?

For a small number of cancer patients, good pain control remains difficult to achieve despite adequate assessment and medical management. In nine cases, effective control of intractable pain from malignant pelvic disease was achieved by open thoracic cordotomy. The technique was well tolerated, with no major complications. Eight of the nine patients decreased their median daily oral morphine requirement from 560 mg (range 360-2600 mg) to 160 mg (range 40-1000 mg). Maximal survival time post-cordotomy was 830 days, with a median of 107 days. No patient experienced recurrent pain in the initially painful site. For patients with intractable pain associated with advanced pelvic malignancy, the use of an open cordotomy should be considered when satisfactory pain control is not achieved by medical or minimally invasive methods.     

Is there still a role for abatacept in the treatment of lupus?

Introduction: The quest for safer and more effective treatments for systemic lupus erythematosus (SLE) has led to the development of many new biologic therapies. Abatacept is the first drug targeting co-stimulation between T cells and antigen presenting cells, with abundant pre-clinical evidence to support its use in SLE.

Areas covered: This review will present the relevant aspects of lupus pathophysiology pertaining to the mechanism of action of abatacept, a summary of murine studies and the latest human clinical trials.

Expert opinion: Abatacept has demonstrated efficacy in both rheumatoid arthritis and psoriatic arthritis, and earlier studies have suggested tantalising evidence of efficacy in SLE. However, the latest randomised double-blinded study showed disappointingly negative results, much like the case of rituximab in SLE. Currently, abatacept remains a possible therapeutic option as an off-label therapy, and it is a part of our therapeutic armamentarium in difficult cases. The need to find appropriate definitions of response and optimal study design continues to be paramount in the field of lupus therapies.     

Is iron oxide a tissue-specific contrast medium in diagnostic ultrasound? A case report

We present a patient with Hodgkin's disease in whom computed tomography suggested focal lesions in the liver. As no lesions were detected by diagnostic ultrasound, magnetic resonance imaging (MRI) with iron oxide as contrast medium was performed for verification. MRI confirmed at least 3 small lesions. The ultrasound study performed immediately after this MRI scan easily detected these lesions. A biopsy was taken and histology showed infiltrates of Hodgkin's disease. The change in echogenicity of the liver and/or the lymphomatous tissue may be an effect of iron oxide. This observation has not been reported before.     

Is there still a role for sucralfate in the treatment of gastritis?

The endoscopic diagnosis of gastritis is usually made when a patient develops symptoms and undergoes an upper gastrointestinal endoscopy. There are often obvious aetiological causes such as smoking, alcohol Helicobacter pylori infection or drug treatment. Lifestyle changes can sometimes improve symptoms but often patients will be treated with a proton pump inhibitor. The stomach mucosa produces a protective mucous to prevent damage cause by gastric acid and exogenous agents can disrupt this layer. Repair of this protective layer can be enhanced by reduction in gastric acid secretion using H2 receptor antagonist or proton pump inhibitors or by cytoprotective drugs such as misoprostol, sucralfate, aluminium ions or bismuth subsalts. Sucralfate is a complex polymer which at a low pH changes its chemical configuration and binds to serum protein to form a protective layer protecting the mucosa against further injury. Cytoprotective drugs were the first line treatment for peptic disease including gastritis for many years but since the launch of cimetidine in 1976 and the subsequent launch of omeprazole in 1988, their use has slowly declined. First line treatment for patients with symptomatic gastritis after removal of potential causative factors is likely to be a proton pump inhibitor in 2019. This is despite the fact that there is some evidence that sucralfate is superior than a H2 receptor antagonist in the endoscopic healing rates in patients with gastritis. The logical treatment choice in patients with resistance symptoms is a combination of a proton pump inhibitor and sucralfate but evidence is lacking. Until such evidence is available In the meantime, we would suggest that there is a role for sucralfate in the treatment of intransigent gastritis and that mucosal protection should be considered even ahead of acid suppression given its favourable safety and toxicity profile.     

Radiology report “disclaimers” increase the use of abdominal CT in the work-up of pediatric abdominal pain

Objective

Pediatric abdominal pain is commonly evaluated in the emergency department (ED) initially by ultrasonography (U/S). Radiology reports often include commentary about U/S limitations and possible need for additional testing or evaluation independent of study interpretation. We sought to determine if presence of a “disclaimer” is associated with additional imaging.

Is faster still better in therapeutic hypothermia?

The rapid institution of therapeutic hypothermia after cardiac arrest has become an accepted practice. In the previous issue of Critical Care, Haugk and colleagues present a retrospective analysis of 13 years of experience with therapeutic hypothermia at their center that suggests an association between rate of cooling and less favorable neurological outcomes. The association most likely reflects easier cooling in patients more severely brain injured by their initial cardiac arrest, and should not lead clinicians to abandon or slow their efforts to achieve post-resuscitative cooling.     

Bed rails. Is there an up side?

In 1995, the United States Food and Drug Administration reported 68 deaths, 22 injuries and 12 entrapments related to the use of side rails. How is it that a seemingly innocuous bed feature, touted for its safety and care assistive properties, has turned into a killer? This article describes how nurses, in an effort to assure the public of safe nursing practice, historically embraced a legally defined consensual understanding of bed rail use rather than one defined by science and research. The result was that bed rails continued to be viewed by practising nurses as a benevolent means of patient protection. This article seeks to challenge those beliefs by presenting current research and encouraging moral and ethical reflection on the current practice of bed rail use. Potential alternatives and the need for accurate assessment and documentation are discussed in relation to the development of an understanding of what is appropriate application of bed rails.     

Is there an optimal hemoglobin value in the cardiac intensive care unit?

Anemia is common in patients admitted to the cardiac intensive care unit. Many unique issues must be considered in the treatment of the anemic cardiac patient. Coronary artery disease and left ventricular dysfunction may significantly increase the risk of anemia. These patients have limited reserve because of a high extraction ratio of oxygen in the cardiac circulation. Left ventricular dysfunction increases the risk of complications from transfusion. Recent observational studies suggest that cardiac patients may benefit from a higher transfusion threshold. However, very few patients with cardiovascular disease have been included in clinical trials comparing high and low transfusion triggers. Experimental data and recent studies in humans suggest that cardiac patients may be intolerant of anemia. Pending definitive clinical trials in cardiac patients, we suggest a more aggressive transfusion trigger (9-10 g/dL) in patients with active cardiac disease. Pulmonary edema may be precipitated by transfusion in patients with left ventricular dysfunction. Large clinical trials are urgently needed to determine optimal transfusion thresholds in patients with cardiovascular disease.