High frequency ultrasonographic findings in plantar fasciitis and assessment of local steroid injection

OBJECTIVE: To investigate the value of ultrasonography in the diagnosis of plantar fasciitis and changes in plantar fascia following ultrasound guided local steroid injection. METHODS: Twenty patients with a clinical diagnosis of plantar fasciitis and 20 healthy subjects were studied prospectively. Ultrasound examination was performed using an ATL Apogee 800 and linear array 11 MHz transducer. The affected heel was injected with 15 mg triamcinolone hexacetonide and 2 ml of 2% lidocaine. Ultrasound examination was performed at time of clinical evaluation, again immediately after injection, and at 1, 6, and 30 weeks later. The thickness, echogenicity, and marginal appearance of plantar fascia were measured. RESULTS: Ultrasonographic measurement of plantar fascia showed a significant increase in symptomatic heels (range 4.8-6.5, mean 5.8 +/- 2.06 mm) compared with healthy subjects (range 1.8-3.4, mean 2.4 +/- 0.64 mm) (p < 0.001). A significant decrease in the thickness of plantar fascia was observed 1 week after local steroid injection (range 2.1-3.5, mean 2.3 +/- 0.91 mm). Complete relief of symptoms and signs was further observed at 6 and 30 weeks. CONCLUSION: Ultrasonographic examination of plantar fascia is easy and quick to perform. Ultrasound procedure should be considered early in diagnosis and management of heel pain. Ultrasound guided local steroid injection proved safe and effective in the treatment of plantar fasciitis.     

The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis

OBJECTIVE: To compare ultrasonography with bone scintigraphy in the diagnosis of plantar fasciitis and to compare ultrasound-guided injection with palpation-guided injection in the management of idiopathic plantar fasciitis. METHODS: Twenty-three patients with a clinical diagnosis of idiopathic plantar fasciitis in 28 heels underwent ultrasonography and bone scintigraphy of both heels at baseline. The patients were randomized to ultrasound- or palpation-guided injection of triamcinolone hexacetonide and xylocaine into the plantar fascia. The 100 mm visual analogue scale (VAS) of pain, the heel tenderness index (HTI), and ultrasonography were performed at baseline and follow-up (mean=13.4 weeks). RESULTS: The mean thickness (+/-standard error of the mean) of the plantar fascia, measured by ultrasonography, was 5.7+/-0.3 mm in symptomatic heels as compared with 3.8+/-0.2 mm in asymptomatic heels (P<0.001). Ultrasonography findings correlated with bone scintigraphic findings in the diagnosis of plantar fasciitis (P<0.001). Fourteen heels were randomized to ultrasound-guided injection, 10 heels were randomized to palpation-guided injection and four heels were not injected. Ultrasound- and palpation-guided injection resulted in significant mean improvements in VAS [39.6+/-9.2 (ultrasound) vs 41.5+/-8 (palpation)] and HTI [1.35+/-0.2 (ultrasound) vs 1.3+/-0.4 (palpation)]. There was no significant difference in the response rate following corticosteroid injection by either modality (ultrasound=13/14, palpation=8/10). Following injection, the mean thickness of the plantar fascia decreased from 5.7+/-0.3 mm to 4.65+/-0.4 mm (P<0.01). CONCLUSION: Ultrasonography and bone scintigraphy are equally effective in the diagnosis of plantar fasciitis. Ultrasound-guided injection is effective in the management of plantar fasciitis but is not more effective than palpation-guided injection. Ultrasonography may be used as an objective measure of response to treatment in plantar fasciitis.     

High‐resolution ultrasonographic diagnosis of plantar fasciitis: a correlation of ultrasound and magnetic resonance imaging

Aim and Method: In a prospective study of nine men and eight women with suspected unilateral or bilateral plantar fasciitis, 23 symptomatic heels were examined by both high‐resolution ultrasound and a preplanned limited sagittal magnetic resonance imaging (MRI) protocol to assess the different signs. Eleven healthy volunteers (22 heels) acted as controls. Results: The plantar fascia was thickened in symptomatic feet. The thickness of the plantar fascia in symptomatic feet was (3.0–7.0 mm; 4.9 ± 1.3) measured by ultrasound which was significantly thicker than in the control group (1.1–2.4 mm; 1.7 ± 0.06); P < 0.05. Other sonographic signs used for the diagnosis of plantar fasciitis in the study were compared to MRI findings. The diagnostic accuracy was 69.5% for abnormal focal echogenicity within the plantar fascia, 60.8% for edema around the plantar fascia, 78.2% for perifascial edema, 69.5% for rupture of the plantar fascia and the lowest diagnostic accuracy of ultrasound was in detection of associated calcaneal spur (56.5%). The findings were tabulated and discussed in relation to other literature. Conclusion: It was concluded that the diagnostic accuracy of ultrasound is comparable to that of MRI in the diagnosis of plantar fasciitis and it could be the straightforward initial imaging modality to confirm clinically suspected plantar fasciitis. MRI may be reserved for cases where a diagnosis of plantar fasciitis does not satisfactorily explain the clinical presentation and when complex pathology is suspected.     

Safety of the transpulmonary ultrasound contrast agent NC100100: a clinical and haemodynamic evaluation in patients with suspected or proved coronary artery disease

OBJECTIVE—To evaluate the clinical and haemodynamic safety of NC100100, a new transpulmonary ultrasound contrast agent intended for vascular use.
DESIGN—Pulmonary artery pressures and gas exchange, left ventricular and systemic blood pressure and ECG were measured at baseline, after saline injection, and after each of two increasing doses of NC100100 injected intravenously.
PATIENTS—30 patients who were evaluated for suspected coronary artery disease.
RESULTS—No change was detected in any of the haemodynamic variables, or in haematological or clinical chemical parameters. Blood gases were unchanged, as were heart rhythm and arterial oxygen saturation. No serious adverse reactions were reported.
CONCLUSIONS—NC100100 appeared to be haemodynamically inert and safe in patients with coronary artery disease.


Keywords: NC100100; ultrasound; safety     

Pseudoaneurysm of femoral artery after catheterisation: treatment by a mechanical compression device guided by colour Doppler ultrasound

Background—Femoral artery pseudoaneurysm is a significant complication in patients undergoing diagnostic or therapeutic catheterisation. First choice treatment for pseudoaneurysm is freehand ultrasound guided compression repair, which is time consuming and uncomfortable for the patient and operator.
Aim—To explore a mechanical compression device (FemoStop) as an alternative treatment for iatrogenic femoral artery pseudoaneurysm.
Methods—Fourteen patients with pseudoaneurysm were considered for treatment with FemoStop after a brief freehand ultrasound guided compression repair to confirm the compressibility of the lesion. The FemoStop compression was applied for 20 minutes. The result was controlled with colour Doppler ultrasound, and a second cycle of 20 minutes followed if necessary.
Results—FemoStop compression was successful in 13 of the 14 patients. The mean compression time was 33 minutes (range, 20-60). The mean number of compression periods was 1.6 (range 1-3). FemoStop compression was successful in all 11 patients not taking anticoagulants and in two of three patients receiving anticoagulants. The mean compression time in patients given oral or intravenous anticoagulants was longer (50 v 27 minutes). Colour Doppler ultrasound 12 hours after the procedure indicated no recurrence of pseudoaneurysm in the 13 patients with initial success.
Conclusions—FemoStop compression for iatrogenic pseudoaneurysm is feasible, and as safe and effective as freehand ultrasound guided compression repair. It is more comfortable for the patient and operator, and probably more economical than freehand compression.

Keywords: pseudoaneurysm;  femoral artery;  angiography complications;  FemoStop     

Detection of small hepatocellular carcinomas in cirrhotic livers using iodised oil computed tomography

Background—The detection of hepatocellular cancers(HCC) is a major role of preoperative imaging in patients with endstage liver disease being considered for orthotopic livertransplantation (OLT).
Aims—To assess the sensitivity of iodised oilcomputed tomography (IOCT).
Patients and methods—A prospective evaluation in50 consecutive patients undergoing OLT included ultrasound scan,contrast enhanced CT, angiography (with intra-arterial injection ofiodised oil), and a second CT (IOCT) 10 days later. Followingtransplantation the explant liver was serially sectioned forpathological evaluation. Soft tissue radiographs of the liver sliceswere used to match histological lesions with CT findings.
Results—Eleven patients were excluded due toprotocol violations. Of the remaining 39, histological evaluationrevealed no cancers in 33 explant livers, in keeping with negativepreoperative imaging. Six explant livers contained 55 HCCs, 84% ofwhich were less than 1 cm in diameter. Pretransplant IOCT detected 3/6patients with cancer (50%) but only 7% of cancerous lesions.Ultrasound, contrast CT, and angiography each detected 2/6 patientswith cancer and 4% of cancerous lesions.
Conclusion—IOCT is an insensitive method for thedetection of small HCCs in livers with advanced cirrhosis but in thisstudy was slightly superior to ultrasound, CT, and angiography.

Keywords:liver cirrhosis; transplantation; hepatocellularcarcinoma; iodised oil; computed tomography

     

Biliary lipid composition in idiopathic bile acid malabsorption

Background—Chronic diarrhoea is the clinicalhallmark of patients presenting with idiopathic bile acidmalabsorption. Its pathogenesis is unknown; colonic water secretion canbe induced by dihydroxy bile acids, but it is not known whetherenrichment of the bile acid pool with these bile acids occurs in suchpatients. Furthermore, bile acid malabsorption is known to affectbiliary lipid composition, but no information is available for theidiopathic type.
Aims—To verify: (a) whetherdiarrhoea in patients with idiopathic bile acid malabsorption isassociated with enrichment of the bile acid pool with dihydroxy bileacids; and (b) whether supersaturation with cholesterol ofduodenal bile occurs in such patients as a result of chronic bile acid depletion.
Patients—Thirteen patients with idiopathic bileacid malabsorption diagnosed according to abnormal ⁷⁵SeHCATtest and absence of other organic diseases, and 23 control subjects.
Methods—Bile rich duodenal fluid was collectedduring intravenous ceruletide infusion in the fasting state. Biliarylipids were analysed by enzymatic assays and bile acids by highperformance liquid chromatography.
Results—Patients with idiopathic bile acidmalabsorption had a cholesterol saturation index similar to controls.Bile acid composition showed only a decrease in percentage cholic acid(29(2)% versus 36 (2)%; p<0.05); the dihydroxy:trihydroxy bile acid ratio was similar to controls.
Conclusions—Patients with idiopathic bile acidmalabsorption do not have an increased risk of forming cholesterolgallstones. The mechanism of diarrhoea does not seem to depend on anenrichment of the bile acid pool with dihydroxy bile acids.

Keywords:primary bile acid malabsorption; bile acids; diarrhoea; ⁷⁵SeHCAT; biliary lipids; cholesterol saturationindex

     

Transseptal left heart catheterisation guided by intracardiac echocardiography

OBJECTIVE—To develop a novel approach of transseptal puncture guided by intracardiac echocardiography and to assess its efficacy.
METHODS—Transcatheter intracardiac echocardiography with a 9 MHz rotating transducer was performed to guide transseptal puncture in 12 patients (mean age 43.1 years, range 31-68) who underwent radiofrequency catheter ablation of left sided accessory pathways. Initially, the echocardiography and transseptal catheters were placed adjacent to each other in the superior vena cava and were withdrawn to the level of the fossa ovalis.
RESULTS—The successful puncture site was associated with visualisation of the fossa ovalis (12 patients, 100%) and the aorta (12 patients, 100%), tenting of the fossa (six patients, 50%), penetration of the needle visualised by the ultrasound catheter (12 patients, 100 %), and echocardiographic contrast material applied in the left atrium (12 patients, 100%). The characteristic jump of the needle onto the fossa ovalis was observed simultaneously with fluoroscopy and intracardiac ultrasound (12 patients, 100%). All procedures were successful. There were no complications associated with the transseptal procedure.
CONCLUSIONS—Intracardiac echocardiography is feasible to guide transseptal puncture. The optimal puncture site can be assessed by simultaneous detection of the characteristic downward jump of the transseptal needle onto the fossa ovalis by intracardiac ultrasound and fluoroscopy.


Keywords: intracardiac echocardiography; transseptal catheterisation     

Lesion characteristics of acute myocardial infarction: an investigation with intravascular ultrasound

OBJECTIVE—To use intravascular ultrasound (IVUS) to compare plaque morphology in acute myocardial infarction and stable angina pectoris.
DESIGN—Retrospective study.
SETTING—Primary care hospital.
PATIENTS—59 consecutive cases of acute myocardial infarction and 50 consecutive cases of stable angina pectoris.
METHODS—IVUS was used before coronary intervention.
MAIN OUTCOME MEASURES—Plaque morphology (incidence of eccentric plaque, subtle dissections, low echoic thrombus, calcification, echolucent areas, and bright speckled echo material), assessed visually using IVUS.
RESULTS—There were no significant differences in plaque eccentricity or calcification between the two groups, but low echoic thrombus (acute myocardial infarction 15% v stable angina pectoris 0%), subtle dissections (37% v 4%), echolucent areas (31% v 0%), and bright speckled echo material (90% v 0%) were more common in the infarction group than in the stable angina group (p < 0.001 for all). There was a longer time between the onset of symptoms and the IVUS examination in patients with low echoic thrombus than in those without (p < 0.03).
CONCLUSIONS—Low echoic thrombus, subtle dissections, echolucent areas, and bright speckled echo material are morphological characteristics associated with plaque at the time of acute myocardial infarction. These findings correspond pathologically to ruptured plaque.


Keywords: intravascular ultrasound; acute myocardial infarction; plaque morphology     

Impaired cardiac adrenergic innervation assessed by MIBG imaging as a predictor of treatment response in childhood dilated cardiomyopathy

OBJECTIVE—To evaluate the prognostic value of metaiodobenzylguanidine (MIBG) imaging in childhood cardiomyopathy.
DESIGN—Prospective cohort study.
SETTING—Tertiary referral centre.
PATIENTS—40 children (21 boys, 19 girls; mean (SD) age, 7.0 (5.6) years) with heart failure resulting from idiopathic dilated cardiomyopathy (n = 23) or various other disorders (n = 17).
METHODS—At the initial examination, cardiac ¹²³I-MIBG uptake and release, circulating noradrenaline (norepinephrine) concentration, x ray cardiothoracic ratio, and echocardiographic variables were recorded. Cardiac MIBG uptake was obtained by measuring the heart to mediastinum activity ratio on the planar image obtained four hours after MIBG injection. MIBG washout rate was evaluated using relative decrease in cardiac activity measured at 20 minutes and four hours. Patients were treated with angiotensin converting enzyme inhibitors, diuretics, and digitalis, and were followed up for 12 (10) months. Fifteen patients did not respond to medical treatment (12 heart transplants; three deaths), and 25 did respond (improved or stable).
RESULTS—Cardiac MIBG uptake was positively correlated with x ray cardiothoracic index (r = 0.55, p = 0.0008) and echocardiographic left ventricular fractional shortening (r = 0.68, p < 0.0001). Among all the clinical and laboratory variables tested, multivariate discriminant analysis showed that the only independent predictor of an unfavourable outcome was a low MIBG uptake (p < 0.001). Survival curves had a mean threshold value of 1.54 for MIBG uptake.
CONCLUSIONS—Impaired cardiac adrenergic innervation is strongly related to adverse outcome in children with dilated cardiomyopathy, independently of the aetiology. MIBG imaging may help to stratify risk in such patients.


Keywords: noradrenaline; MIBG; single photon imaging; children; cardiomyopathy     

Heart rate variability and baroreflex sensitivity in idiopathic dilated cardiomyopathy

OBJECTIVE—To examine the relation between cardiac autonomic tone, assessed by baroreflex sensitivity and heart rate variability, and left ventricular function, arrhythmias on Holter monitoring, and clinical variables in patients with idiopathic dilated cardiomyopathy.
DESIGN—A prospective observational study.
PATIENTS—160 patients with idiopathic dilated cardiomyopathy and preserved sinus rhythm in the absence of antiarrhythmic drug treatment. Measures of heart rate variability obtained by digital 24 hour Holter recordings included the mean of all coupling intervals between normal beats (RRm), the standard deviation of the mean of normal RR intervals (SDNN), and the square root of the mean of the squared differences between adjacent normal RR intervals (rMSSD). Baroreflex sensitivity testing was performed using the phenylephrine method.
RESULTS—Mean SDNN (SEM) was 112 (46) ms, and baroreflex sensitivity was 7.5 (5.0) ms/mm Hg. SDNN showed a weak correlation with baroreflex sensitivity (r = 0.19, p < 0.05) and with left ventricular ejection fraction (r = 0.29, p < 0.05). SDNN showed no significant correlation with age (r = −0.07), the presence of non-sustained ventricular tachycardia (r = −0.13), or left ventricular end diastolic diameter (r = −0.07). In addition, baroreflex sensitivity showed no significant correlation with age (r = −0.13), non-sustained ventricular tachycardia (r = −0.08), left ventricular end diastolic diameter (r = 0.09), or ejection fraction (r = 0.14).
CONCLUSIONS—The weak correlation between baroreflex sensitivity and heart rate variability suggests that these two indices explore different aspects of cardiac autonomic control in patients with idiopathic dilated cardiomyopathy. The weak or absent correlation between baroreflex sensitivity, heart rate variability, and other potential non-invasive risk predictors, including left ventricular ejection fraction, left ventricular end diastolic diameter, and non-sustained ventricular tachycardia on Holter monitoring, indicate that these variables may have independent prognostic value in idiopathic dilated cardiomyopathy.


Keywords: cardiomyopathy; baroreflex sensitivity; heart rate variability     

Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms

OBJECTIVE—To study the effect of accuracy on the clinical outcome of local steroid injections to the shoulder.
METHODS—37 patients with shoulder symptoms of at least two months' duration received local injections of a mixture of triamcinolone and radiographic contrast material using a standardised technique. Radiographs of the joint were taken immediately afterwards. Details of the patients' symptoms (assessed by visual analogue scales) and range of movement at the joint were obtained before and two weeks after the injection. At follow up the patients were also assessed by means of a five point global rating scale of maximum and current benefit.
RESULTS—14 of the 38 procedures (37%) were judged to be accurately placed: four of the 14 attempted subacromial injections (29%) and 10 of the 24 attempted glenohumeral injections (42%). There were significant differences in relation to outcome between the accurately placed and the inaccurately placed groups.
CONCLUSIONS—Accuracy of steroid placement by injection in patients with shoulder symptoms may significantly affect the clinical outcome.

     

Ultrasonographic findings of Achilles tendon and plantar fascia in patients with calcium pyrophosphate deposition disease

The aims of the study were to detect the frequency of involvement of the Achilles tendon and plantar fascia in patients with calcium pyrophosphate deposition disease (CPPD) by high-frequency gray-scale ultrasonography (US) and power Doppler sonography (PDS) and to correlate these findings with demographic and clinical data. Two groups of patients were enrolled: group I (38 patients with CPPD) and group II (22 patients with knee OA). US/PDS examination of the heels was performed to both groups. In the CPPD group, US/PDS examination of the Achilles tendon revealed: calcification in 57.9%, enthesophytosis in 57.9%, enthesopathy in 23.7%, vascular sign in 21%, bursitis in 13.2%, and cortical bone irregularity in 10.5%. US/PDS examination of plantar fascia in the CPPD group revealed: calcification in 15.8%, cortical bone irregularity in 78.9%, enthesophytosis in 60.5%, and planter fasciitis in 42.1%. In patients with CPPD, age was significantly correlated with enthesophytosis and deep retrocalcaneal bursitis (p = 0.01 and p = 0.04, respectively). Heel tenderness and posterior talalgia were significantly correlated with Achilles tendon enthesopathy, vascular sign, and deep retrocalcaneal bursitis (p = 0.0001 for each). Inferior talalgia was significantly correlated with plantar fasciitis (p = 0.0001). The sensitivity of ultrasonography for detection of calcifications in Achilles tendon and plantar fascia was 57.9% and 15.8%, respectively, and the specificity was 100% for both. To conclude, ultrasonographic Achilles tendon and plantar fascia calcifications are frequent findings in patients with CPPD. These calcifications have a high specificity and can be used as a useful indirect sign of CPPD.     

Pathology of idiopathic megarectum and megacolon

Background—The aetiology and pathology of bothidiopathic megarectum and idiopathic megacolon are unknown. Inparticular, it is unknown whether there are abnormalities involvingenteric nerves or smooth muscle.
Methods—Resected tissue was examined from 24 patients who underwent surgery for idiopathic megarectum, from sixpatients who had tissue resected for idiopathic megacolon, and 17 control patients who had surgery for non-obstructing large bowelcancer. Qualitative and quantitative histological examination wasperformed after staining with haematoxylin and eosin, periodic acidSchiff (PAS), Martius scarlet blue (MSB), and phosphotungstic acidhaematoxylin (PTAH). Neural and glial tissue were examined afterimmunostaining with S100 and PGP9.5.
Results—Compared with controls, patients withidiopathic megarectum had significant thickening of their muscularismucosae (median 78 v 33 µm, p<0.005), circular muscle(1000 v 633 µm, p<0.005), and longitudinal muscle (1083 v 303 µm, p<0.005), despite rectal dilatation. Thisthickening was relatively greater in the longitudinal than in thecircular muscle. Fibrosis of the longitudinal muscle was seen, usingMSB staining, in 58%, of circular muscle in 38%, and of muscularismucosae in 29% of patients. The relation between muscle thickening andfibrosis was variable. The density of neural tissue in the longitudinalmuscle seemed to be reduced in patients with idiopathic megarectum.There was no thickening of enteric muscle or alteration in the densityof innervation in patients with idiopathic megacolon.
Conclusion—There is notable thickening of theenteric smooth muscle in patients with idiopathic megarectum, but thearchitecture of the enteric innervation seems to be intact. Functionalabnormalities of the latter remain a possible cause of the smoothmuscle hypertrophy.

Keywords:idiopathic megarectum; idiopathic megacolon

     

Potential impact of antiarrhythmic drugs versus implantable defibrillators on the management of ventricular arrhythmias: the Midlands trial of empirical amiodarone versus electrophysiologically guided intervention and cardioverter implant registry data

Background—Survival was prolonged in selected patients with sustained ventricular arrhythmias who received implantable cardioverter defibrillators (ICDs) in the antiarrhythmics versus implantable defibrillators (AVID) study. The Midlands trial of empirical amiodarone versus electrophysiologically guided intervention and cardioverter implant in ventricular arrhythmias (MAVERIC) registry is a population based trial.
Objective—To determine the number of patients who satisfy the AVID criteria because of the high cost of ICDs.
Design—Observational study, based on a continuing trial.
Setting—All coronary care units in the Midlands region in the United Kingdom (population 9.1 million).
Patients—Patients presenting to a coronary care unit with sustained ventricular arrhythmias not related to an acute myocardial infarction are entered onto the registry. Those who consent to the MAVERIC study are randomised to receive either empirical amiodarone or electrophysiologically guided treatment. Demographic data, details of clinical presentation, and echocardiographic findings are collected. These data have been used to calculate the number of patients who satisfy the AVID criteria and would benefit from ICD implantation. The financial implications have been calculated for the region and nationally.
Results—132 patients were entered onto the registry during the first five months of the MAVERIC study; 69 patients fulfilled the AVID criteria. Extrapolation of these data over a 12 month period suggests implantation of at least 166 new ICDs (compared with 23 implants in 1996). This would increase the UK ICD implant rate from five to at least 18 per million of the population, costing the National Health Service £24.1 million per annum.
Conclusion—Application of the AVID criteria in the UK will cause a great increase in the ICD implant rate, with serious financial implications.

Keywords: AVID study;  MAVERIC trial;  implantable cardioverter defibrillator;  economics;  arrhythmias     

Transhepatic approach for cardiac catheterisation in children: initial experience

AIM—To assess initial experience of cardiac catheterisation in children by the transhepatic approach where conventional venous access is impossible.
PATIENTS AND METHODS—Percutaneous transhepatic cardiac catheterisation was performed on six occasions in five children (three male) aged 4 to 36 months (mean 17 months). All children had documented femoral venous occlusion and all but one had occlusion of the superior vena cava. Ultrasound was used in five of the six procedures to help identify a large hepatic vein. A 4 F or 5 F sheath was introduced into the vein using the Seldinger technique. In the fourth patient, hepatic venous access was obtained immediately without the assistance of ultrasound.
RESULTS—Percutaneous transhepatic catheterisation was successfully performed at all six attempts. Total procedure time ranged from 120 to 200 minutes (mean 138 minutes) and screening time from 14 to 22 minutes (mean 16.8 minutes). A serious complication was encountered in only one patient who had a retroperitoneal bleed after administration of thrombolysis for loss of femoral arterial pulse.
CONCLUSIONS—The percutaneous transhepatic technique can provide a safe alternative approach for cardiac catheterisation in children with multiple venous occlusion. The procedure can be performed very simply using the Seldinger technique and equipment normally used for conventional venous cannulation for cardiac catheterisation.


Keywords: cardiac catheterisation; transhepatic approach; congenital heart defects     

Factors affecting splanchnic haemodynamics in Crohn's disease: a prospective controlled study using Doppler ultrasound

Background—Current knowledge on splanchnichaemodynamics in Crohn's disease is limited.
Aims—To investigate which features of Crohn'sdisease affect splanchnic haemodynamics, and to establish whetherportal vein (PV) and superior mesenteric artery (SMA) blood supplyreflects clinical or biochemical activity of Crohn's disease.
Methods—Seventy nine patients with Crohn'sdisease and 40 controls were evaluated by Doppler ultrasound (US). Themean velocity of PV and SMA flow, the volume of blood flow of the PVand SMA, and the resistance index of SMA were studied. A series ofclinical, biochemical, and US variables including Crohn's diseaseactivity index, serum C reactive protein concentrations, diseaseduration and its anatomical location, smoking habits, abdominalcomplications, and current medical therapy, as well as the maximumbowel wall thickness as measured by US, were determined. The relationbetween PV and SMA blood flow and these variables was assessed byunivariate and multivariate analysis.
Results—Patients with Crohn's disease hadsignificantly higher PV and SMA flow and a lower SMA resistance indexthan controls. Stepwise multiple regression analysis identified bowelwall thickness and location of the disease as the main predictivevariables of both PV and SMA blood flow variation, accounting for 36%and 45% of their variability, respectively. No relation was foundbetween splanchnic haemodynamics and disease activity.
Conclusion—A hyperdynamic mesenteric circulationdoes exist in Crohn's disease; however splanchnic blood flow does notreflect the clinical or biochemical activity of the disease, but seems to be linked more to other Crohn's disease characteristics, such asmaximum bowel thickness and anatomical location.

Keywords:Crohn's disease; Doppler ultrasound; splanchnicblood flow

     

Do gastroenterologists want to be trained in ultrasound? A national survey of trainees in gastroenterology

Aims—(1) To establish whethergastroenterologists wish to train in abdominal ultrasound according tothe Royal College of Radiologists' document,Guidance for the training in ultrasound of medicalnon-radiologists. (2) To determine whether the ultrasound workload generated by gastroenterologists differs from that by other clinicians.
Methods—A postal questionnaire wassent to all 278gastroenterology trainees. The indications and findingsof 100consecutive gastroenterologist requested scans were comparedwith 100 scans requested sequentially by other clinicians through a teaching hospital radiology department.
Results—82% of the survey formswere returned. 77% of trainees wished to train in abdominal ultrasoundand 68% were prepared to train in the manner outlined in the guidelinedocument. However, 86% felt that they would ideally prefer not toassess renal or pelvic pathology, restricting to hepatobiliarydiagnosis only. 73% of trainees did not anticipate that a further scanby a radiologist would be required. Comparison of gastroenterology scans with those requested by other clinicians revealed a relative excess of hepatobiliary indications and findings, and a notable paucityof renal and pelvic pathology in gastroenterology practice.
Conclusions—There is generalinterest in abdominal ultrasound training among gastroenterologytrainees and broad acceptance of the guideline document. However, mosttrainees perceive a focus of training restricted to hepatobiliarydisease to be most appropriate. The case mix study provides support forthis viewpoint. It is suggested that a more focused ultrasound trainingfor gastroenterologists be considered.

Keywords:gastroenterology; training; ultrasound

     

Molecular enhancement of porcine cardiac chronotropy

OBJECTIVE—To test the potential of gene transfer approaches to enhance cardiac chronotropy in a porcine system as a model of the human heart.
METHODS—Plasmids encoding either the human β₂ adrenergic receptor or control constructs were injected into the right atria of native Yorkshire pig hearts. Percutaneous electrophysiological recording catheters equipped with 33 gauge circular injection needles were positioned in the mid-lateral right atrium. At the site of the earliest atrial potential the circular injection needles were rotated into the myocardium and the β₂ adrenergic receptor (n = 6) or control plasmid constructs (n = 5) were injected.
RESULTS—Injection of the β₂ adrenergic receptor construct significantly enhanced chronotropy compared with control injections. The average (SD) heart rate of the pigs was 108 (16) beats/min before injection. Two days after injection with control plasmids the heart rate was 127 (25) beats/min (NS compared with preinjection rates). After injection with plasmid encoding the β₂ adrenergic receptor the heart rate increased by 50% to 163 (33) beats/min (p < 0.05 compared with preinjection and postinjection control rates).
CONCLUSIONS—The present studies showed in a large animal model that local targeting of gene expression may be a feasible modality to regulate cardiac pacemaking activity. In addition, these investigations provide an experimental basis for developing future clinical gene transfer approaches to upregulate heart rate and modulate cardiac conduction.


Keywords: sinus node; adrenergic receptor; chronotropic agents; conduction system; gene therapy     

Clinical outcome following coronary angioplasty in dialysis patients: a case-control study in the era of coronary stenting

BACKGROUND—Balloon coronary angioplasty has been reported to be ineffective in patients treated for end stage renal disease because of a high restenosis rate.
OBJECTIVE—To compare the clinical outcome following coronary angioplasty with provisional stenting in dialysis versus non-dialysis patients.
DESIGN—A case-control study.
PATIENTS—Of 1428 consecutive patients who underwent coronary angioplasty, 100 (7%) were being treated for end stage renal disease. These were compared with 100 control patients matched for age, sex, coronary lesions, presence of diabetes mellitus, and rate of coronary stenting (40%).
MAIN OUTCOME MEASURES—In-hospital and one year clinical outcome.
RESULTS—The rates of procedural success (90% v 93%), in-hospital mortality (1% v 0%), stent thrombosis (0% v 0%), and Q wave myocardial infarction (0% v 1%) were similar in dialysis and non-dialysis patients. One year clinical outcome after coronary angioplasty was similar in the two groups in terms of clinical restenosis (31% v 28%) and myocardial infarction (6% v 2%), but cardiac death was more common in dialysed patients (11% v 2%, p < 0.03).
CONCLUSIONS—Dialysis does not increase the risk of clinical restenosis after coronary angioplasty with provisional stenting. Coronary angioplasty is a safe and effective therapeutic procedure in selected dialysis patients with culprit lesions accessible to stenting. However, the one year survival is reduced in this high risk population.


Keywords: renal disease; angioplasty; stents; restenosis