Feasibility of real-time echocardiographic evaluation during patient transport.

Echocardiography is a key diagnostic tool in evaluating patients with cardiac emergencies and chest trauma. The lack of qualified real-time interpretation limits its use by emergency first responders. Early diagnosis of cardiac emergencies has the potential to facilitate triage and medical intervention to improve outcomes. We investigated the feasibility of remote, real-time interpretation of echocardiograms during patient transport. Echocardiograms using a hand-carried ultrasound device were transmitted from an ambulance in transit to a tertiary care facility using a distributed mobile local area network. Transmitted studies were reviewed by a cardiologist for ability to interpret predefined features. Transmission quality and reliability were assessed. Echocardiographic images were successfully transmitted greater than 88% of transport time. The evaluation of left-ventricular size and function, and presence of pericardial effusion were greater than 90% concordant, but only 66% of all echocardiographic features were concordant. Most transmission losses were brief (相似文献   

Optimizing study design for interobserver reliability: IUGA–ICS classification of complications of prostheses and graft insertion

Introduction and hypothesis

Results of interobserver reliability studies for the International Urogynecological Association–International Continence Society (IUGA-ICS) Complication Classification coding can be greatly influenced by study design factors such as participant instruction, motivation, and test-question clarity. We attempted to optimize these factors.

Methods

After a 15-min instructional lecture with eight clinical case examples (including images) and with classification/coding charts available, those clinicians attending an IUGA Surgical Complications workshop were presented with eight similar-style test cases over 10 min and asked to code them using the Category, Time and Site classification. Answers were compared to predetermined correct codes obtained by five instigators of the IUGA-ICS prostheses and grafts complications classification. Prelecture and postquiz participant confidence levels using a five-step Likert scale were assessed.

Results

Complete sets of answers to the questions (24 codings) were provided by 34 respondents, only three of whom reported prior use of the charts. Average score [n (%)] out of eight, as well as median score (range) for each coding category were: (i) Category: 7.3 (91 %); 7 (4–8); (ii) Time: 7.8 (98 %); 7 (6–8); (iii) Site: 7.2 (90 %); 7 (5–8). Overall, the equivalent calculations (out of 24) were 22.3 (93 %) and 22 (18–24). Mean prelecture confidence was 1.37 (out of 5), rising to 3.85 postquiz. Urogynecologists had the highest correlation with correct coding, followed closely by fellows and general gynecologists.

Conclusions

Optimizing training and study design can lead to excellent results for interobserver reliability of the IUGA-ICS Complication Classification coding, with increased participant confidence in complication-coding ability.     

Adult respiratory distress syndrome. Strategies to provide support and enhance oxygen delivery.

Respiratory failure itself is rarely the cause of death in patients with adult respiratory distress syndrome (ARDS). The multiple-organ failure that often accompanies the syndrome or the underlying disease or trauma that leads to ARDS is more frequently the cause. Thus, care of these patients consists of providing life-sustaining support until they respond to therapy. The authors explain what happens in respiratory failure and how gas exchange can be enhanced in these critically ill patients.     

Intrathecal baclofen in subjects with spastic hemiplegia: assessment of the antispastic effect during gait

OBJECTIVE: To determine whether leg muscle stiffness is measurably reduced after intrathecal baclofen (ITB) in subjects with spastic hemiplegia. DESIGN: Nonrandomized trial. SETTING: Inpatient multidisciplinary rehabilitation unit in France. PARTICIPANTS: Seven consecutive subjects with spastic hemiplegia having Ashworth Scale scores for their quadriceps and triceps greater than 2. INTERVENTION: Subjects were given ITB by lumbar puncture after a dose-selecting test period. MAIN OUTCOME MEASURES: Triceps and quadriceps Ashworth scores, gait analysis at preferred and maximal speed measured by a motion analysis system with 2 forceplates, and electromyographic recording of leg muscles before and 4 hours after ITB. The slopes of the moment-angle curves were measured on the hemiplegic side at the onset of ankle and knee flexion to assess muscle stiffness during walking. Pre- and post-ITB spatiotemporal, kinetic, and kinematic data were compared by using a nonparametric test (Wilcoxon signed-rank test). RESULTS: Ashworth scores of the quadriceps and triceps of all subjects decreased significantly after ITB. Maximal walking speed increased significantly, with a significant increase in stride length, but the preferred walking speed was unchanged. Minimal knee extension and maximal ankle flexion were the only kinematic data significantly different (increased) after ITB. The slope of the ankle moment-angle curve decreased significantly after ITB at preferred gait speed; it also decreased at maximal gait speed in all but 1 subject. Of the 4 available moment-angle curves, 3 showed decreased knee extensor muscle stiffness. The duration of the bursts of spastic muscles decreased after ITB. CONCLUSION: Acute ITB improved walking and reduced muscle stiffness at both the ankles and knees on the spastic hemiplegic side of our subjects. Electromyographic findings suggest that some of the post-ITB reduction in muscle stiffness might be attributed to decreased spasticity.     

Antiarthritic effects of relaxin, in combination with estrogen, in rat adjuvant-induced arthritis

The incidence and severity of rheumatoid arthritis (RA) are reduced during pregnancy. Estradiol-17beta and relaxin (RLX), hormones of pregnancy, are implicated in decreased immune responsiveness. The aim of this study was to determine the effects of estrogen and RLX, alone or in combination, on the development of adjuvant-induced arthritis (AIA) in ovariectomized (OVX) Lewis rats. Arthritis was induced on day 0 by adjuvant injection in the left hind paw. Rats were treated with estradiol valerate (E), porcine RLX, E + RLX, or vehicle. Healthy OVX control animals were used for comparison. Treatment with RLX or E alone decreased adjuvant-induced inflammation in both the injected (primary) and noninjected (secondary) hind paws. Combined treatment with E and RLX was more effective than either hormone alone in blocking secondary paw inflammation. Furthermore, E plus RLX reduced changes to spleen and thymus weights induced by adjuvant injection. Both E and RLX alone decreased circulating tumor necrosis factor (TNF) alpha. The combination of E and RLX resulted in a greater decline in TNFalpha than treatment with either hormone alone. There was no effect of hormones on the proinflammatory cytokine, interleukin (IL)-1beta. The anti-inflammatory cytokine IL-10 increased in response to E and E plus RLX. In conclusion, combined therapy with E and RLX was more effective than either hormone alone in reducing chronic inflammation, joint changes, and high circulating TNFalpha associated with AIA in rats. Accordingly, these hormones could play a role in reducing RA-induced inflammation during pregnancy by an effect on the immune system.     

gp100/pmel 17 Is a Murine Tumor Rejection Antigen: Induction of “Self”-reactive,Tumoricidal T Cells Using High-affinity,Altered Peptide Ligand

Many tumor-associated antigens are nonmutated, poorly immunogenic tissue differentiation antigens. Their weak immunogenicity may be due to “self”-tolerance. To induce autoreactive T cells, we studied immune responses to gp100/pmel 17, an antigen naturally expressed by both normal melanocytes and melanoma cells. Although a recombinant vaccinia virus (rVV) encoding the mouse homologue of gp100 was nonimmunogenic, immunization of normal C57BL/6 mice with the rVV encoding the human gp100 elicited a specific CD8⁺ T cell response. These lymphocytes were cross-reactive with mgp100 in vitro and treated established B16 melanoma upon adoptive transfer. To understand the mechanism of the greater immunogenicity of the human version of gp100, we characterized a 9-amino acid (AA) epitope, restricted by H-2D^b, that was recognized by the T cells. The ability to induce specific T cells with human but not mouse gp100 resulted from differences within the major histocompatibility complex (MHC) class I–restricted epitope and not from differences elsewhere in the molecule, as was evidenced by experiments in which mice were immunized with rVV containing minigenes encoding these epitopes. Although the human (hgp100_25–33) and mouse (mgp100_25–33) epitopes were homologous, differences in the three NH₂-terminal AAs resulted in a 2-log increase in the ability of the human peptide to stabilize “empty” D^b on RMA-S cells and a 3-log increase in its ability to trigger interferon γ release by T cells. Thus, the fortuitous existence of a peptide homologue with significantly greater avidity for MHC class I resulted in the generation of self-reactive T cells. High-affinity, altered peptide ligands might be useful in the rational design of recombinant and synthetic vaccines that target tissue differentiation antigens expressed by tumors.     

Intra-laboratory analytical variability of biochemical markers of fibrosis (Fibrotest) and activity (Actitest) and reference ranges in healthy blood donors.

Combinations of tests comprising alpha2-macroglobulin, haptoglobin, apolipoprotein Al, gamma-glutamyltransferase, total bilirubin (Fibrotest) and alanine aminotransferase (Actitest) are being developed as alternatives to liver biopsy in patients with chronic hepatitis C. The aim of this study was to assess in the same laboratory the impact of parameter assay variations on Fibrotest and Actitest results and intra-patient reproducibility of the two tests. The stability of the samples for each test was studied after storage at -80 degrees C and -20 degrees C. Within-run, between-run and total imprecision for each parameter assay, and for Fibrotest and Actitest results, were determined. Transferability of assay results between different analyzers was studied. Intra-patient reproducibility was assessed in 55 hospitalized patients. Fibrotest and Actitest reference ranges were determined in 300 blood donors (reference group). The stability of the parameters was affected by serum storage at -20 degrees C only. The impact of parameter analytical variability on Fibrotest and Actitest results was less than 10% and intra-patient reproducibility was acceptable (p > 0.05). The transferability between different analyzers of results of assays performed under the same standardized and calibration conditions was excellent. Fibrotest and Actitest reference ranges in blood donors were (mean+/-SE) 0.075+/-0.004 and 0.068+/-0.004, respectively. The low intra-laboratory and intra-patient variability in Fibrotest and Actitest results confirm Fibrotest and Actitest reliability.