A Randomized Trial of Complications of Peripherally and Centrally Inserted Central Lines in the Neuro-Intensive Care Unit: Results of the NSPVC Trial

Neurocritical Care - The objective of this study was to compare the relative number of complications from peripherally inserted central venous catheters (PICC) and centrally inserted central venous...     

Right Ventricular Involvement of an Aggressive Malignant Peripheral Nerve Sheath Tumor

We present a case of a 58-year-old woman who had a painful right thigh mass for a few months. A transthoracic echocardiogram revealed no evidence of an intracardiac mass. She had a whole-body positron emission tomography/computed tomography scan two months later that revealed masses in her right lower extremity and a mass in her right ventricle that had not been initially reported. She had been initially diagnosed with an undifferentiated pleomorphic sarcoma, but this diagnosis was changed to a malignant peripheral nerve sheath tumor with repeat pathology. She was subsequently hospitalized. An echocardiogram showed a mass covering 80% of her right ventricle (RV). Serial cardiac magnetic resonance imaging revealed a 9.4 × 5.6 cm RV mass with vascular and avascular portions and inflow and outflow tract obstruction. Computed tomography showed no other metastases. Due to a delay in diagnosis and a decline in left ventricular ejection fraction, the patient could not undergo palliative chemotherapy or radiotherapy     

Diagnosis of effort angina pectoris at rest by first derivative electrocardiography

OBJECTIVES: First derivative electrocardiography (FDECG) records the slope of the wave of the standard 12-lead electrocardiography (ECG) and enables quantification of ECG-T wave symmetry. This study investigated the usefulness of FDECG to diagnose effort angina pectoris in patients with chest pain. METHODS: All 62 patients who visited our hospital with exertional chest pain underwent FDECG at rest, and exercise electrocardiography or stress thallium scintigraphy. Patients with possible ischemic change underwent coronary angiography, and those with significant coronary artery stenosis (> or = 75% reduction) were classified as the angina pectoris group (23 subjects). The other patients (without ischemic change or without significant coronary artery stenosis) formed the non-angina pectoris group (39 subjects). The FDECG is a simple differential wave with two peaks. The first peak of the FDECG-T wave designated as the T1 wave and the second peak as the T2 wave. The heights (the T1 and T2 wave amplitude) and the T2/T1 ratio (T2 wave heights/T1 wave heights) were calculated in the two groups. RESULTS: The T2/T1 ratios in leads I, V3, V4, V5 and V6 were significantly (I, V3, V4: p < 0.01, V5: p < 0.0001, V6: p < 0.001) decreased in the angina pectoris group. Using the criterion of a T2/T1 ratio at the V5 lead of less than 1.30, FDECG could detect effort angina pectoris patients with 65% in sensitivity, 74% specificity and 71% accuracy. CONCLUSIONS: ECG-T waves in the angina pectoris group were symmetrical. T2/T1 ratio of the FDECG-T wave is a useful index to diagnose effort angina pectoris at rest.     

An Unusual Combination of an Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) and a Right Coronary Artery System with Two Separate Ostia from the Aorta in an Adult

We describe a patient with an infrequent combination of variants in both the right and the left coronary arterial ostia, namely a combination of two separate right coronary artery (RCA) ostia from the aorta, and an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). To our knowledge, such a combination has not been previously reported. Based on published statistics for individual variants, such a combination is expected to occur approximately once for every 500,000 to one million live births. ALCAPA and dual RCA anatomy was characterized in our patient by echocardiography, conventional angiography, and multidetector computed tomography before and after Takeuchi repair. (Echocardiography 2010;27:E13-E17)     

Perceptions of specialized inpatient palliative care: a population-based survey in Japan

This study aimed to clarify and compare the awareness and perceptions of the specialized inpatient palliative care service. A cross-sectional questionnaire survey was performed on the general population selected by stratified two-stage random sampling (n=2,548) and bereaved families who actually received specialized inpatient palliative care at 12 palliative care units (PCUs) in Japan (n=513). The respondents reported their awareness and perceptions of PCUs. Thirty-eight percent of the general population answered that they had "considerable" or "moderate" knowledge of PCUs, but 24% answered that they had "no" knowledge. Bereaved families who received PCU care (PCU-bereaved families) were likely to have better perceptions of PCUs than the general population: "alleviates pain" (68% of the general population and 87% of PCU-bereaved families agreed), "provides care for families" (67% and 86%, respectively), and "provides compassionate care" (67% and 87%, respectively). Both groups, however, expressed concerns about PCUs: "a place where people only wait to die" (30% and 40%, respectively) and "shortens the patient's life" (8% and 17%, respectively). These perceptions were associated with overall satisfaction with received care, and differed among the 12 PCUs. In conclusion, public awareness of PCUs was insufficient in Japan. Although PCU-bereaved families were generally likely to have better perceptions of PCUs than the general population, both groups shared concerns that a PCU was a place where people only wait to die. To facilitate appropriate use of specialized palliative care services, more efforts to inform the general population about the actual palliative care system are needed. In addition, the role of PCUs might be reconsidered in terms of the continuum of cancer care.     

Treatment of Tympanic Membrane Retraction Pockets by Excision and Cartilage Tympanoplasty: A Prospective Study

To assess the role of cartilage tympanoplasty in management of retraction pockets of the pars flaccida. This was a prospective study at a tertiary care centre. Twenty patients having grade III or grade IV retraction pockets were included in the study. Retraction pockets were treated by excision and cartilage tympanoplasty. Findings noted on follow-up were recorded and analysed. Graft was taken up in 18 (90%) cases with residual perforation in 2 (10%) cases. Recurrence of retraction pockets was observed in 6 (30%) cases. Hearing was improved up to 15 dB in 16 (80%) cases. It is concluded that grade III and IV retraction pockets can be well managed by excision and cartilage tympanoplasty.     

Optimal phase for coronary interpretations and correlation of ejection fraction using late-diastole and end-diastole imaging in cardiac computed tomography angiography: implications for prospective triggering

A typical acquisition protocol for multi-row detector computed tomography (MDCT) angiography is to obtain all phases of the cardiac cycle, allowing calculation of ejection fraction (EF) simultaneously with plaque burden. New MDCT protocols scanner, designed to reduce radiation, use prospectively acquired ECG gated image acquisition to obtain images at certain specific phases of the cardiac cycle with least coronary artery motion. These protocols do not we allow acquisition of functional data which involves measurement of ejection fraction requiring end-systolic and end-diastolic phases. We aimed to quantitatively identify the cardiac cycle phase that produced the optimal images as well as aimed to evaluate, if obtaining only 35% (end-systole) and 75% (as a surrogate for end-diastole) would be similar to obtaining the full cardiac cycle and calculating end diastolic volumes (EDV) and EF from the 35th and 95th percentile images. 1,085 patients with no history of coronary artery disease were included; 10 images separated by 10% of R–R interval were retrospectively constructed. Images with motion in the mid portion of RCA were graded from 1 to 3; with ‘1’ being no motion, ‘2’ if 0 to <1 mm motion, and ‘3’ if there is >1 mm motion and/or non-interpretable study. In a subgroup of 216 patients with EF > 50%, we measured left ventricular (LV) volumes in the 10 phases, and used those obtained during 25, 35, 75 and 95% phase to calculate the EF for each patient. The average heart rate (HR) for our patient group was 56.5 ± 8.4 (range 33–140). The distribution of image quality at all heart rates was 958 (88.3%) in Grade 1, 113 (10.42%) in Grade 2 and 14 (1.29%) in Grade 3 images. The area under the curve for optimum image quality (Grade 1 or 2) in patients with HR > 60 bpm for phase 75% was 0.77 ± 0.04 [95% CI: 0.61–0.87], while for similar heart rates the area under the curve for phases 75 + 65 + 55 + 45% combined was 0.92 ± 0.02. LV volume at 75% phase was strongly correlated with EDV (LV volume at 95% phase) (r = 0.970, P < 0.001). There was also a strong correlation between LVEF (75_35) and LVEF (95_35) (r = 0.93, P < 0.001). Subsequently, we developed a formula to correct for the decrement in LVEF using 35–75% phase: LVEF (95_35) = 0.783 × LVEF (75_35) + 20.68; adjusted R ² = 0.874, P < 0.001. Using 64 MDCT scanners, in order to acquire >90% interpretable studies, if HR < 60 bpm 75% phase of RR interval provides optimal images; while for HR > 60 analysis of images in 4 phases (75, 35, 45 and 55%) is needed. Our data demonstrates that LVEF can be predicted with reasonable accuracy by using data acquired in phases 35 and 75% of the R–R interval. Future prospective acquisition that obtains two phases (35 and 75%) will allow for motion free images of the coronary arteries and EF estimates in over 90% of patients.