A new method of measuring the stiffness of corpus cavernosum penis with ShearWave? Elastography

Objective:

To evaluate the feasibility of measuring the stiffness of corpus cavernosum penis (CCP) with ShearWave™ Elastography (SWE; SuperSonic Imagine, Aix-en-Provence, France).

Methods:

40 healthy volunteers with ages ranging from 19 to 81 years (mean, 36 years; standard deviation, 17 years) were selected in this study. The ultrafast ultrasound device Aixplorer^® (SuperSonic Imagine) was used for the research and the probe selected was SuperLinear™ SL15-4 (SuperSonic Imagine). The shear wave stiffness (SWS) of CCP was measured using SWE images. The measurement indexes of SWS included (1) SWS of CCP measured in the transverse section (SWS-T), (2) SWS of CCP measured in the longitudinal section (SWS-L) and (3) mean of SWS-T and SWS-L (SWS-M). The interval between hormone test and SWE examination of each subject was less than 7 days. The paired t-test was used to analyse the differences between SWS-T and SWS-L. The Pearson correlation was used to analyse the correlation of SWS of CCP with age as well as with sex hormone levels.

Results:

There was no significant difference between SWS-T and SWS-L (p > 0.05). SWS (SWS-T, SWS-L, SWS-M) was negatively correlated with age and oestradiol value, and SWS (SWS-T, SWS-L, SWS-M) was positively correlated with testosterone value.

Conclusion:

SWE could serve as a new non-invasive method of evaluating the stiffness of CCP.

Advances in knowledge:

It is the first time that we have discussed the feasibility of measuring the stiffness of CCP with SWE and analysed the correlation of SWS of CCP with age as well as with sex hormone levels.ShearWave™ Elastography (SWE; SuperSonic Imagine, Aix-en-Provence, France) is a new ultrasound technology that could be used to assess tissue stiffness in clinic and is currently the only elastography technology certified by the US Food and Drug Administration. This technology makes it possible to quantify the tissue stiffness accurately. Unlike early elastography methods, which rely on manual compression and measuring tissue displacement, SWE requires no manual compression, and it uses ultrasonic pulse to make the tissue generate shear waves. A real-time SWE map is produced by detection of shear wave velocity and colour coding. Since the propagation speed of the shear wave is determined by the stiffness of tissue, the real-time SWE map could be used to measure the overall and local stiffness of tissue exactly. Studies have shown that this technology could be used to evaluate the stiffness of intravital tissue accurately.^1–3Furthermore, SWE is a safe, non-ionizing and non-invasive technique that has the same thermal and mechanical energy as conventional Doppler imaging. It is applicable to the examination of human reproductive organs. The tissue structure of corpus cavernosum penis (CCP) has important impact on the stiffness of CCP. Therefore, the stiffness of CCP could be used as an index for assessing the tissue structure of CCP. At the same time, the tissue structure of CCP has important impact on the erectile function. So, it is of great clinical significance to measure the stiffness of CCP.The stiffness of CCP is closely associated with age.⁴ Previous pathological studies have indicated that, with increase in age, sinusoids in CCP gradually decrease, occlusion and fibrosis occur, the smooth muscle cells also atrophy and decrease gradually. These changes in tissue structure and composition of CCP can directly lead to the change of its stiffness. The stiffness of CCP is also associated with sex hormone levels. Testosterone can promote the generation of smooth muscle cells and enhance cell vitality in CCP. Cell vitality and generation of smooth muscle cells in CCP decline with testosterone decrease, which can lead to cell atrophy and reduction in their number and consequently a change of stiffness of CCP.^5–7However, at present, no accurate and non-invasive method can be used to assess stiffness of CCP in clinic. In this study, we evaluated the feasibility of measuring stiffness of CCP with SWE by analysing the correlation of the stiffness value of CCP with age as well as sex hormone levels.     

Outcome of off-pump coronary artery bypass in renal dialysis patients

BACKGROUND: Renal dialysis patients are a subgroup at major operative risk when undergoing coronary artery bypass grafting (CABG). Even though CABG without cardiopulmonary bypass (CPB) has decreased the surgical risk and provided good short-term results, the long-term survival seems uncertain. We report here on the long-term outcome of CABG without CPB in renal dialysis patients. METHODS: From 1998 to 2002, 44 renal dialysis patients underwent elective CABG without CPB, including 17 minimally invasive direct coronary artery bypass (MIDCAB) and 27 off-pump CABG (OPCAB) procedures. There were 5 one-vessel, 12 two-vessel and 27 multi-vessel coronary artery disease patients, who mainly had left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) grafting with an additional saphenous vein graft to non-LAD coronaries. RESULTS: All 44 patients were followed up for 44.4 +/- 31.2 months. Three (6.8 %) surgical deaths within 30 days occurred and 25 late mortalities happened over a period of 2 - 79 months. The 5-year cumulative rate of total survival is 38.2 % and the freedom from cardiac death is 70.9 %. Using hazard analysis, old age (> 60 years) and incomplete coronary revascularization was found to significantly affect the total survival. CONCLUSIONS: CABG without CPB provided an acceptable surgical mortality and morbidity. The high incidence of non-cardiac death associated with dialysis complications had an adverse impact on the overall outcome. The LITA bypass operation method combined with intensive care for dialysis complications would hopefully fulfill the goal to improve the short- and long-term results in this subgroup.     

Telaprevir- and boceprevir-based tritherapies in real practice for F3-F4 pretreated hepatitis C virus patients

AIM:To assess,in a routine practice setting,the sus-tained virologic response(SVR) to telaprevir(TPV) or boceprevir(BOC) in hepatitis C virus(HCV) nullresponders or relapsers with severe liver fibrosis.METHODS:One hundred twenty-five patients were treated prospectively for 48 wk with TPV or BOC + pegylated-interferon(peg-INF) α2a + ribavirin(PR) according to standard treatment schedules without randomization.These patients were treated in routine practice settings in 10 public or private health care centers,and the data were prospectively collected.Only patients with severe liver fibrosis(Metavir scores of F3 or F4 upon liver biopsy or liver stiffness assessed by elastography),genotype 1 HCV and who were null-responders or relapsers to prior PR combination therapy were included in this study.RESULTS:The Metavir fibrosis scores were F3 in 35(28%) and F4 in 90(72%) of the patients.In total,62.9% of the patients were null-responders and 37.1% relapsers to the previous PR therapy.The overall SVR rate at 24 wk post-treatment withdrawal was 59.8%.The SVR was 65.9% in the TPV group and 44.1% in the BOC group.Independent predictive factors of an SVR included a response to previous treatment,relapsers vs null-responders [OR = 3.9;(1.4,10.6),P = 0.0084],a rapid virological response(RVR) [OR 6.9(2.6,18.2),P = 0.001] and liver stiffness lower than 21.3 kPa [OR = 8.2(2.3,29.5),P = 0.001].During treatment,63 patients(50.8%) had at least one severe adverse event(SAE) of grade 3 or 4.A multivariate analysis identified two factors associated with SAEs:female gender [OR = 2.4(1.1,5.6),P = 0.037] and a platelet count below 150 × 103/ mm3 [OR = 5.3(2.3,12.4),P ≤ 0.001].CONCLUSION:More than half of these difficult-to-treat patients achieved an SVR and had SAEs in an actual practice setting.The SVR rate was influenced by the response to previous PR treatment,the RVR and liver stiffness.     

Study of Once Daily Levemir (SOLVE™): insights into the timing of insulin initiation in people with poorly controlled type 2 diabetes in routine clinical practice

Aims: The aim of this analysis is to determine the timing of insulin initiation in routine clinical practice, especially in relation to glycaemic control and use of oral antidiabetic drugs (OADs). Methods: Study of Once Daily Levemir was a 24‐week international observational study involving 10 countries which evaluated the safety and effectiveness of initiating once‐daily insulin detemir in people with type 2 diabetes mellitus (T2DM) being treated with one or more OADs (clinical trial number NCT00825643 and NCT00740519). Results: A total of 17 374 participants were enrolled in the study: aged 62 ± 12 years, 53% male, T2DM duration 10 ± 7 years, body mass index 29.3 ± 5.4 kg/m². Pre‐insulin HbA1c was 8.9 ± 1.6%. The proportion of patients with HbA1c ≥9.0% ranged from 64% (UK) to 23% (Poland). Pre‐insulin OAD treatment included metformin (81%), sulphonylureas (59%), glinides (16%), thiazolidinediones (TZD) (12%), α‐glucosidase inhibitors (12%) and dipeptidyl peptidase (DPP)‐IV inhibitors (7%). The mean starting dose of insulin detemir for the total cohort was 0.16 ± 0.09 U/kg. Differences in OAD use and insulin doses at initiation were evident among participating countries. The largest proportional changes in OAD prescribing at insulin initiation were seen with glinides (+15%), sulphonylureas (?19%), TZD (?31%) and DPP‐IV inhibitors (?28%). Conclusions: Despite well‐documented benefits of timely glycaemic control and consensus guidelines encouraging earlier use of insulin, considerable clinical inertia exists with respect to initiating appropriate insulin therapy in people with T2DM. Considerable regional differences exist in the timing of insulin initiation and in the use of OADs.     

Hypothermie thérapeutique en traumatologie crânienne grave

Therapeutic hypothermia (TH) is considered a standard of care in the post-resuscitation phase of cardiac arrest. In experimental models of traumatic brain injury (TBI), TH was found to have neuroprotective properties. However, TH failed to demonstrate beneficial effects on neurological outcome in patients with TBI. The absence of benefits of TH uniformly applied in TBI patients should not question the use of TH as a second-tier therapy to treat elevated intracranial pressure. The management of all the practical aspects of TH is a key factor to avoid side effects and to optimize the potential benefit of TH in the treatment of intracranial hypertension. Induction of TH can be achieved with external surface cooling or with intra-vascular devices. The therapeutic target should be set at a 35 °C using brain temperature as reference, and should be maintained at least during 48 hours and ideally over the entire period of elevated intracranial pressure. The control of the rewarming phase is crucial to avoid temperature overshooting and should not exceed 1 °C/day. Besides its use in the management of intracranial hypertension, therapeutic cooling is also essential to treat hyperthermia in brain-injured patients. In this review, we will discuss the benefit-risk balance and practical aspects of therapeutic temperature management in TBI patients.     

Trauma network for severely injured patients

Survival after severe trauma may depend on a structured chain of care from the management at the scene of trauma to hospital care and rehabilitation. In the USA, the trauma system is organized according to a pre-hospital triage by paramedics to facilitate the admission of patients to tertiary trauma centres. In France, trauma patients are transported to the most suitable facility, according to the on-scene triage by an emergency physician. Because French hospital's resources become scarce and expensive, the access to all techniques of resuscitation after severe trauma is restricted to tertiary trauma centres, at the expense of prolonged duration of transfer to these centres with a possible impact on mortality. The Northern French Alps Emergency Network created a regional trauma network system in 2008. This organization was based upon the interplay between the resources of each hospital participating to the network and the categorization of trauma severity at the scene. A regional registry allows the assessment of trauma system, which has included 3,690 severe trauma patients within the past 3 years. Bystanders, medical call dispatch centres, and interdisciplinary trauma team should form a structured and continuous chain of care to allocate each severe trauma patient to the best place of treatment.     

Ly6Chigh Monocytes Protect against Kidney Damage during Sepsis via a CX3CR1-Dependent Adhesion Mechanism

Monocytes have a crucial role in both proinflammatory and anti-inflammatory phenomena occurring during sepsis. Monocyte recruitment and activation are orchestrated by the chemokine receptors CX3CR1 and CCR2 and their cognate ligands. However, little is known about the roles of these cells and chemokines during the acute phase of inflammation in sepsis. Using intravital microscopy in a murine model of polymicrobial sepsis, we showed that inflammatory Ly6C^high monocytes infiltrated kidneys, exhibited altered motility, and adhered strongly to the renal vascular wall in a chemokine receptor CX3CR1-dependent manner. Adoptive transfer of Cx3cr1-proficient monocyte-enriched bone marrow cells into septic Cx3cr1-depleted mice prevented kidney damage and promoted mouse survival. Modulation of CX3CR1 activation in septic mice controlled monocyte adhesion, regulated proinflammatory and anti-inflammatory cytokine expression, and was associated with the extent of kidney lesions such that the number of lesions decreased when CX3CR1 activity increased. Consistent with these results, the pro-adhesive I249 CX3CR1 allele in humans was associated with a lower incidence of AKI in patients with sepsis. These data show that inflammatory monocytes have a protective effect during sepsis via a CX3CR1-dependent adhesion mechanism. This receptor might be a new therapeutic target for kidney injury during sepsis.