Respiratory variation of intra-abdominal pressure: indirect indicator of abdominal compliance?

OBJECTIVE: To assess if the observed respiratory cycle-related variation in intra-abdominal pressure is reliably quantifiable and a possible indirect indicator of abdominal compliance. Secondary issues were to assess the roles played by respiratory parameters in determining this oscillation and by patients' position in increasing their intra-abdominal pressure. DESIGN AND SETTING: Prospective observational study in a 26-bed medical-surgical intensive care unit. PATIENTS: Sixteen consecutive patients admitted to intensive care for at least 24 h, requiring mechanical ventilation and intra-abdominal pressure monitoring. MEASUREMENTS AND RESULTS: Intra-abdominal pressure was measured with a modified Kron technique; its waveform was recorded and inspiratory and expiratory values were measured during five consecutive respiratory cycles for 5 days, both in the supine and the 30 degrees head-up position. Inspiratory values were significantly higher than expiratory values (p = 0.001) and a correlation was found between their difference and intra-abdominal pressure basal values (p = 0.025). A positive linear relationship was shown between intra-abdominal pressure and the amplitude of its oscillation (r = 0.4), particularly in the subgroup of patients with intra-abdominal hypertension (r = 0.9). Intra-abdominal pressure was lower in patients supine than in the 30 degrees head-up position (p = 0.001). CONCLUSIONS: Respiratory cycle-related variations in intra-abdominal pressure were specifically investigated, quantified and shown as linearly increasing with end-expiratory intra-abdominal pressure; this phenomenon could be explained by patients' abdominal compliance status. Supine posture should be an important consideration in specific patients affected by intra-abdominal hypertension.     

Depigmentation of the vulvar area: Is it an alarming sign?

A 34‐year‐old female patient presented with recurrent bilateral hypopigmented macules on the labia majora. The lesions were treated with topical steroids, which led to mild improvement, but erosive plaques developed after discontinuing the treatment. Histopathological findings were compatible with extramammary Paget disease (EMPD), which was treated with radical vulvectomy with no recurrence in the next months of follow‐up.     

Is it just an obstructive pyelonephritis?

Pyelocaliceal obstruction is a diagnostic challenge, and it is important to identify the obstruction cause. Some patients present extra‐renal compressive masses that need further imagiologic investigation and a biopsy, to establish the diagnosis.     

Is the CVI an acceptable indicator of content validity? Appraisal and recommendations

Nurse researchers typically provide evidence of content validity for instruments by computing a content validity index (CVI), based on experts' ratings of item relevance. We compared the CVI to alternative indexes and concluded that the widely-used CVI has advantages with regard to ease of computation, understandability, focus on agreement of relevance rather than agreement per se, focus on consensus rather than consistency, and provision of both item and scale information. One weakness is its failure to adjust for chance agreement. We solved this by translating item-level CVIs (I-CVIs) into values of a modified kappa statistic. Our translation suggests that items with an I-CVI of .78 or higher for three or more experts could be considered evidence of good content validity.     

Procalcitonin in pediatric burn patients: an early indicator of sepsis?

To determine whether changes in procalcitonin (PCT) could be used to predict the onset of sepsis, daily PCT levels were monitored in 20 burned children. Analysis indicated a PCT rise of 5 ng/ml or greater as the best indication of sepsis. We compared the surgeons' determination of sepsis, which was based on changes in platelet count, C-reactive protein (CRP), and other clinical manifestations, with the prediction of sepsis from PCT. There were 26 septic episodes and 36 nonseptic episodes in the 20 patients. PCT results were classified as to true positives, false positives, true negatives, and false negatives. As an indicator of sepsis, the PCT assay had a sensitivity of 42%, a specificity of 67%, and an efficiency of 57%. Even when the assay correctly identified sepsis, the determination was made an average of 0.8 days after the surgeon had already made the diagnosis based on CRP and/or platelet count. We conclude that PCT is not as effective as CRP and/or platelet count in the early detection of sepsis in burned children.     

Soleus strain: an underestimated injury?

The medial gastrocnemius is the most commonly injured muscle in the calf, and while traumatic lesions of the medial gastrocnemius are frequently described in the medical literature and clinical and sonographic diagnoses are easy, those of the soleus are less easily recognisable clinically or by sonography. We present a case of traumatic lesions of the medial gastrocnemius, diagnosed clinically and with ultrasound, while MRI also detected two lesions of the soleus. The case presented and the review of the literature highlight how clinical and ultrasound examinations can lead to misunderstandings about traumatic injury to the soleus.     

Hypernatremia in the intensive care unit: an indicator of quality of care?

OBJECTIVE: To assess the frequency of hypernatremia in patients who were admitted to an intensive care unit (ICU) and to determine the correlation of hypernatremia with the clinical outcomes, durations of the patients' stays in the ICU, and other clinical variables. DESIGN: Retrospective survey. SETTING: University teaching hospital. PATIENTS: All patients (total, 389) who were admitted to the medical ICU of the department of internal medicine during 1 yr. MEASUREMENTS: The database of our hospital's mainframe computer was searched for sodium values > or = 150 mmol/L that were registered in the year 1995. These data were then matched with the registration numbers of all patients who were admitted to our medical ICU between January 1 and December 31, 1995. In this way, we identified all patients in whom hypernatremia was present at admission or those who developed hypernatremia in the course of their stay in our ICU. The prevalence and duration of hypernatremia (defined as a serum sodium concentration of > or = 150 mmol/L or more) were determined; the correlation of hypernatremia with clinical outcome, duration of ICU stay, Acute Physiology and Chronic Health Evaluation II scores, and other clinical variables were evaluated; and changes in fluid administration in response to hypernatremia and fluid regimens in the period preceding hypernatremia were examined. MAIN RESULTS: Of a total of 389 patients who were admitted in 1995, hypernatremia was present at admission in 34 patients (8.9%). The average duration of hypernatremia in these patients was 16.2 (range, 4-56) hrs. A total of 22 patients (5.7%) developed hypernatremia in the course of their stay in the ICU. The average duration of hypernatremia in this group was 34.7 (range, 4-89) hrs. Moderately elevated levels of sodium had been detected in most of these patients (n = 21) in the days before the development of severe hypernatremia; however, adjustments in fluid infusion aimed at preventing the occurrence of hypernatremia were either lacking (n = 7) or inadequate (n = 11). Hospital-acquired hypernatremia vs. hypernatremia present at admission to the ICU was associated with a higher mortality rate (32% vs. 20.3%, respectively; p < .01). CONCLUSIONS: Despite frequent measurement of sodium levels in patients in the ICU, hypernatremia is a relatively common occurrence. Initial treatment of hypernatremia is often inadequate, and sometimes treatment is delayed. The development of hypernatremia is associated with adverse outcomes for patients developing hypernatremia in the ICU. Hypernatremia could potentially be used as an indicator of quality of care in the medical ICU.     

Radionuclide Imaging of Viable Myocardium: Is it Underutilized?

Coronary artery disease is the major cause of heart failure in North America. Viability assessment is important as it aims to identify patients who stand to benefit from coronary revascularization. Radionuclide modalities currently used in the assessment of viability include ²⁰¹Tl SPECT, ^99mTc-based SPECT imaging, and ¹⁸F-fluorodexoyglucose (¹⁸F-FDG)-PET imaging. Different advances have been made in the last year to improve the sensitivity and specificity of these modalities. In addition, the optimum amount of viable (yet dysfunctional) myocardium is important to identify in patients, as a risk–benefit ratio must be considered. Patients with predominantly viable/hibernating myocardium can benefit from revascularization from a mortality and morbidity standpoint. However, in patients with minimal viability (predominantly scarred myocardium), revascularization risk may certainly be too high to justify revascularization without expected benefit. Understanding different radionuclide modalities and new developments in the assessment of viability in ischemic heart failure patients is the focus of this discussion.     

Tortuosity of coronary arteries: an indicator for impaired left ventricular relaxation?

Objective To investigate the relationship between coronary tortuosity and impaired left ventricular relaxation. Methods One hundred and four subjects who underwent coronary angiography were included in the study. Left anterior descending, left circumflex, and right coronary arteries were traced. Tortuosity was identified by the finding of ≥3 bends (defined as ≥45° change in vessel direction) along main trunk of at least one artery. Study population were divided into tortuosity (n = 54) and no tortuosity (n = 50) groups. Subjects were all submitted to pulsed-wave Doppler and two-dimensional echocardiographic examination to assess left ventricular functions. Results For subjects with tortuosity, early transmitral inflow (E) velocity was lower, late transmitral inflow (A) velocity was higher, E/A ratio was smaller compared with subjects without tortuosity (P < 0.001). Subjects with tortuosity had longer deceleration time of E velocity (DT) and isovolumic relaxation time (IVRT) than did subjects without tortuosity (P < 0.001). End-diastolic interventricular septal and left ventricular posterior wall thicknesses were greater in subjects with tortuosity than those without tortuosity (P = 0.01 and P = 0.005). There was an inverse correlation between total number of arteries with tortuosity and E/A ratio (r = −0.750, P < 0.001). Total number of arteries with tortuosity displayed correlations with DT (r = 0.723, P < 0.001) and IVRT (r = 0.703, P < 0.001). Conclusions This study depicts that coronary tortuosity is associated with impaired left ventricular relaxation.Thus, coronary tortuosity might be an indicator of impaired left ventricular relaxation.     

Roller coaster migraine: an underreported injury?

A 28-year-old woman presented with severe headache, sleep problems, memory problems, and irritability 2 months after a violent roller coaster ride. She was diagnosed with posttraumatic migraine, and intravenous dihydroergotamine resolved her symptoms. Imaging studies, electroencephalogram, and visual and auditory evoked responses were normal. Imipramine, divalproex sodium, and propranolol were prescribed to prevent the headaches from recurring and dihydroergotamine nasal spray was prescribed for breakthrough headaches. We consider the many short but significant brain insults delivered during the roller coaster ride a critical factor in triggering this instance of posttraumatic migraine, which while unmanaged was a source of significant disability for the patient.     

How reliable an indicator of inflammation is myeloperoxidase activity?

BACKGROUND: Myeloperoxidase (MPO) and interleukin-6 (IL-6) are often used as markers of inflammation. The aim of this study was to ascertain whether MPO activity is as reliable as IL-6 as an indicator of inflammation. METHODS: Inflammation was induced in mice, using either turpentine or indomethacin. Duodenal tissue was removed from these animals at various time periods ranging from 6 h to 7 days later. Concentrations of IL-6 and MPO activity were estimated in the tissue. Histopathological examination was also carried out at some of the time periods to determine the presence of neutrophil infiltration in turpentine-treated mice. RESULTS: Concentrations of IL-6 and MPO activity were significantly higher in tissue that had been treated with the agents used, at all the time periods studied, when compared with corresponding control tissue. Fold-increases in MPO activity were higher than fold-increases in IL-6. Concentrations of the 2 parameters showed significant positive correlation. Histopathological examination did not show significantly higher numbers of neutrophils infiltrating the tissue in response to turpentine, at the time periods studied. CONCLUSIONS: Estimation of MPO activity is a reliable indicator of inflammation, being more sensitive than histopathological examination of tissue and as good as measurement of IL-6 concentrations.     

In-hospital cardiac arrest: Is it time for an in-hospital ‘chain of prevention’?

The ‘chain of survival’ has been a useful tool for improving the understanding of, and the quality of the response to, cardiac arrest for many years. In the 2005 European Resuscitation Council Guidelines the importance of recognising critical illness and preventing cardiac arrest was highlighted by their inclusion as the first link in a new four-ring ‘chain of survival’. However, recognising critical illness and preventing cardiac arrest are complex tasks, each requiring the presence of several essential steps to ensure clinical success. This article proposes the adoption of an additional chain for in-hospital settings - a ‘chain of prevention’ - to assist hospitals in structuring their care processes to prevent and detect patient deterioration and cardiac arrest. The five rings of the chain represent ‘staff education’, ‘monitoring’, ‘recognition’, the ‘call for help’ and the ‘response’. It is believed that a ‘chain of prevention’ has the potential to be understood well by hospital clinical staff of all grades, disciplines and specialties, patients, and their families and friends. The chain provides a structure for research to identify the importance of each of the various components of rapid response systems.