Patient-ventilator interaction during the triggering phase

Partial patient-controlled mechanical support mode ventilators provide positive pressure assistance whenever a patient's inspiratory effort decreases pressure or flow in the ventilator circuit below the sensitivity set by clinicians; these modes minimize disuse atrophy of the respiratory muscles, can facilitate the weaning process, and usually require lower ventilator pressures. The capability of restoring gas exchange, unloading respiratory muscles, and relieving the patient's dyspnea with partial patient-controlled mechanical support modes depends on matching between the ventilator setting and the patient's ventilatory demand (ie, patient-ventilator interactions).     

Effect of β-Blockers and Other Antihypertensive Drugs On the Risk of Melanoma Recurrence and Death

ObjectiveTo verify preliminary studies on patients with melanoma exposed to β-blockers that suggested a reduced risk of disease recurrence and death.Patients and MethodsData were obtained from all consecutive patients diagnosed as having melanoma between January 1, 1993, and December 31, 2009, at the Department of Dermatology of the University of Florence, Azienda Sanitaria di Firenze. Participants were excluded if at baseline they reported a previous diagnosis of cutaneous malignant melanoma or another malignant disease. We also excluded participants with evidence of visceral, lymph nodal, and in-transit metastasis at the time of the diagnosis.ResultsOf 741 consecutive patients with melanoma, 79 (11%) were prescribed β-blockers (for hypertension in most cases) for 1 or more years (treated) and 662 (89%) were not (untreated). The multivariate Cox model indicated that the treated group had improved overall survival after a median follow-up of 4 years (P=.005). For each year of β-blocker use, the risk of death was reduced by 38%. The presence of hypertension, the use of antihypertensive agents for 1 or more years, or the use of other commonly used medicines were not associated with a better outcome for patients with melanoma.ConclusionThe results confirm and strengthen previous findings that β-blocker use is associated with a reduced risk of melanoma recurrence and death. The results also indicate the strong need for a randomized clinical trial to conclusively assess whether β-blockers afford protection against melanoma recurrence and death.     

Eccentric calf muscle training in athletic patients with Achilles tendinopathy

Purpose. To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy.

Methods. Forty-five athletic patients (29 men, average age 26 years ± 12.8, range 18 – 42; 16 women, average age 28 years ± 13.1, range 20 – 46; average height: 173 ± 16.8, range 158 – 191; average weight 70.8 kg ± 15.3, range 51.4 – 100.5) with a clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.

Results. The mean pre-management VISA-A scores of 36 (SD 23.8; 95% CI: 29 – 46) improved to 52 (SD 27.5; 95% CI: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.

Conclusions. ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.     

Thalamo-cortical network activity between migraine attacks: Insights from MRI-based microstructural and functional resting-state network correlation analysis

Background

Resting state magnetic resonance imaging allows studying functionally interconnected brain networks. Here we were aimed to verify functional connectivity between brain networks at rest and its relationship with thalamic microstructure in migraine without aura (MO) patients between attacks.

Methods

Eighteen patients with untreated MO underwent 3 T MRI scans and were compared to a group of 19 healthy volunteers (HV). We used MRI to collect resting state data among two selected resting state networks, identified using group independent component (IC) analysis. Fractional anisotropy (FA) and mean diffusivity (MD) values of bilateral thalami were retrieved from a previous diffusion tensor imaging study on the same subjects and correlated with resting state ICs Z-scores.

Results

In comparison to HV, in MO we found significant reduced functional connectivity between the default mode network and the visuo-spatial system. Both HV and migraine patients selected ICs Z-scores correlated negatively with FA values of the thalamus bilaterally.

Conclusions

The present results are the first evidence supporting the hypothesis that an abnormal resting within networks connectivity associated with significant differences in baseline thalamic microstructure could contribute to interictal migraine pathophysiology.

     

Intervertebral disc regeneration: from the degenerative cascade to molecular therapy and tissue engineering

Low back pain is one of the major health problems in industrialized countries, as a leading source of disability in the working population. Intervertebral disc degeneration has been identified as its main cause, being a progressive process mainly characterized by alteration of extracellular matrix composition and water content. Many factors are involved in the degenerative cascade, such as anabolism/catabolism imbalance, reduction of nutrition supply and progressive cell loss. Currently available treatments are symptomatic, and surgical procedures consisting of disc removal are often necessary. Recent advances in our understanding of intervertebral disc biology led to an increased interest in the development of novel biological treatments aimed at disc regeneration. Growth factors, gene therapy, stem cell transplantation and biomaterials‐based tissue engineering might support intervertebral disc regeneration by overcoming the limitation of the self‐renewal mechanism. The aim of this paper is to overview the literature discussing the current status of our knowledge from the degenerative cascade of the intervertebral disc to the latest molecular, cell‐based therapies and tissue‐engineering strategies for disc regeneration. Copyright © 2013 John Wiley & Sons, Ltd.     

Heart rate and blood pressure variability in subjects with vasovagal syncope

Autonomic nervous system control in subjects with vasovagal syncope is controversial. In the present study, we used short-term spectral analysis to evaluate autonomic control in subjects with recurrent vasovagal syncope. We assessed the ability of spectral indices of HR (heart rate) variability to predict tilt-test responses. A series of 47 outpatients with recurrent vasovagal syncope and with positive responses to head-up tilt testing underwent a further study of RR variability during controlled breathing at rest and during tilt testing. During controlled breathing, RR interval variability of total power (TP(RR); P<0.001), low-frequency power (LF(RR); P<0.05), high-frequency power (HF(RR); P<0.001) and HF expressed in normalized units (HFnu(RR); P<0.001) were all higher, and LF expressed in normalized units (LFnu(RR)) and LF/HF ratio were lower in subjects with vasovagal syncope than in controls (P<0.001). To assess the ability of spectral components of RR variability to predict tilt-test responses, we prospectively studied 109 subjects with recurrent vasovagal syncope. The two normalized measures, HFnu(RR) and LFnu(RR), determined during controlled breathing alone predicted a positive tilt-test response (sensitivity, 76%; specificity, 99%; positive predictive value, 96%; and negative predictive value, 90%). During tilting, subjects with vasovagal syncope had lower SBP (systolic blood pressure; P<0.05), LF component of peak SBP variability (LF(SBP)) and LFnu(RR) than controls, and higher TP(RR), HF(RR), HFnu(RR) and alpha HF (P<0.001). These spectral data indicate that vagal sinus modulation is increased at rest in subjects with vasovagal syncope. Spectral analysis of RR variability during controlled breathing, a procedure that predicts tilt-test responses, could be a useful guide in choosing the method of tilt testing.     

Reproducibility of fetal lung volume measurements with 3-dimensional ultrasonography.

OBJECTIVE: To build a nomogram of normal fetal lung volumes and to assess the reproducibility of measurements using 3-dimensional ultrasonography. METHODS: Inclusion criteria were healthy women, singleton normal pregnancies, reliable dating, and 20 to 30 weeks' gestation. Exclusion criteria were discordance between clinical and ultrasonographic dating, patients lost to follow-up, and birth weight disorders. Patients were scanned at intervals longer than 2 weeks. Three volumes were acquired for each patient; only data from the volume with the best image quality was used for analysis. Volumes were rated and measured by the manual tracing method. We recorded whether the clavicle was visualized. Only good-quality volumes were included in analysis. The best volume was chosen, and each lung was measured. RESULTS: A total of 75 patients were studied over a 9-month period, from which 182 volumes were analyzed. Of the 182 volumes, 15 (8.2%) were excluded for poor quality. The remaining 167 volumes were included in the final analysis. In 83 volumes (50%), the clavicle was not visualized. The best fit for total lung volume was a second-degree polynomial regression curve. Lung volume was 10.28 mL at 20 weeks and 51.49 mL at 30 weeks. Assessment of agreement was studied by selection of 40 volumes. Intraobserver variability was 5.48 mL (10.6%) and 3.07 mL (5.96%). Interobserver variability was 7 mL. CONCLUSIONS: Our findings suggest that 3-dimensional ultrasonographically derived measurements are reliable and reproducible up to 30 weeks if a standard measurement technique is used.     

Sonographically guided small-bore chest tubes and sonographic monitoring for rapid sclerotherapy of recurrent malignant pleural effusions.

OBJECTIVE: To evaluate the role of sonographically guided small-bore chest catheters and sonographically based monitoring of fluid evacuation in rapid sclerotherapy of malignant pleural effusions. METHODS: In 50 patients with recurrent malignant pleural effusions, a 9F catheter was inserted into the pleural space under sonographic guidance. When sonography documented complete fluid evacuation, bleomycin (0.75 mg/kg) was injected via the tube. Fluid drainage was monitored for 12 hours; if fluid output was less than 100 mL, the pleural catheter was removed; otherwise, a second dose of bleomycin was administered after 24 hours. If loculations or fluid reaccumulations due to tube malfunctioning were detected, they were evacuated by sonographically guided thoracentesis, and bleomycin (1.5 mg/100 mL of fluid) was injected through the thoracentesis needle. All patients were monitored for fluid recurrence with thoracic sonography. RESULTS: Twenty-nine patients received 1 dose of bleomycin, and 21 received 2 doses. In 11 patients with residual loculations, sonographically guided thoracentesis was performed, and bleomycin was injected into the loculations. In 29 patients, pleurodesis was completed within 24 hours; in 21, it was completed within 48 hours. The 30-day response was 84%; the long-term response was 60%. No complications or serious side effects were observed. CONCLUSIONS: Rapid pleurodesis can be accomplished within 24 to 48 hours, with good short- and long-term responses. Thoracic sonography plays a pivotal role. It guides placement of the pleural catheter and is valuable in the monitoring of fluid evacuation for determining the right time for sclerosing agent administration and in the detection and treatment of loculations or residual pleural fluid due to tube malfunctioning.     

Usefulness of Rehabilitation in Patients with Rotator Cuff Calcific Tendinopathy after Ultrasound-Guided Percutaneous Treatment

Objective

To evaluate the efficacy of a specific rehabilitation program for patients in whom ultrasound-guided percutaneous treatment (UGPT) was performed for rotator cuff calcific tendinopathy (RCCT).

Subjects and Methods

In this prospective observational study, 86 patients (22 males and 64 females) with shoulder calcific tendinopathy treated with UGPT were enrolled. At the end of the procedure, a corticosteroid injection into the subacromial-subdeltoid bursa was performed. The patients were then asked to follow a specific rehabilitation protocol (2 times/week for 5 weeks) that focused on mobility, strength and function. At baseline and after 6 weeks, clinical parameters, visual analog scale (VAS) and Constant-Murley scale (CMS) scores and ultrasound (US) features were collected.

Results

The mean age of the patients was 48.9 ± 8.4 years and their mean BMI was 22.7 ± 2.1. Considering the whole cohort, the treatment was effective, with a significant decrease in the VAS score and an improvement in the CMS score. Thereafter, on the basis of the compliance to the rehabilitation program (by self-report), 53 and 33 patients were included in the rehabilitation group (Rehab group; performed exercises ≥2 times/week) and the No Rehab group (performed exercises <2 times/week), respectively. The comparison between the groups showed that the subjects who performed the exercises regularly had better results in terms of pain and functional recovery, and less associated diseases (e.g. adhesive bursitis and tenosynovitis of the long head of the biceps) than those who were less compliant with the program.

Conclusions

UGPT, followed by a specific postprocedure rehabilitation program, was an effective treatment for RCCT.Key Words: Rotator cuff calcific tendinopathy, Rehabilitative treatment, Ultrasound