Caregiver expressed emotion and depression in Alzheimer's disease

Expressed Emotion (EE) has been a useful construct for understanding the relationship between family interactions and depression in patients with psychiatric disorders. It has not, however, been well studied in patients with Alzheimer's disease (AD) and their caregivers despite its potential utility in clarifying patient-caregiver interactions and how such interactions may affect patient function, and caregiver burden, mood and quality of care. This study investigated the rate of EE in caregivers of patients with AD and depression. It also investigated the relationship of caregiver EE to patient status and caregiver burden and depression. Fifty-seven AD patient-caregiver dyads were studied in a cross-sectional design. Caregiver measures included the EE Speech Sample, Burden Inventory, and Center for Epidemiological Studies-Depression Scale. Patient measures included the Hamilton Depression Rating Scale, Record of Independent Living, and Revised Memory and Behavior Problem Checklist. Twenty-three (40%) caregivers were high in EE, 34 (60%) were low. This percentage is higher than reported in normal older adults but is consistent with other psychiatric populations. High EE caregivers were significantly more likely to be clinically depressed and have higher levels of burden. They also endorsed fewer positive aspects of caregiving. No relationship was found between caregiver EE status and patient variables. Caregiver EE offers a novel approach to understanding important aspects of caregiver-patient interactions which may impact long term patient functioning and caregivers' ability to provide effective care.     

Optimizing Albunex in the left ventricle: An analysis of the technical parameters of four ultrasound systems in canines and humans

Albunex, an intravascular ultrasound contrast agent, has been used clinically to enhance echocardiographic images. The purpose of this study is (1) to determine whether varying the settings on commercially available ultrasound machines has an effect on left ventricular opacification after intravenously administered Albunex and if there is an effect on left ventricular opacification and (2) to determine the ideal settings for each ultrasound scanner. Six canine hearts were imaged with 1 ml injections of intravenously administered Albunex while varying the transducer frequency, preprocessing curves, postprocessing curves, and dynamic range on a variety of ultrasound units. Subsequently, 50 human subjects underwent imaging with the various machines while the dynamic range and transducer frequencies were altered. All subjects received two or three intravenous injections of 10 ml Albunex. The opacification of the left ventricular cavitary images in both parts of the study were interpreted visually on a scale of 0 to 4 (0 = none, 1 = trace, 2 = moderate, 3 = dense, and 4 = ideal) by four observers. The maximum compression and transducer frequency of 3.5 MHz showed significant improvement of left ventricular opacification in both canines and humans. These studies have shown that (1) varying the ultrasound unit's parameters affects the quality of left ventricular imaging when Albunex is used to enhance the image, and (2) higher compression and a transducer frequency of 3.5 MHz tend to enhance Albunex images of canine and human hearts.     

Echocardiographic evaluation of left superior vena cava to the left atrium

We report two cases of left superior vena cava draining directly to the left atrium in the absence of complex congenital heart disease. This is a rare finding causing a decrease in patient oxygen saturations. The location and diagnosis of this systemic venous anomaly requires diligence on the part of the cardiac sonographer, who should be able to identify the structure during the course of a thorough echocardiographic examination. Both adult and pediatric cardiac sonographers should be alerted to the possible presence of this vessel. Once the vessel has been successfully identified, repair and follow-up are relatively simple with positive patient prognosis.     

Subvalvular Aortic Membrane Masquerading as Valvular Aortic Stenosis

Discrete subvalvular aortic membrane is an unusual cause of left ventricular outflow tract obstruction. While commonly presenting during childhood, one quarter of the individuals are asymptomatic in childhood but remain vulnerable to progressive outflow tract obstruction as well as bacterial endocarditis in adulthood. Unfortunately, because the condition is so uncommon in adults, the diagnosis of subvalvular membrane is often missed or delayed. We recently had the opportunity to care for an adult patient who finally had subvalvular membrane identified as the cause of a left ventricular outflow obstruction, only after a protracted series of diagnostic investigations. Pitfalls in the noninvasive and invasive diagnosis of this condition are reviewed.     

Ultrasound‐guided dorsal penile nerve block performed in a case of zipper entrapment injury

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34‐year‐old patient after the application of an ultrasound‐guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45 :589–591, 2017     

Extent of myocardial viability predicts response to biventricular pacing in ischemic cardiomyopathy

BACKGROUND: The clinical response to biventricular pacing is unpredictable, especially in patients with ischemic cardiomyopathy. OBJECTIVES: The purpose of this study was to prospectively examine the relationship between the extent of myocardial viability and the response to cardiac resynchronization therapy. METHODS: Twenty-one patients with ischemic left ventricular (LV) dysfunction (left ventricular ejection fraction [LVEF] 21 +/- 5%), New York Heart Association (NYHA) functional class III-IV, and QRS >120 ms received biventricular devices. Myocardial viability was assessed by myocardial contrast echocardiography, and a perfusion score index (PSI) was calculated from summed segmental perfusion scores. LV performance was assessed by echocardiography on the day after implantation and at 6 months. RESULTS: PSI was closely correlated with acute improvement in LVEF (P = .003, r = 0.65), stroke volume (P = .02, r = 0.54), and end-systolic volume (P = .05, r = -0.49). PSI also correlated with early diastolic LV relaxation (E', P < .05, r = 0.50) and global myocardial performance or Tei index (P = .003, r = 0.63). By multiple linear regression analysis, PSI provided incremental predictive value to the degree of dyssynchrony, measured by tissue Doppler imaging, for predicting improvement in LVEF. At 6 months, PSI remained positively correlated with improvement in ventricular performance and with reduction in LV end-diastolic dimension (P = .003, r = -0.68). PSI also influenced the clinical variables of NYHA class, 6-minute walk distance, quality-of-life score, and number of hospitalizations for heart failure. CONCLUSION: In patients with ischemic cardiomyopathy, the extent of myocardial viability predicts acute and long-term improvement in LV performance, exercise tolerance, and reduction in LV end-diastolic dimension with biventricular pacing.     

Total anomalous pulmonary venous connection (TAPVC): A familial cluster of 3 siblings

Total anomalous pulmonary venous connection (TAPVC) is a rare form of cyanotic congenital heart disease (CHD) that occurs when the pulmonary veins drain into a site other than the morphologic left atrium. As with other forms of CHD, TAPVC has been shown to cluster in families and is known to have genetic association. We report on a case series of familial TAPVC in three consecutive siblings. A combination of fetal echocardiography, transthoracic echocardiography, as well as cross‐sectional imaging was utilized in the diagnosis as well as management of each sibling. The third sibling was subsequently found to have a partial deletion in chromosome 15q13.3, which has been rarely associated with other forms of congenital heart disease.