Bladder volume determination: portable 3-D versus stationary 2-D ultrasound device

OBJECTIVE: To investigate how accurately a portable three-dimensional (3-D) scanner and a multipurpose two-dimensional (2-D) real-time scanner determined bladder volumes. STUDY DESIGN: Prospective, controlled clinical trial, single-blind, crossover design. SETTING AND PARTICIPANTS: Twenty-three inpatients with permanent bladder catheters participated voluntarily in this study. METHODS: The bladders of 20 patients were filled through an indwelling catheter with 60, 110, 160, 210, and 260 mL sterile normal saline. Volumes were measured twice with each device. Measurements were compared with the actual bladder volumes. RESULTS: The 2-D device showed better reproducibility, particularly at lower bladder volumes. The 3-D scanner showed a significant difference between the two measurements at 160 mL (p<.05) and had poor reproducibility at 110, 210, and 260 mL. Both devices overestimated actual bladder volume at fillings of <160 mL and underestimated it at fillings of > or =160 mL. The range between the 25th and 75th percentiles was always larger for the 3-D scanner, except for the 210 mL reading. CONCLUSION: Both devices showed sufficient accuracy for clinical practice. Ultrasound measurements of >110 mL should be followed by catheterization to detect potentially harmful bladder volumes.     

Effectiveness of the portable ultrasound bladder scanner in the measurement of residual urine volume after total mesorectal extirpation

The measurement of residual urine volume by bladder catheterization causes quite some suffering to the patient and sometimes causes urinary tract infections. To evaluate the postoperative measurement of residual urine volume with a portable ultrasound bladder scanner (Bladder Scan BVI 3000) and the cost-benefit analysis as compared with postoperative catheterization we carried out a study on 30 patients with primary rectal cancer. The data were then compared with actual urine volumes. This was a prospective study dealing with the economical benefit of ultrasound scanning over catheterization during the hospital stay. The ultrasound bladder scanner was found to be a reliable method of estimating residual urine volume since its data correlated with actual volumes with a coefficient of 0.9. The results satisfied both physicians and patients. Ultrasound scanning of the bladder to measure residual urine volume reduced the frequency of catheterization by 38% as compared with the patients on intermittent catheterization, with 17.4 catheters saved for each patient. In conclusion, the ultrasound bladder scanner could protect patients from the discomfort and urethral injury which might have been caused by bladder catheters, thus decreasing medical expenses. This technique will play an important role in determining whether to conduct invasive urethral catheterization for postoperative urinary disturbance in rectal cancer.     

Comparison of an advanced minimally invasive cardiac output monitoring with a continuous invasive cardiac output monitoring during lung transplantation

The aim of this study was to compare a continuous non-calibrated left heart cardiac index (CI) measurement by arterial waveform analysis (FloTrac^®/Vigileo^®) with a continuous calibrated right heart CI measurement by pulmonary artery thermodilution (CCOmbo-PAC^®/Vigilance II^®) for hemodynamic monitoring during lung transplantation. CI was measured simultaneously by both techniques in 13 consecutive lung transplants (n = 4 single-lung transplants, n = 9 sequential double-lung transplants) at distinct time points perioperatively. Linear regression analysis and Bland–Altman analysis with percentage error calculation were used for statistical comparison of CI measurements by both techniques. In this study the FloTrac^® system underestimated the CI in comparison with the continuous pulmonary arterial thermodilution (p < 0.000). For all measurement pairs we calculated a bias of ?0.55 l/min/m² with limits of agreement between ?2.31 and 1.21 l/min/m² and a percentage error of 55 %. The overall correlations before clamping a branch oft the pulmonary artery (percentage error 41 %) and during the clamping periods of a branch oft the pulmonary artery (percentage error 66 %) failed to reached the required percentage error of less than 30 %. We found good agreement of both CI measurements techniques only during the measurement point “15 min after starting the second one-lung ventilation period” (percentage error 30 %). No agreement was found during all other measurement points. This pilot study shows for the first time that the CI of the FloTrac^® system is not comparable with the continuous pulmonary-artery thermodilution during lung transplantation including the time periods without clamping a branch of the pulmonary artery. Arterial waveform and continuous pulmonary artery thermodilution are, therefore, not interchangeable during these complex operations.     

Utility of stroke volume variation measured using non-invasive bioreactance as a predictor of fluid responsiveness in the prone position

The aim of this prospective study was to evaluate the usefulness of stroke volume variation (SVV) derived from NICOM^® to predict fluid responsiveness in the prone position. Forty adult patients undergoing spinal surgery in the prone position were included in this study. We measured SVV from NICOM^® (SVV_NICOM) and FloTrac?/Vigileo? systems (SVV_Vigileo), and pulse pressure variation (PPV) using automatic (PPV_auto) and manual (PPV_manual) calculations at four time points including supine and prone positions, and before and after fluid loading of 6 ml kg^?1 colloid solution. Fluid responsiveness was defined as an increase in the cardiac index from Vigileo? of ≥12 %. There were 19 responders and 21 non-responders. Prone positioning induced a significant decrease in SVV_NICOM, SVV_Vigileo, PPV_auto, and PPV_manual. However, all of these parameters successfully predicted fluid responsiveness in the prone position with area under the receiver-operator characteristic curves for SVV_NICOM, SVV_Vigileo, PPV_auto, and PPV_manual of 0.78 [95 % confidence interval (CI) 0.62–0.90, P = 0.0001], 0.79 (95 % CI 0.63–0.90, P = 0.0001), 0.76 (95 % CI 0.6–0.88, P = 0.0006), and 0.84 (95 % CI 0.69–0.94, P < 0.0001), respectively. The optimal cut-off values were 12 % for SVV_NICOM, SVV_Vigileo, and PPV_auto, and 10 % for PPV_manual. SVV from NICOM^® successfully predicts fluid responsiveness during surgery in the prone position. This totally non-invasive technique for assessing individual functional intravenous volume status would be useful in a wide range of surgeries performed in the prone position.     

Automated,continuous and non-invasive assessment of pulse pressure variations using CNAP<Superscript>®</Superscript> system

Non-invasive respiratory variations in arterial pulse pressure using infrared-plethysmography (PPV_CNAP) are able to predict fluid responsiveness in mechanically ventilated patients. However, they cannot be continuously monitored. The present study evaluated a new algorithm allowing continuous measurements of PPV_CNAP (PPV_CNAPauto) (CNSystem, Graz, Austria). Thirty-five patients undergoing vascular surgery were studied after induction of general anaesthesia. Stroke volume was measured using the Vigileo^TM/FloTrac^TM. Invasive pulse pressure variations were manually calculated using an arterial line (PPV_ART) and PPV_CNAPauto was continuously displayed. PPV_ART and PPV_CNAPauto were simultaneously recorded before and after volume expansion (500 ml hydroxyethylstarch). Subjects were defined as responders if stroke volume increased by ≥15 %. Twenty-one patients were responders. Before volume expansion, PPV_ART and PPV_CNAPauto exhibited a bias of 0.1 % and limits of agreement from ?7.9 % to 7.9 %. After volume expansion, PPV_ART and PPV_CNAPauto exhibited a bias of ?0.4 % and limits of agreement from ?5.3 % to 4.5 %. A 14 % baseline PPV_ART threshold discriminated responders with a sensitivity of 86 % (95 % CI 64–97 %) and a specificity of 100 % (95 % CI 77–100 %). Area under the receiver operating characteristic (ROC) curve for PPV_ART was 0.93 (95 % CI 0.79–0.99). A 15 % baseline PPV_CNAPauto threshold discriminated responders with a sensitivity of 76% (95 % CI 53–92 %) and a specificity of 93 % (95 % CI 66–99 %). Area under the ROC curves for PPV_CNAPauto was 0.91 (95 % CI 0.76–0.98), which was not different from that for PPV_ART. When compared with PPV_ART, PPV_CNAPauto performs satisfactorily in assessing fluid responsiveness in hemodynamically stable surgical patients.     

Efficacy and safety of empagliflozin in type 2 diabetes mellitus: a meta-analysis of randomized controlled trials

Objectives: The prevalence of diabetes has increased in the recent decades and optimum glycemic control is required to reduce morbidity and mortality. We meta-analyzed randomized controlled trials in order to assess the efficacy and safety of empagliflozin compared to placebo in type 2 diabetes mellitus patients.

Methods: We included double-blind, placebo controlled trials of empagliflozin that evaluated glycemic efficacy and safety (10 mg or 25 mg) either as monotherapy or as add-on to existing diabetes pharmacotherapy.

Results: The results demonstrated significant improvements in HbA1c (SMD ?0.929%, 95 % CI ?1.064 to ?0.793, for 10 mg and ?1.064%, 95 % CI ?1.184 to ?0.944, for 25 mg) and FPG (SMD ?0.929%, 95 % CI ?1.064 to ?0.793, for 10 mg and ?1.064%, 95 % CI ?1.184 to ?0.944, for 25 mg) with empagliflozin monotherapy (n = 609) compared to placebo. Significant improvements in HbA1c [SMD ?1.582%, 95% CI ?2.164 to ?1.000, for 10 mg (n = 1079) and ?1.668%, 95% CI ?2.260 to ?1.077, for 25 mg (n = 1070)] and FPG [SMD ?0.865 mmol/L, 95 % CI ?1.309 to ?0.420, for 10 mg (n = 854) and ?0.996 mmol/L, 95% CI ?1.456 to ?0.536, for 25 mg (n = 854)] were also observed in empagliflozin add-on therapy trials. Reductions in blood pressure and body weight were also seen in both monotherapy and add-on therapy. Empagliflozin was associated with increased risk of hypoglycemia, genital and urinary tract infections (OR 1.043, 2.814, 1.119 respectively).

Conclusion: This meta-analysis shows empagliflozin is safe and effective for the treatment of T2DM along with existing diabetes pharmacotherapy.     

A retrospective study to evaluate the time burden associated with outpatient red blood transfusions indicated for anemia due to concomitantly administered chemotherapy in cancer patients

Purpose

Anemia in cancer patients can be treated with red blood cell (RBC) transfusions. The patient burden associated with a treatment in terms of total time spent is an important factor to consider when measuring the benefits and challenges of a therapy. This study estimates the time-related patient burden associated with outpatient RBC transfusion.

Methods

A retrospective chart review of outpatient cancer patients receiving a RBC transfusion was conducted at 10 US centers. RBC transfusion time was measured as time elapsed from pre- to post-transfusion vital sign assessment and from transfusion start to stop time. Elapsed time from hemoglobin level testing and blood draw for cross-match to transfusion, estimated travel time and distance, and clinical and demographic data were also collected.

Results

Data from 110 patients (48.2 % male; mean age 64?±?12 years) showed that the mean elapsed time between pre- and post-vital sign assessment was 4.2 h (95 % confidence interval (CI), 3.64–4.81) including 3.6 h (95 % CI, 3.0–4.1) on average to receive the actual RBC transfusion treatment. Hemoglobin level testing (mean Hg level, 8.33 g/dL?±?0.67) and blood drawn for cross-match were completed in an average of 31.2 h (95 % CI, 17.0–45.5) and 18.2 h (95 % CI, 12.1–24.2) prior to transfusion, respectively. Patient one-way travel time averaged 30.0 min (95 % CI, 25.9–34.3).

Conclusions

In the US, CIA patients experience an important time burden when being treated with RBC transfusion in addition to the burden already added by chemotherapy.     

The effects of advanced monitoring on hemodynamic management in critically ill patients: a pre and post questionnaire study

In critically ill patients, many decisions depend on accurate assessment of the hemodynamic status. We evaluated the accuracy of physicians’ conventional hemodynamic assessment and the impact that additional advanced monitoring had on therapeutic decisions. Physicians from seven European countries filled in a questionnaire in patients in whom advanced hemodynamic monitoring using transpulmonary thermodilution (PiCCO system; Pulsion Medical Systems SE, Feldkirchen, Germany) was going to be initialized as part of routine care. The collected information included the currently proposed therapeutic intervention(s) and a prediction of the expected transpulmonary thermodilution-derived variables. After transpulmonary thermodilution measurements, physicians recorded any changes that were eventually made in the original therapeutic plan. A total of 315 questionnaires pertaining to 206 patients were completed. The mean difference (±standard deviation; 95 % limits of agreement) between estimated and measured hemodynamic variables was ?1.54 (±2.16; ?5.77 to 2.69) L/min for the cardiac output (CO), ?74 (±235; ?536 to 387) mL/m² for the global end-diastolic volume index (GEDVI), and ?0.5 (±5.2; ?10.6 to 9.7) mL/kg for the extravascular lung water index (EVLWI). The percentage error for the CO, GEDVI, and EVLWI was 66, 64, and 95 %, respectively. In 54 % of cases physicians underestimated the actual CO by more than 20 %. The information provided by the additional advanced monitoring led 33, 22, 22, and 13 % of physicians to change their decisions about fluids, inotropes, vasoconstrictors, and diuretics, respectively. The limited clinical ability of physicians to correctly assess the hemodynamic status, and the significant impact that more physiological information has on major therapeutic decisions, support the use of advanced hemodynamic monitoring in critically ill patients.     

A novel electromechanical autoinjector,AutoTouch™, for self-injection of etanercept: real-world use and benefits

Objectives: We assessed the ability of patients with autoimmune inflammatory diseases to successfully use the investigational AutoTouch? reusable autoinjector as well as patient preference for AutoTouch? versus the currently marketed single-use prefilled etanercept SureClick® autoinjector.

Methods: Two multicenter studies were performed: a Home Use Study and a Patient Preference Study. In the Home Use Study, 77 patients with rheumatoid arthritis (RA) or psoriatic arthritis self-administered etanercept once weekly for 5 weeks. The primary end point was successful self-injection of etanercept via AutoTouch?. The Patient Preference Study was an open-label, randomized, 8-week crossover trial (4 weeks for each device) in 216 patients with RA or psoriasis (PsO). The primary end point was preference for AutoTouch? versus SureClick®.

Results: In the Home Use Study, the proportion of successful self-injections with AutoTouch? during weeks 1 through 5 was 97.8% (95% CI, 96.3?99.3). In the Patient Preference Study, patients had a preference rate for AutoTouch? of 41.7% (95% CI, 34.9–48.4) overall, 43.5% (95% CI, 35.5?51.6) for patients with RA, and 36.8% (95% CI, 24.3?49.4) for patients with PsO. Needle apprehension was not different at initiation of the autoinjectors, nor was there a difference between the injectors after 4 weeks. Overall, patients preferred AutoTouch? for ease of self-injecting, ease of pressing the start button, ease of following injection progress, and certainty of knowing when the injection was completed. SureClick® was preferred for fewer steps and experiencing less injection site discomfort or pain.

Conclusion: The introduction of the AutoTouch? will give patients a choice between two different autoinjectors for self-administration of etanercept.     

Relationship between intra-operative vein graft treatment with DuraGraft® or saline and clinical outcomes after coronary artery bypass grafting

ABSTRACT

Background: Saphenous vein grafts (SVGs) remain the most often used conduits for coronary bypass grafting (CABG). Progressive intimal hyperplasia contributes to vein-graft disease and vein-graft failure (VGF). We compared the impact of intraoperative preservation of SVGs in a storage solution (DuraGraft®) versus heparinized saline on VGF-related outcomes after CABG.

Methods: From 1996 to 2004, 2436 patients underwent isolated CABG with ≥ 1 SVG. SVGs were consecutively treated with DuraGraft in 1036 patients (2001?2004) and heparinized saline in 1400 patients (1996?1999). Short- (< 30 days) and long-term (≥ 1000 days) outcomes were assessed using repeat revascularization (primary end point), and major adverse cardiac events (MACE) consisting of the composite of death, nonfatal myocardial infarction, or repeat revascularization.

Results: Mean follow-up in the DuraGraft group was 8.5 ± 4.2 years and 9.9 ± 5.6 years in controls. Short-term event rates were low and generally did not differ between groups. DuraGraft was associated with a 45% lower occurrence of nonfatal myocardial infarction after 1000 days (hazard ratio 0.55, 95% CI 0.41?0.74; P < 0.0001). There was 35% and 19% lower long-term risk for revascularization (HR 0.65, 95% CI 0.44?0.97; P = 0.037) and MACE (HR 0.81, 95% CI 0.70?0.94; P = 0.0051), respectively, after DuraGraft. Mortality was comparable between both groups at 1, 5, and 10 years. There was no statistically significant association between DuraGraft exposure and time to death starting at 30 or 1000 days (HR 0.91, 95% CI 0.76?1.09; P = 0.29).

Conclusion: In this study, intraoperative treatment of SVGs with DuraGraft was associated with a lower risk of long-term adverse events suggesting that efficient intraoperative SVG treatment may reduce VGF-related complications post-CABG. These data warrant randomized clinical trials to validate these findings.     

Left atrial expansion index is an independent predictor of diastolic dysfunction in patients with preserved left ventricular systolic function: a three dimensional echocardiography study

In the absence of mitral valve disease left atrial (LA) volume is a marker of diastolic dysfunction and its severity. This study investigated the relationship between left ventricular (LV) end diastolic pressure (LVEDP) and LA volumes and phasic atrial functions detected by real-time full volume three-dimensional echocardiography (RT3DE), in a patient population with preserved LV systolic function. Seventy-two (39 female and 33 male; mean age 56.1 ± 9.0 years) stable patients with normal LV ejection fraction (EF) undergoing cardiac catheterization were studied. All patients underwent comprehensive echocardiographic examination just before catheterization and LVEDP was obtained. In addition to conventional echocardiographic measurements and Doppler indices; by using RT3DE LA maximum, minimum and pre-a-wave volumes were measured; LA total, passive and active emptying volumes and fractions were calculated. LV systolic function was assessed by EF and global longitudinal strain by speckle tracking. RT3DE minimum LA volume index, RT3DE active LAEF and LA expansion index (EI) were statistically significant univariate predictors of LVEDP ≥ 16 mmHg. When age and hypertension adjusted multivariate analysis was performed EI [β = ?1.741, p = 0.015; OR 0.175; 95 % CI (0.043–0.717)] was an independent predictor of elevated LVEDP. RT3DE evaluation of LA function during entire cardiac cycle has incremental value for the diagnosis of diastolic dysfunction in patients with preserved EF. We suggest that RT3DE evaluation of LA may find clinical application in this field.     

Comparative assessment of three drug eluting stents with different platforms but with the same biodegradable polymer and the drug based on quantitative coronary angiography and optical coherence tomography at 12-month follow-up

The aim of this study was to compare neointima proliferation in three drug-eluting stents (DES) produced by the same company (Balton, Poland) which are covered with a biodegradable polymer and elute sirolimus (concentration: 1.0 and 1.2 µg/mm²), but have different stent platforms and strut thickness: stainless steel Prolim^® (115 µm) and BiOSS LIM^® (120 µm) and cobalt-chromium Alex^® (70 µm). We analyzed data of patients with quantitative coronary angiography (QCA) and optical coherence tomography (OCT) at 12 months from BiOSS LIM Registry, Prolim Registry and Alex OCT clinical trial. There were 56 patients enrolled, in whom 29 Prolim^® stents were deployed, in 11—BiOSS LIM^® and in 16—Alex stents. The late lumen loss was the smallest in Prolim^® subgroup (0.26?±?0.17 mm) and did not differ from Alex^® subgroup (0.28?±?0.47 mm). This parameter was significantly bigger in BiOSS^® subgroup (0.38?±?0.19 mm; p?<?0.05). In OCT analysis there was no statistically significant difference between Prolim^® and Alex^® subgroups in terms of mean neointima burden (24.6?±?8.6 vs. 19.27?±?8.11%) and neointima volume (28.16?±?15.10 vs. 24.51?±?17.64 mm³). In BiOSS^® group mean neointima burden (30.9?±?6.2%) and mean neointima volume (44.9?±?4.9 mm³) were significantly larger. The morphological analysis revealed that in most cases in all groups the neointima was homogenous with plaque presence only around stent struts. In the QCA and OCT analysis regular DES (Prolim^® and Alex^®) obtained similar results, whereas more pronounced response from the vessel wall was found in the BiOSS^® subgroup.     

Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study

Purpose

To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting.

Methods

This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. The program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. The network administration and an external consultant provided performance feedback and benchmarking within the network. The primary outcome was compliance with the resuscitation bundle. The secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness.

Results

The proportion of patients who received all the required items for the resuscitation bundle improved from 13 % [95 % confidence interval (CI) 8–18 %] at baseline to 62 % (95 % CI 54–69 %) in the last trimester (p < 0.001). Hospital mortality decreased from 55 % (95 % CI 48–62 %) to 26 % (95 % CI 19–32 %, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95 % CI 0.56–0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95 % CI 23.9–35.4) to 17.5 (95 % CI 14.3–21.1) thousand US dollars from baseline to the last 3 months (mean difference ?11,815; 95 % CI ?18,604 to ?5,338). The mean QALY increased from 2.63 (95 % CI 2.15–3.14) to 4.06 (95 % CI 3.58–4.57). For each QALY, the full compliance saves US$5,383.

Conclusions

A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. The intervention was cost-effective and associated with a reduction in mortality.     

Alternative lipid emulsions in the critically ill: a systematic review of the evidence

Purpose

Parenteral lipid emulsions (LEs) are commonly rich in long-chain triglycerides derived from soybean oil (SO). SO-containing emulsions may promote systemic inflammation and therefore may adversely affect clinical outcomes. We hypothesized that alternative oil-based LEs (SO-sparing strategies) may improve clinical outcomes in critically ill adult patients compared to products containing SO emulsion only. The purpose of this systematic review was to evaluate the effect of parenteral SO-sparing strategies on clinical outcomes in intensive care unit (ICU) patients.

Methods

We searched computerized databases from 1980 to 2013. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated SO-sparing strategies versus SO-based LEs in the context of parenteral nutrition.

Results

A total of 12 RCTs met the inclusion criteria. When the results of these RCTs were statistically aggregated, SO-sparing strategies were associated with clinically important reductions in mortality (risk ratio, RR 0.83; 95 % confidence intervals, CI 0.62, 1.11; P = 0.20), in duration of ventilation (weighted mean difference, WMD ?2.57; 95 % CI ?5.51, 0.37; P = 0.09), and in ICU length of stay (LOS) (WMD ?2.31; 95 % CI ?5.28, 0.66; P = 0.13) but none of these differences were statistically significant. SO-sparing strategies had no effect on infectious complications (RR 1.13; 95 % CI 0.87, 1.46; P = 0.35).

Conclusion

Alternative oil-based LEs may be associated with clinically important reductions in mortality, duration of ventilation, and ICU LOS but lack of statistical precision precludes any clinical recommendations at this time. Further research is warranted to confirm these potential positive treatment effects.     

Effects of Telestroke on Thrombolysis Times and Outcomes: A Meta-analysis

Objective: Telestroke systems are tools, used to provide an advanced stroke care in regions without sufficient neurologic services. We performed this meta-analysis to assess the effects of telemedicine on treatment times and clinical outcomes of acute stroke care. Methods: A literature search of PubMed, SCOPUS, and Cochrane CENTRAL was conducted for original studies investigating telemedicine applications in acute stroke care. Dichotomous data on treatment outcomes were pooled as odds ratios (ORs), while continuous data on thrombolysis times were pooled as mean differences (MDs) with 95% confidence interval (CI), using RevMan software (version 5.3). Results: Pooling data from 26 studies (6605 thrombolysed patients) showed no significant differences between the telestroke and control groups in terms of in-hospital mortality (OR = 1.21, 95% CI [0.98, 1.49]), 90-day mortality (OR = 1.08, 95% CI [0.85, 1.37]), symptomatic intracranial hemorrhage (sICH) (OR = 1.10, 95% CI [0.79, 1.53]), and favorable clinical outcome at discharge (OR = 1.03, 95% CI [0.69, 1.53]) and 90 days later (OR = 0.99, 95% CI [0.82, 1.18]). The onset-to-door (OTD) duration (MD = ?10.4 minutes, 95% CI [?14.79, ?.01]) and length of hospital stay (MD = ?0.55 days, 95% CI [?1.02, ?0.07]) were significantly shorter in the telestroke group, compared to the control group. Although the overall effect estimate (under the fixed-effect model) showed a significant decrease in the onset-to-treatment (OTT) duration in the telestroke group (MD = ?5.83 minutes, 95% CI [?8.57, ?3.09]), employing the random-effects model for between-study heterogeneity abolished this significance (MD = ?5.90 minutes, 95% CI [?13.23, 1.42]). Conclusion: Telestroke significantly reduced OTD and hospital stay durations in stroke patients without increasing the risk of mortality or sICH. Therefore, telemedicine can improve stroke care in regional areas with minor experience in thrombolysis. Further randomized controlled trials are needed to assess the benefits of telestroke systems, especially in terms of cost-effectiveness and quality of life outcomes.     

清洁间歇导尿在小儿脊髓栓系综合症术后护理中对膀胱功能恢复的作用

目的：研究清洁间歇导尿在小儿脊髓栓系综合症术后护理中对膀胱功能恢复的作用;方法：对2010年1月至2015年12月5年间收治入院的45例具有排尿障碍的脊髓栓系综合症并进行脊髓栓系松解术的患儿进行研究,对照组采用传统方式训练膀胱功能并拔除导尿管,实验组采用清洁间歇导尿训练膀胱功能,随访6个月后膀胱残余尿量减少量;结果;对照组膀胱残余尿量减少量5.0±8.8ml,实验组膀胱残余尿量减少量11.3±11.3ml,两者差异具有统计学意义(p＜0.05);结论：清洁间歇导尿在小儿脊髓栓系综合症术后护理中可以提高膀胱功能恢复水平。     

The accuracy of clinical assessment of bladder volume

OBJECTIVE: To determine the usefulness of physical examination in detecting elevated bladder volume. DESIGN: A blinded study of clinical examination by physicians to detect elevated bladder volumes compared with a criterion standard (ultrasonic bladder volume measurement). SETTING: Outpatient department of a general hospital in New Zealand. PARTICIPANTS: Sixteen healthy adult volunteers (age range, 21-37 y; body mass index range, 22.9-37.2 kg/m(2)) and 8 qualified resident physicians with 2 to 6 years of clinical experience. INTERVENTION: Elevated bladder volumes were achieved by randomly allocating the volunteers to void or not to void before the clinical examination. MAIN OUTCOME MEASURE: Clinical examination of the abdomen by abdominal palpation and suprapubic percussion, compared with portable ultrasound findings, to determine whether a healthy adult has a full bladder. RESULTS: For bladder volumes of 400 to 600 mL, physical examination to detect a full bladder was 81% sensitive (95% confidence interval [CI], 54-96), 50% specific (95% CI, 39-68), and 55% accurate (95% CI, 45-65). The likelihood ratio for a positive finding on physical examination was 1.62 (95% CI, 1.17-2.24). CONCLUSION: Physical examination of the abdomen by relatively junior physicians is unreliable in detecting bladder volumes between 400 and 600 mL in healthy volunteers.     

Application of portable ultrasound scanners in the measurement of post-void residual urine

The aims of the present study were to investigate the impact of research subjects' characteristics on the accuracy of the BladderScan when the latter is used to measure post-void residual urine volume, and to evaluate differences between BladderScan and catheterization in terms of the expenditure of time and of human and material resources. Subjects in the present study were 71 patients undergoing inpatient or outpatient rehabilitation therapy. Post-void residual urine was measured with the BladderScan BVI 3000, followed by intermittent catheterization. Repeated- measures ANOVA revealed no statistically significant difference between the post-void residual urine volume measured by the bladder ultrasound and that of catheterization, or among the factors: sex, diagnosis, body position, thickness of abdominal fat, bladder shape, urine volume, and time intervals between operations. The BladderScan averaged 45 seconds (range=17-119 seconds), while catheterization averaged 293 seconds (range=136-664 seconds); the time required for catheterization was 3 to 8 times that for the BladderScan. The BladderScan gave accurate measurements of post-void residual urine volume for all of the subjects. Using the BladderScan first to measure post-void residual urine volume can reduce the frequency of catheterization, and can save medical human resources costs as well.     

Prognostic value of T1-mapping in TAVR patients: extra-cellular volume as a possible predictor for peri- and post-TAVR adverse events

The benefit of a transcatheter aortic valve replacement (TAVR) can differ in patients, and therapy bears severe risks. High-degree aortic stenosis can lead to cardiac damage such as diffuse myocardial fibrosis, evaluable by extra-cellular volume (ECV) in CMR. Therefore, fibrosis might be a possible risk factor for unfavorable outcome after TAVR. We sought to assess the prognostic value of T1-mapping and ECV to predict adverse events during and after TAVR. The study population consisted of patients undergoing clinically indicated TAVR by performing additional CMR with native and contrast-enhanced T1-mapping sequences for additional evaluation of ECV. Study endpoints were congestive heart failure (CHF) and TAVR-associated conduction abnormalities defined as new onset of left bundle branch block (LBBB), AV-Block or implantation of a pacemaker. 94 patients were examined and followed. Median follow up time was 187 days (IQR 79–357 days). ECV was increased (>30?%) in 38 patients (40?%). There was no significant correlation between ECV and death, Hazard ratio (HR) 0.847 (95?% CI 0.335; 2.14), p?=?0.72. ECV in patients with subsequent CHF was higher than in those without an event (33.5?±?4.6 and 29.1?±?4.1?%, respectively), but the difference just did not reach the level of significance HR 2.16 (95?% CI 0.969; 4.84), p?=?0.06. Patients with post-TAVR conduction abnormality (LBBB, AV-block or pacemaker implantation) had statistically relevant lower ECV values compared to those without an event. Patients with an event had a mean ECV of 28.1?±?3.16?%; patients without an event had a mean ECV of 29.8?±?4.53, HR 0.56 (95?% CI 0.32; 0.96), p?=?0.036. In this study, elevated myocardial ECV is a predictor of CHF by trend; CMR may be helpful in identifying patients with a high risk for post-TAVR cardiac decompensation benefitting from an intensified post-interventional surveillance. Patients with post-TAVR conductions abnormalities have a significantly decreased ECV. Nevertheless, it remains unclear which precise molecular tissue alteration is the protective factor or risk factor in this case.