Low-dose chest computed tomography for quantitative and visual anatomical analysis in patients with acute respiratory distress syndrome

Purpose

Chest computed tomography (CT) is a fundamental tool for the characterization of acute respiratory distress syndrome (ARDS). Its frequent use is, however, hindered by the associated radiation exposure. The aim of the present study was to evaluate, in patients with ARDS, the accuracy of quantitative and visual anatomical lung analysis performed on low-dose CT. We hypothesized that low-dose CT would provide accurate quantitative and visual anatomical results.

Methods

Chest CT was performed in 45 ARDS patients in static conditions at set airway pressures of 45 and 15 or 45 and 5 cmH₂O. During each pause, two consecutive scans were obtained at two different tube current–time products (mAs). In 24 patients 110 mAs was coupled with 60 mAs; in 21 patients 110 was coupled with 30 mAs. All other CT parameters were kept unaltered. Quantitative and visual anatomical results obtained at different mAs were compared via Bland–Altman analysis.

Results

Good agreements were observed between 110 and 60 mAs and between 110 and 30 mAs both for quantitative and visual anatomical results (all biases below 1.5 %). Estimated mean effective dose at 110, 60, and 30 mAs corresponded to 5.3 ± 1.6, 2.8 ± 0.8, and 1.4 ± 0.3 mSv, respectively.

Conclusions

In patients with ARDS a reduction of mAs up to 30 (70 % effective dose reduction) can be achieved without significant effect on quantitative and visual anatomical results. Low-dose chest CT, with related quantitative and visual anatomical analysis, could be a valuable tool to characterize and potentially monitor lung disease in patients with ARDS.     

Growth differentiation factor-15 and prognosis in acute respiratory distress syndrome: a retrospective cohort study

Introduction

We sought to determine whether higher levels of the novel biomarker growth differentiation factor-15 (GDF-15) are associated with poor outcomes and the presence of pulmonary vascular dysfunction (PVD) in patients with acute respiratory distress syndrome (ARDS).

Methods

We conducted a retrospective cohort study in patients enrolled in the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment (FACT) Trial. Patients enrolled in the FACT Trial who received a pulmonary artery catheter (PAC), had plasma available from the same study day and sufficient hemodynamic data to determine the presence of PVD were included. Logistic regression was used to determine the association between GDF-15 level and 60-day mortality.

Results

Of the 513 patients enrolled in the FACT Trial assigned to receive a PAC, 400 were included in this analysis. Mortality at 60 days was significantly higher in patients whose GDF-15 levels were in the third (28%) or fourth (49%) quartile when compared to patients with GDF-15 levels in the first quartile (12%) (P <0.001). Adjusting for severity of illness measured by APACHE III score, the odds of death for patients with GDF-15 levels in the fourth quartile when compared to the first quartile was 4.26 (95% CI 2.18, 10.92, P <0.001). When added to APACHE III alone for prediction of 60-day mortality, GDF-15 levels increased the area under the receiver operating characteristic curve from 0.72 to 0.77. At an optimal cutoff of 8,103 pg/mL, the sensitivity and specificity of GDF-15 for predicting 60-day mortality were 62% (95% CI 53%, 71%) and 76% (95% CI 71%, 81%), respectively. Levels of GDF-15 were not useful in identifying the presence of PVD, as defined by hemodynamic measurements obtained by a PAC.

Conclusions

In patients with ARDS, higher levels of GDF-15 are significantly associated with poor outcome but not PVD.     

Risk factors for acute respiratory distress syndrome during neutropenia recovery in patients with hematologic malignancies

Introduction

Neutropenia recovery may be associated with deterioration in oxygenation and exacerbation of pre-existing pulmonary disease. However, risk factors for acute respiratory distress syndrome (ARDS) during neutropenia recovery in patients with hematologic malignancies have not been studied.

Methods

We studied critically ill patients with hematologic malignancies with the dual objectives of describing patients with ARDS during neutropenia recovery and identifying risk factors for ARDS during neutropenia recovery. A cohort of consecutive neutropenic patients with hematologic malignancies who were admitted to the intensive care unit (ICU) was studied. During a 6-year period, 71 patients recovered from neutropenia, of whom 38 (53.5%) developed ARDS during recovery.

Results

Compared with non-ARDS patients, patients who experienced ARDS during neutropenia recovery were more likely to have pneumonia, be admitted to the ICU for respiratory failure, and receive mechanical ventilator therapy. The in-ICU mortality was significantly different between the two groups (86.8% versus 51.5%, respectively, for patients who developed ARDS during neutropenia recovery versus those who did not during neutropenia recovery). In multivariate analysis, only occurrence of pneumonia during the neutropenic episode was associated with a marked increase in the risk of ARDS (odds ratio, 4.76).

Conclusions

Patients with hematologic malignancies complicated by pneumonia during neutropenia are at increased risk for ARDS during neutropenia recovery.     

Exploring the heterogeneity of effects of corticosteroids on acute respiratory distress syndrome: a systematic review and meta-analysis

Introduction

The effectiveness of corticosteroid therapy on the mortality of acute respiratory distress syndrome (ARDS) remains under debate. We aimed to explore the grounds for the inconsistent results in previous studies and update the evidence.

Methods

We searched MEDLINE, Cochrane Central Register of Controlled Trials and Web of Science up to December 2013. Eligible studies included randomized clinical trials (RCTs) and cohort studies that reported mortality and that had corticosteroid nonusers for comparison. The effect of corticosteroids on ARDS mortality was assessed by relative risk (RR) and risk difference (RD) for ICU, hospital, and 60-day mortality using a random-effects model.

Results

Eight RCTs and 10 cohort studies were included for analysis. In RCTs, corticosteroids had a possible but statistically insignificant effect on ICU mortality (RD, −0.28; 95% confidence interval (CI), −0.53 to −0.03 and RR, 0.55; 95% CI, 0.24 to 1.25) but no effect on 60-day mortality (RD, −0.01; 95% CI, −0.12 to 0.10 and RR, 0.97; 95% CI, 0.75 to 1.26). In cohort studies, corticosteroids had no effect on ICU mortality (RR, 1.05; 95% CI, 0.74 to 1.49) but non-significantly increased 60-day mortality (RR, 1.30; 95% CI, 0.96 to 1.78). In the subgroup analysis by ARDS etiology, corticosteroids significantly increased mortality in influenza-related ARDS (three cohort studies, RR, 2.45, 95% CI, 1.40 to 4.27).

Conclusions

The effects of corticosteroids on the mortality of ARDS differed by duration of outcome measures and etiologies. Corticosteroids did not improve longer-term outcomes and may cause harm in certain subgroups. Current data do not support routine use of corticosteroids in ARDS. More clinical trials are needed to specify the favorable and unfavorable subgroups for corticosteroid therapy.     

Steroids in early ARDS?

Citation

Annane D, Sebille V, Bellissant E: Effect of low doses of corticosteroids in septic shock patients with or without early acute respiratory distress syndrome. Crit Care Med 2006, 34:22–30 [1].

Background

Experimental evidence suggests that corticosteroids may be beneficial in early acute respiratory distress syndrome (ARDS).

Methods

Objective

To investigate the efficacy of low doses of corticosteroids in septic shock patients with or without early ARDS by post hoc analysis of a previously completed clinical trial.

Design

Retrospective analysis of a placebo-controlled, randomized, double-blind trial of low doses of corticosteroids in septic shock.

Setting

Nineteen intensive care units in France.

Subjects

Among the 300 septic shock patients enrolled, we selected those meeting standard criteria for ARDS at inclusion.

Intervention

Seven-day treatment with 50 mg of hydrocortisone every 6 hrs and 50 μg of 9-alpha-fludrocortisone once a day.

Measurements and main results

There were 177 patients with ARDS (placebo, n = 92; corticosteroids, n = 85) including 129 (placebo, n = 67; corticosteroids, n = 62) nonresponders and 48 (placebo, n = 25; corticosteroids, n = 23) responders. In nonresponders, there were 50 deaths (75%) in the placebo group and 33 deaths (53%) in the steroid group (hazard ratio 0.57, 95% confidence interval 0.36–0.89, p = .013; relative risk 0.71, 95% confidence interval 0.54–0.94, p = .011). The number of days alive and off the ventilator was 2.6 +/- 6.6 in the placebo group and 5.7 +/- 8.6 in the steroid group (p = .006). There was no significant difference between groups in responders. There was no significant difference between groups in the two subsets of patients without ARDS. Adverse events rates were similar in the two groups.

Conclusion

This post hoc analysis shows that a 7-day treatment with low doses of corticosteroids was associated with better outcomes in septic shock-associated early ARDS nonresponders, but not in responders and not in septic shock patients without ARDS.     

Steroids in late ARDS?

Citation

Steinberg KP, Hudson LD, Goodman RB, Hough CL, Lanken PN, Hyzy R, Thompson BT, Ancukiewicz M: Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med 2006, 354:1671–1684 [1].

Background

Persistent acute respiratory distress syndrome (ARDS) is characterized by excessive fibroproliferation, ongoing inflammation, prolonged mechanical ventilation, and a substantial risk of death. Because previous reports suggested that corticosteroids may improve survival, the study authors performed a multicenter, randomized controlled trial of corticosteroids in patients with persistent ARDS.

Methods

Objective

To determine if low dose corticosteroids would improve survival among patients with persistent ARDS.

Design

Multicenter randomized controlled trial.

Setting

25 hospitals in the United States that were part of the ARDS Clinical Trials Network.

Subjects

180 mechanically ventilated patients with ARDS of at least seven days duration.

Intervention

Subjects were randomized to either intravenous methylprednisolone (steroid group) or placebo in a double-blind fashion. Those in the steroid group received 2 mg/kg loading dose followed by 0.5 mg/kg every 6 hours for 14 days, 0.5 mg/kg every 12 hours for 7 days, and then tapering of the dose over 2–4 days.

Measurements and main results

The primary end point was mortality at 60 days. Secondary end points included the number of ventilator-free days and organ-failure-free days, biochemical markers of inflammation and fibroproliferation, and infectious complications. At 60 days, the hospital mortality rate was 28.6 percent in the placebo group (95 percent confidence interval, 20.3 to 38.6 percent) and 29.2 percent in the methylprednisolone group (95 percent confidence interval, 20.8 to 39.4 percent; P = 1.0); at 180 days, the rates were 31.9 percent (95 percent confidence interval, 23.2 to 42.0 percent) and 31.5 percent (95 percent confidence interval, 22.8 to 41.7 percent; P = 1.0), respectively. Methylprednisolone was associated with significantly increased 60- and 180-day mortality rates among patients enrolled at least 14 days after the onset of ARDS. Methylprednisolone increased the number of ventilator-free and shock-free days during the first 28 days in association with an improvement in oxygenation, respiratory-system compliance, and blood pressure with fewer days of vasopressor therapy. As compared with placebo, methylprednisolone did not increase the rate of infectious complications but was associated with a higher rate of neuromuscular weakness.

Conclusion

These results do not support the routine use of methylprednisolone for persistent ARDS despite the improvement in cardiopulmonary physiology. In addition, starting methylprednisolone therapy more than two weeks after the onset of ARDS may increase the risk of death. (ClinicalTrials.gov number, {"type":"clinical-trial","attrs":{"text":"NCT00295269","term_id":"NCT00295269"}}NCT00295269.)     

Low plasma citrulline levels are associated with acute respiratory distress syndrome in patients with severe sepsis

Introduction

The role of nitric oxide synthase (NOS) in the pathophysiology of acute respiratory distress syndrome (ARDS) is not well understood. Inducible NOS is upregulated during physiologic stress; however, if NOS substrate is insufficient then NOS can uncouple and switch from NO generation to production of damaging peroxynitrites. We hypothesized that NOS substrate levels are low in patients with severe sepsis and that low levels of the NOS substrate citrulline would be associated with end organ damage including ARDS in severe sepsis.

Methods

Plasma citrulline, arginine and ornithine levels and nitrate/nitrite were measured at baseline in 135 patients with severe sepsis. ARDS was diagnosed by consensus definitions.

Results

Plasma citrulline levels were below normal in all patients (median 9.2 uM, IQR 5.2 - 14.4) and were significantly lower in ARDS compared to the no ARDS group (6.0 (3.3 - 10.4) vs. 10.1 (6.2 - 16.6), P = 0.002). The rate of ARDS was 50% in the lowest citrulline quartile compared to 15% in the highest citrulline quartile (P = 0.002). In multivariable analyses, citrulline levels were associated with ARDS even after adjustment for covariates including severity of illness.

Conclusions

In severe sepsis, levels of the NOS substrate citrulline are low and are associated with ARDS. Low NOS substrate levels have been shown in other disease states to lead to NOS uncoupling and oxidative injury suggesting a potential mechanism for the association between low citrulline and ARDS. Further studies are needed to determine whether citrulline supplementation could prevent the development of ARDS in patients with severe sepsis and to determine its role in NOS coupling and function.     

Estimation of optic nerve sheath diameter on an initial brain computed tomography scan can contribute prognostic information in traumatic brain injury patients

Introduction

The aim of this study was to evaluate the prognostic value of optic nerve sheath diameter (ONSD) measured on the initial brain computed tomography (CT) scan for intensive care unit (ICU) mortality in severe traumatic brain injury (TBI) patients.

Methods

A prospective observational study of all severe TBI patients admitted to a neurosurgical ICU (over a 10-month period). Demographic and clinical data and brain CT scan results were recorded. ONSD for each eye was measured on the initial CT scan. The group of ICU survivors was compared to non-survivors. Glasgow Outcome Scale (GOS) was evaluated six months after ICU discharge.

Results

Seventy-seven patients were included (age: 43 ± 18; 81% males; mean Injury Severity Score: 35 ± 15; ICU mortality: 28.5% (n = 22)). Mean ONSD on the initial brain CT scan was 7.8 ± 0.1 mm in non-survivors vs. 6.8 ± 0.1 mm in survivors (P < 0.001). The operative value of ONSD was a good predictor of mortality (area under the curve: 0.805). An ONSD cutoff ≥ 7.3 had a sensitivity of 86.4% and a specificity of 74.6% and was independently associated with mortality in this population (adjusted odds ratio 95% confidence interval: 22.7 (3.2 to 159.6), P = 0.002). There was a relationship between initial ONSD values and six-month GOS (P = 0.03).

Conclusions

ONSD measured on the initial brain CT scan is independently associated with ICU mortality rate (when ≥ 7.3 mm) in severe TBI patients.     

Contrast enhanced ultrasonography (CEUS) in peripheral lung lesions: A study of 60 cases

Introduction

The authors report their experience in 60 patients with infectious and neoplastic peripheral pulmonary lesions studied by conventional radiology, B-Mode ultrasound (US) and computed tomography (CT). In view of the particular pulmonary vascularization (consisting of both pulmonary and bronchial arteries) the patients underwent also contrast enhanced ultrasound (CEUS) using a II-generation contrast agent, SonoVue (sulphur hexafluoride microbubbles surrounded by a phospholipid shell).

Methods and results

In this study, the sensitivity of CEUS reached 95% in the characterization of peripheral pulmonary lesions, which is similar to the sensitivity of CT (97%). The method used in this case-study was free of significant side effects.

Discussion

This preliminary clinical experience seems to confirm the possibility of using SonoVue enhanced US to make a differential diagnosis between infectious and neoplastic lesions based on a qualitative and quantitative assessment, by evaluating the enhancement pattern (homogeneous or inhomogeneous), arrival time of the contrast agent in the lesion, the possibility to identify the pulmonary arteries and time of contrast agent elimination.     

Long-term quality of life in patients with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation for refractory hypoxaemia

Introduction

The purpose of the study was to assess the long term outcome and quality of life of patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia.

Methods

A retrospective observational study with prospective health related quality of life (HRQoL) assessment was conducted in ARDS patients who had ECMO as a rescue therapy for reversible refractory hypoxemia from January 2009 until April 2011 in a tertiary Australian centre. Survival and long-term quality of life assessment, using the Short-Form 36 (SF-36) and the EuroQol health related quality of life questionnaire (EQ5D) were assessed and compared to international data from other research groups.

Results

Twenty-one patients (mean age 36.3 years) with ARDS receiving ECMO for refractory hypoxemia were studied. Eighteen (86%) patients were retrieved from external intensive care units (ICUs) by a dedicated ECMO retrieval team. Eleven (55%) had H1N1 influenza A-associated pneumonitis. Eighteen (86%) patients survived to hospital discharge. Of the 18 survivors, ten (56%) were discharged to other hospitals and 8 (44%) were discharged directly home. Sequelae and health related quality of life were evaluated for 15 of the 18 (71%) long-term survivors (assessment at median 8 months). Mean SF-36 scores were significantly lower across all domains compared to age and sex matched Australian norms. Mean SF-36 scores were lower (minimum important difference at least 5 points) than previously described ARDS survivors in the domains of general health, mental health, vitality and social function. One patient had long-term disability as a result of ICU acquired weakness. Only 26% of survivors had returned to previous work levels at the time of follow-up.

Conclusions

This ARDS cohort had a high survival rate (86%) after use of ECMO support for reversible refractory hypoxemia. Long term survivors had similar physical health but decreased mental health, general health, vitality and social function compared to other ARDS survivors and an unexpectedly poor return to work.     

Knee bursitis: a sonographic evaluation

Objective

To evaluate the use of ultrasound for the diagnosis of knee bursitis.

Materials and methods

One-hundred and fifty-eight patients who, from May 2013 to May 2014, had an ultrasound examination of the knee and magnetic resonance imaging (MRI) of the knee during the following month were eligible for the study. The exams were reviewed by two musculoskeletal radiologists with 20 years of experience.

Results

Of these patients, 15 (7 men, 8 women) had bursitis, while 143 (76 men, 67 women) had no bursitis. In evaluating knee bursitis, US, when compared to MRI, correctly identified 13 out of 15 cases of bursitis, showing a sensitivity of 86.67 %, specificity 100 %, and K index of 0.92. Particularly in the suprapatellar bursa, ultrasound showed bursitis in 5 cases versus 7 by MRI (sensitivity of 71.4 %, specificity of 100 %, and K index of 0.82).

Conclusion

Ultrasound can be used as a valuable tool for the evaluation of bursitis of the superficial bursae in patients who cannot undergo MRI.     

Influence of obstructive sleep apnea syndrome in the fluctuation of the submaximal isometric torque of knee extensors in patients with early-grade osteoarthritis

OBJECTIVE:

The aim of this study was to investigate whether obstructive sleep apnea (OSA) alters the fluctuation of submaximal isometric torque of the knee extensors in patients with early-grade osteoarthritis (OA).

METHOD:

The study included 60 male volunteers, aged 40 to 70 years, divided into four groups: Group 1 (G1) - Control (n=15): without OA and without OSA; Group 2 (G2) (n=15): with OA and without OSA; Group 3 (G3) (n=15): without OA and with OSA; and Group 4 (G4) (n=15) with OA and with OSA. Five patients underwent maximal isometric contractions of 10 seconds duration each, with the knee at 60° of flexion to determine peak torque at 60°. To evaluate the fluctuation of torque, 5 submaximal isometric contractions (50% of maximum peak torque) of 10 seconds each, which were calculated from the standard deviation of torque and coefficient of variation, were performed.

RESULTS:

Significant differences were observed between groups for maximum peak torque, while G4 showed a lower value compared with G1 (p=0.005). Additionally, for the average torque exerted, G4 showed a lower value compared to the G1 (p=0.036). However, no differences were found between the groups for the standard deviation (p=0.844) and the coefficient of variation (p=0.143).

CONCLUSION:

The authors concluded that OSA did not change the parameters of the fluctuation of isometric submaximal torque of knee extensors in patients with early-grade OA.     

Biomarkers of lung epithelial injury and inflammation distinguish severe sepsis patients with acute respiratory distress syndrome

Introduction

Despite recent modifications, the clinical definition of the acute respiratory distress syndrome (ARDS) remains non-specific, leading to under-diagnosis and under-treatment. This study was designed to test the hypothesis that a biomarker panel would be useful for biologic confirmation of the clinical diagnosis of ARDS in patients at risk of developing ARDS due to severe sepsis.

Methods

This was a retrospective case control study of 100 patients with severe sepsis and no evidence of ARDS compared to 100 patients with severe sepsis and evidence of ARDS on at least two of their first four ICU days. A panel that included 11 biomarkers of inflammation, fibroblast activation, proteolytic injury, endothelial injury, and lung epithelial injury was measured in plasma from the morning of ICU day two. A backward elimination model building strategy on 1,000 bootstrapped data was used to select the best performing biomarkers for further consideration in a logistic regression model for diagnosis of ARDS.

Results

Using the five best-performing biomarkers (surfactant protein-D (SP-D), receptor for advanced glycation end-products (RAGE), interleukin-8 (IL-8), club cell secretory protein (CC-16), and interleukin-6 (IL-6)) the area under the receiver operator characteristic curve (AUC) was 0.75 (95% CI: 0.7 to 0.84) for the diagnosis of ARDS. The AUC improved to 0.82 (95% CI: 0.77 to 0.90) for diagnosis of severe ARDS, defined as ARDS present on all four of the first four ICU days.

Conclusions

Abnormal levels of five plasma biomarkers including three biomarkers generated by lung epithelium (SP-D, RAGE, CC-16) provided excellent discrimination for diagnosis of ARDS in patients with severe sepsis. Altered levels of plasma biomarkers may be useful biologic confirmation of the diagnosis of ARDS in patients with sepsis, and also potentially for selecting patients for clinical trials that are designed to reduce lung epithelial injury.     

Real-time cardiovascular magnetic resonance at 1.5?T using balanced SSFP and 40?ms resolution

Background

While cardiovascular magnetic resonance (CMR) commonly employs ECG-synchronized cine acquisitions with balanced steady-state free precession (SSFP) contrast at 1.5 T, recent developments at 3 T demonstrate significant potential for T1-weighted real-time imaging at high spatiotemporal resolution using undersampled radial FLASH. The purpose of this work was to combine both ideas and to evaluate a corresponding real-time CMR method at 1.5 T with SSFP contrast.

Methods

Radial gradient-echo sequences with fully balanced gradients and at least 15-fold undersampling were implemented on two CMR systems with different gradient performance. Image reconstruction by regularized nonlinear inversion (NLINV) was performed offline and resulted in real-time SSFP CMR images at a nominal resolution of 1.8 mm and with acquisition times of 40 ms.

Results

Studies of healthy subjects demonstrated technical feasibility in terms of robustness and general image quality. Clinical applicability with access to quantitative evaluations (e.g., ejection fraction) was confirmed by preliminary applications to 27 patients with typical indications for CMR including arrhythmias and abnormal wall motion. Real-time image quality was slightly lower than for cine SSFP recordings, but considered diagnostic in all cases.

Conclusions

Extending conventional cine approaches, real-time radial SSFP CMR with NLINV reconstruction provides access to individual cardiac cycles and allows for studies of patients with irregular heartbeat.     

Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors

Introduction

We assessed rates and predictive factors of non-invasive ventilation (NIV) failure in patients admitted to the intensive care unit (ICU) for non-hypercapnic acute hypoxemic respiratory failure (AHRF).

Methods

This is an observational cohort study using data prospectively collected over a three-year period in a medical ICU of a university hospital.

Results

Among 113 patients receiving NIV for AHRF, 82 had acute respiratory distress syndrome (ARDS) and 31 had non-ARDS. Intubation rates significantly differed between ARDS and non-ARDS patients (61% versus 35%, P = 0.015) and according to clinical severity of ARDS: 31% in mild, 62% in moderate, and 84% in severe ARDS (P = 0.0016). In-ICU mortality rates were 13% in non-ARDS, and, respectively, 19%, 32% and 32% in mild, moderate and severe ARDS (P = 0.22). Among patients with moderate ARDS, NIV failure was lower among those having a PaO₂/FiO₂ >150 mmHg (45% vs. 74%, p = 0.04). NIV failure was associated with active cancer, shock, moderate/severe ARDS, lower Glasgow coma score and lower positive end-expiratory pressure level at NIV initiation. Among intubated patients, ICU mortality rate was 46% overall and did not differ according to the time to intubation.

Conclusions

With intubation rates below 35% in non-ARDS and mild ARDS, NIV stands as the first-line approach; NIV may be attempted in ARDS patients with a PaO₂/FiO₂ > 150. By contrast, 84% of severe ARDS required intubation and NIV did not appear beneficial in this subset of patients. However, the time to intubation had no influence on mortality.     

Shoulder isokinetic profile of male handball players of the Brazilian National Team

Background

Data obtained on an isokinetic dynamometer are useful to characterize muscle status and have been reported in muscle imbalance studies in different types of sport. However, few studies have assessed elite handball players to establish reference values.

Objective

The purpose of this study was to compare, for the dominant (D) and non-dominant (ND) side, the isokinetic profile of shoulder rotator muscle strength between male handball players (H) and asymptomatic non-athletes (NA).

Method

Isokinetic concentric and eccentric strength tests for D upper limbs were performed by the H group (n=20) and the NA group (n=12). Internal and external rotator muscle peak torque in concentric action was assessed at 60°/s and 300°/s and in eccentric action at 300°/s. We also calculated conventional balance (the ratio of external rotator peak torque to internal rotator peak torque in concentric action) and functional balance (the ratio of external rotator peak torque in eccentric action to internal rotator peak torque in concentric action).

Results

In the H group, dominant limbs were stronger in concentric action for external rotation at 60 and 300°/s. The conventional balance ratio for the D side was significantly lower at 60 and 300°/s for H compared to NA. The functional ratio for the D side was significantly lower at 300º/s for H compared to NA.

Conclusions

Compared to asymptomatic non-athletes, handball players presented significant muscular imbalance resulting from daily sports practice, a known risk factor for shoulder injuries.     

Early fluid loading in acute respiratory distress syndrome with septic shock deteriorates lung aeration without impairing arterial oxygenation: a lung ultrasound observational study

Introduction

The study was designed to assess the impact of fluid loading on lung aeration, oxygenation and hemodynamics in patients with septic shock and acute respiratory distress syndrome (ARDS).

Methods

During a 1-year period, a prospective observational study was performed in 32 patients with septic shock and ARDS. Cardiorespiratory parameters were measured using Swan Ganz (n = 29) or PiCCO catheters (n = 3). Lung aeration and regional pulmonary blood flows were measured using bedside transthoracic ultrasound. Measurements were performed before (T0), at the end of volume expansion (T1) and 40 minutes later (T2), consisting of 1-L of saline over 30 minutes during the first 48 h following onset of septic shock and ARDS.

Results

Lung ultrasound score increased by 23% at T2, from 13 at baseline to 16 (P < 0.001). Cardiac index and cardiac filling pressures increased significantly at T1 (P < 0.001) and returned to control values at T2. The increase in lung ultrasound score was statistically correlated with fluid loading-induced increase in cardiac index and was not associated with increase in pulmonary shunt or regional pulmonary blood flow. At T1, PaO₂/FiO₂ significantly increased (P < 0.005) from 144 (123 to 198) to 165 (128 to 226) and returned to control values at T2, whereas lung ultrasound score continued to increase.

Conclusions

Early fluid loading transitorily improves hemodynamics and oxygenation and worsens lung aeration. Aeration changes can be detected at the bedside by transthoracic lung ultrasound, which may serve as a safeguard against excessive fluid loading.     

Evaluation of left ventricular diastolic function by fractional area change using cine cardiovascular magnetic resonance: a feasibility study

Background

Evaluation of left ventricular (LV) diastolic function is essential for the management of heart failure. We verified whether LV diastolic function could be evaluated by measuring the fractional area change (FAC) using cine cardiovascular magnetic resonance (CMR).

Methods

We collected clinical data from 59 patients who underwent echocardiography and cine CMR. Normal, impaired relaxation, pseudonormal, and restrictive LV filling were observed in 15, 28, 11, and 5 patients, respectively. We calculated FAC during the first 30% of diastole (diastolic-index%) in the short-axis view, by tracing the contours on only three MR cine images.

Results

The diastolic index was significantly lower (p < 0.0001) in patients with impaired relaxation (32.4 ± 7.5), pseudonormal filling (25.4 ± 5.6), and restrictive filling (9.5 ± 1.5) compared to those with normal diastolic function (67.7 ± 10.8), and the index decreased significantly with worsening of diastolic dysfunction. The diastolic index correlated positively with early diastolic mitral annular velocity measured by tissue Doppler imaging (r = 0.75, p < 0.0001), respectively.

Conclusions

Measurement of FAC can be useful for the evaluation of LV diastolic function using cine CMR.