Extravasation Rate Research Articles

Dynamic contrast-enhanced MR imaging of carotid vasa vasorum in relation to coronary and cerebrovascular events

Background and aimsDynamic contrast-enhanced MR imaging (DCE-MRI) provides a noninvasive approach to the functional status of carotid adventitial vasa vasorum. Contrast extravasation rate, or Ktrans, derived from kinetic modeling of adventitial enhancement, has been correlated with plaque neovascularization and inflammation. This study sought to clarify the clinical implications of Ktrans by evaluating its relationship with documented cardiovascular events (CVE). MethodsSeventy patients with carotid plaque at clinical ultrasound examination were recruited and imaged with a previously-described bright-blood DCE-MRI protocol (spatial resolution: 0.55 × 0.58 mm2; time resolution: 18 s). Patients were classified by the presence of documented coronary and/or cerebrovascular events. Adventitial Ktrans was estimated via kinetic modeling of outer wall enhancement as captured by DCE-MRI. ResultsAfter excluding six patients with insufficient image quality, 64 patients (66 ± 12 years, 51 male) had DCE-MRI measurements. Patients with documented CVE showed significantly higher adventitial Ktrans than those without (0.056 ± 0.024 versus 0.034 ± 0.008 min−1, p < 0.001), whereas comparable measurements were seen among the subgroups with CVE (p > 0.05): 0.054 ± 0.027 min−1 in patients with coronary events alone, 0.056 ± 0.018 min−1 in patients with cerebrovascular events alone, and 0.069 ± 0.022 min−1 in patients with both. Carotid adventitial Ktrans was negatively correlated with time since clinical event (Spearman's rho = −0.40, p = 0.003). ConclusionsPatients with documented CVE demonstrated increased rate of contrast extravasation from carotid adventitial vasa vasorum on DCE-MRI irrespective of the territory of events. Systemic factors implicated in the pathophysiology of acute atherothrombotic events may influence the functional status of adventitial vasa vasorum.

The effect of four-phasic versus three-phasic contrast media injection protocols on extravasation rate in coronary CT angiography: a randomized controlled trial

ObjectivesContrast media (CM) extravasation is a well-known complication of CT angiography (CTA). Our prospective randomized control study aimed to assess whether a four-phasic CM administration protocol reduces the risk of extravasation compared to the routinely used three-phasic protocol in coronary CTA.MethodsPatients referred to coronary CTA due to suspected coronary artery disease were included in the study. All patients received 400 mg/ml iomeprol CM injected with dual-syringe automated injector. Patients were randomized into a three-phasic injection-protocol group, with a CM bolus of 85 ml followed by 40 ml of 75%:25% saline/CM mixture and 30 ml saline chaser bolus; and a four-phasic injection-protocol group, with a saline pacer bolus of 10 ml injected at a lower flow rate before the three-phasic protocol.Results2,445 consecutive patients were enrolled (mean age 60.6 ± 12.1 years; females 43.6%). Overall rate of extravasation was 0.9% (23/2,445): 1.4% (17/1,229) in the three-phasic group and 0.5% (6/1,216) in the four-phasic group (p = 0.034).ConclusionsFour-phasic CM administration protocol is easy to implement in the clinical routine at no extra cost. The extravasation rate is reduced by 65% with the application of the four-phasic protocol compared to the three-phasic protocol in coronary CTA.Key Points• Four-phasic CM injection-protocol reduces extravasation rate by 65% compared to three-phasic.• The saline pacer bolus substantially reduces the risk of CM extravasation.• The implementation of four-phasic injection-protocol is at no cost.

Peripheral Intravenous Catheter (PIVC) Related Local Complications among Patients in KFCH-Jizan

Background: Peripheral intravenous catheterization is a common invasive nursing procedure performed in healthcare institutions. It is a technique which involves insertion of a needle into the peripheral veins for various reasons. As one of the commonest nursing procedures being performed, it also brought significant risks to patients resulting to prolong hospital stay and delay in recovery period if not properly executed. Objectives: The study primarily aims to determine the incidence rate of peripheral intravenous cannula related local complications in the hospital. Design: The study is a descriptive type of research since it mainly deals with identifying the incident rate of phlebitis, infiltration, extravasation and hematoma and its underlying causes. Settings: Study was conducted in one of the Ministry of Health hospitals in Jazan, Saudi Arabia. Participants: All the patients admitted in the hospital during the data gathering period was included regardless of their demographic status. A total of 406 patients, with 458 peripheral cannula were assessed. Methods: The study is quantitative type of research since it mainly sought to find out the number of phlebitis, infiltration, extravasation and hematoma cases in the above mentioned healthcare institution. Result: The findings show that the rate of phlebitis, infiltration, extravasation and hematoma are 21, 7, 3.5, 12 percent respectively. Conclusions: There were high incidence of intravenous cannula related complications in the hospital which needs to be reduced or completely eradicated in order to improve overall patient's health outcome.

Predictive Value of CTA Spot Sign on Hematoma Expansion in Intracerebral Hemorrhage Patients.

Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage and leads to high rates of mortality and morbidity. Currently, contrast extravasation within hematoma, termed the spot sign on computed tomography angiography (CTA), has been identified as a strong independent predictor of early hematoma expansion. Past studies indicate that the spot sign is a dynamic entity and is indicative of active hemorrhage. Furthermore, to enhance the spot sign's accuracy of predicting HE, spot parameters observed on CTA or dynamic CTA were used for its quantification. In addition, spot signs detected on multiphase CTA and dynamic CTA are shown to have higher sensitivity and specificity when compared with simple standardized spot sign detection in recent studies. Based on the spot sign, novel methods such as leakage sign and rate of contrast extravasation were explored to redefine HE prediction in combination with clinical characteristics and spot sign on CTA to assist clinical judgment. The spot sign is an accepted independent predictor of active hemorrhage and is used in both secondary intracerebral hemorrhage and the process of surgical assessment for hemorrhagic risk in patients with ischemic stroke. Spot sign predicts patients at high risk for hematoma expansion.

Selection of peripheral intravenous catheters with 24-gauge side-holes versus those with 22-gauge end-hole for MDCT: A prospective randomized study

PurposeTo compare the 24-gauge side-holes catheter and conventional 22-gauge end-hole catheter in terms of safety, injection pressure, and contrast enhancement on multi-detector computed tomography (MDCT). Materials & methodsIn a randomized single-center study, 180 patients were randomized to either the 24-gauge side-holes catheter or the 22-gauge end-hole catheter groups. The primary endpoint was safety during intravenous administration of contrast material for MDCT, using a non-inferiority analysis (lower limit 95% CI greater than −10% non-inferiority margin for the group difference). The secondary endpoints were injection pressure and contrast enhancement. ResultsA total of 174 patients were analyzed for safety during intravenous contrast material administration for MDCT. The overall extravasation rate was 1.1% (2/174 patients); 1 (1.2%) minor episode occurred in the 24-gauge side-holes catheter group and 1 (1.1%) in the 22-gauge end-hole catheter group (difference: 0.1%, 95% CI: −3.17% to 3.28%, non-inferiority P=1). The mean maximum pressure was higher with the 24-gauge side-holes catheter than with the 22-gauge end-hole catheter (8.16±0.95kg/cm2 vs. 4.79±0.63kg/cm2, P<0.001). The mean contrast enhancement of the abdominal aorta, celiac artery, superior mesenteric artery, and pancreatic parenchyma in the two groups were not significantly different. ConclusionIn conclusion, our study showed that the 24-gauge side-holes catheter is safe and suitable for delivering iodine with a concentration of 300mg/mL at a flow-rate of 3mL/s, and it may contribute to the care of some patients, such as patients who have fragile and small veins. (Trial registration: UMIN000023727)

Abstract A126: The role of macrophages and monocytes during cancer cell extravasation in 3D vascularized microfluidic models

Abstract Recent in vivo mouse studies have revealed that macrophages can promote metastasis, while certain subsets of monocytes either help or block metastasis. Further studies are warranted to understand the underlying mechanisms, so as to target pharmacologically these immune cells as a means to halt metastasis. Intravital imaging can be performed in mice and has proven extremely useful in uncovering the role of macrophage and monocytes in metastasis, but requires specialized expertise and equipment. Concurrently, microfluidic models have been developed to dissect certain steps of the metastatic spread, because they allow for easier imaging at high resolution and facilitate an improved microenvironment control over more traditional macro-scale in vitro systems. In this study, a microfluidic model was used to investigate the effects of monocytes and macrophages on cancer cell extravasation. A previously developed microfluidic assay was used to form a 3D microvascular network (MVN) that consists of 3 separate compartments, flanked by media channels connected to reservoirs. In the two lateral compartments, normal human lung fibroblasts were seeded at 5 million/ml, while in the central compartment GFP HUVECs were placed at 4 million/ml all in a 3D fibrin gel. After 4 days, the HUVECs self-assemble into a MVN, which forms lumens that open directly to the media channel. Therefore, cancer cells can be perfused within the MVN via the reservoirs, and their transendothelial migration is tracked by confocal imaging over time for up to 12 hours. In this study, we mix the HUVECs with the macrophages (ratio 40:1) such that the macrophages are found in the fibrin on the outside of the vessels. Alternatively, we perfuse monocytes in the MVN, most of which have extravasated 4 days later (94±2%), thus replicating macrophage differentiation from recruited monocytes. In another study, monocytes were perfused with cancer cells in the MVN to test whether the monocytes could affect cancer cell extravasation intra-luminally, as they would in the blood circulation. Both monocytes and macrophages were derived from healthy donors' blood. Monocyte-derived macrophages (MDMs) were on average 33.4±4.4 μm (mean±SEM) away from the MVN, of which 40% were found within 10 μm. Interestingly, 46.4±3.1% stained positive for MRC-1. The MDM:MDA-MB-231 ratio was 2±0.5. The presence of MDM around the microvascular networks did not affect cancer cell extravasation rate; 10 hours after the cancer cells were perfused within the MVN, 57±15 vs. 60±6% of MDA-MB-231 had extravasated with or without MDMs, respectively. 11±6% of MDA-MB-231s came in contact with MDMs, for 5.1±0.6 hrs. Contact was mostly established after cancer cells had extravasated (73±19% of cancer cells), and less often while the cancer cell was extravasating (15±9%) or inside the vessels (12±12%). At t = 0, the average shortest distance between a MDM and a cancer cell arrested within the vessels was 98.4±6.3 μm, and was the same for cancer cells that did or did not eventually extravasate. However, the cancer cells that extravasated migrated further away from the μVN surface in presence of MDMs; 4.5 hrs after extravasation, cells were found 16.5±4.9 vs. 5.4±2.1 μm away from the endothelial wall with or without MDMs, respectively (p = 0.044, unpaired student t-test). In a separate study, monocytes were found to significantly decrease cancer cell extravasation. 11 hrs after cancer cells were perfused with monocytes inside the MVN, 19.8±6.1% of MDA-MB-231 had extravasated vs. 53.5±11% when cancer cells were perfused alone (p = 0.041, unpaired t-test). In conclusion, monocytes but not macrophage seem to affect cancer cell extravasation. Further studies will generalize the results to other cancer cell lines, and investigate how monocytes might decrease extravasation, and how this effect could be exacerbated pharmacologically to decrease metastasis. Citation Format: Alexandra Boussommier-Calleja, Roger D. Kamm. The role of macrophages and monocytes during cancer cell extravasation in 3D vascularized microfluidic models [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr A126.

Using the Delphi method to develop nursing‐sensitive quality indicators for the NICU

To develop nursing-sensitive quality indicators consistent with current medical practices in Chinese neonatal intensive care units. The development of nursing-sensitive quality indicators has become a top priority in nursing management. To the best of our knowledge, there has been no objective, scientific and sensitive evaluation of the quality of neonatal intensive care unit nursing in China. A modified Delphi technique was used to seek opinions from experts about what should be used and prioritised as indicators of quality care in neonatal intensive care unit nursing. Based on a literature review, we identified 21 indicators of nursing-sensitive quality in the neonatal intensive care unit. Our group of 11 consultants chose 13 indicators to be discussed using the Delphi method. In October and November 2014, 39 neonatal intensive care unit experts in 18 tertiary hospitals spread across six provinces participated in two rounds of Delphi panels. Of the 13 indicators discussed, 11 were identified as indicators of nursing-sensitive quality in the neonatal intensive care unit: rate of nosocomial infections, rate of accidental endotracheal extubation, rate of errors in medication administration, rate of treatment for pain, rate of peripheral venous extravasation, rate of compliance with handwashing techniques, incidence of pressure ulcers, incidence of noise, the bed-to-care ratio, the proportion of nurses with greater than fiveyears neonatal intensive care unit experience and incidence of retinopathy. The 11 neonatal intensive care unit nursing-sensitive indicators identified by the Delphi method integrated with basic Chinese practices provide a basis for nursing management and the monitoring of nursing quality. This study identified nursing-sensitive quality indicators for neonatal intensive care unit care that are suitable for current clinical practice in China.

Abstract 1578: Exploring the role of tumor-conditioned macrophage metabolism on extravasation of pancreatic ductal adenocarcinoma cells

Abstract A persistently low survival rate and more than 80% of patients experiencing relapse after surgery combine to make pancreatic ductal adenocarcinoma (PDAC) the 4th leading cause of death from cancer. Recent studies showed that the presence of tumor-associated macrophages (TAMs) may support cancer cells in each step of the metastatic cascade: growth at the primary site followed by epithelial-mesenchymal transition (EMT), intravasation into lymph and blood vessels, circulation to a distant site, stoppage due to adhesion or size restriction, extravasation into tissue, and colonization in this secondary organ. However, the role of TAMs and their metabolic profile in tumor progression need further investigation. The objective of our studies was to examine the potential for macrophages to switch from oxidative phosphorylation to aerobic glycolysis (the Warburg effect), similar to what is observed in cancer cells, and how this metabolic conversion may influence their pro-metastatic activity. To address this question we differentiated human peripheral blood monocytes with non tumor- and tumor-conditioned media to obtain macrophages and TAMs, respectively. First, we showed in a live glycolytic stress test that TAMs had a greater glycolytic capacity compared to non tumor-conditioned macrophages. Next, a 3D in-vitro microfluidic extravasation assay consisting of an endothelial monolayer was used to assess the effect of macrophages on PDAC cell extravasation across the endothelial wall into an extracellular matrix-like hydrogel. We observed that the extravasation propensity of PDAC cells was increased by the presence of TAMs but was not significantly affected by non tumor-conditioned macrophages. This suggests that the tumor-conditioned media fostered monocyte differentiation toward pro-metastatic macrophages. To assess if the macrophage metabolic switch toward glycolysis was the key factor promoting the increment in cancer cell extravasation, we treated the TAMs with 2-Deoxyglucose (2-DG), a competitive inhibitor of glycolysis at the level of hexokinase. Indeed, we observed a significant reduction in the rate of PDAC cell extravasation when TAMs were treated with 2-DG compared to untreated TAMs. Our results confirmed that the glycolytic metabolism was involved in modulating pro-tumoural macrophage function. Taken together, our data suggest that the macrophage metabolic pathway is a potential therapeutic target for controlling immune cell contributions to tumor progression and that patient responses to current treatments might be improved by inhibition of macrophage glycolysis. Citation Format: Giulia Adriani, Hweixian L. Penny, Je Lin Sieow, Siew Cheng Wong, Roger D. Kamm. Exploring the role of tumor-conditioned macrophage metabolism on extravasation of pancreatic ductal adenocarcinoma cells. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1578.

Evaluation of the effect of transcytolemmal water exchange analysis for therapeutic response assessment using DCE-MRI: a comparison study

This study compares the shutter-speed (SS) and the Tofts models as used in assessing therapeutic response in a longitudinal DCE-MRI experiment. Sixteen nu/nu mice with implanted colorectal adenocarcinoma cell line (LS-174T) were randomly assigned into treatment/control groups (n = 8/group) and received bevacizumab/saline twice weekly (Day1/Day4/Day8). All mice were scanned at one pre- (Day0) and two post-treatment (Day2/Day9) time points using a high spatiotemporal resolution DCE-MRI pulse sequence. The CA extravasation rate constant from the Tofts/SS model and the mean intracellular water residence time from the SS model were analyzed. A biological subvolume (BV) within the tumor was identified based on the intensity distribution, and the SS model parameters within the BV ( and ) were analyzed. It is found that and have a similar spatial distribution in the tumor volume. The Bayesian information criterion results show that the SS model was a better fit for all scans. At Day9, the treatment group had significantly higher tumor mean (p = 0.021), (p = 0.021) and (p = 0.045). When BV from transcytolemmal water exchange analysis was adopted, the treatment group had higher mean at both Day2 (p = 0.038) and Day9 (p = 0.007). Additionally, at Day9, the treatment group had higher mean (p = 0.045) and higher spatial heterogeneity indices (Rényi dimensions) d1 (p = 0.010) and d2 (p = 0.021). When mean and its coefficient of variation (CV) were used to separate treatment/control group samples using supporting vector machine, the accuracy of treatment/control classification was 68.8% at Day2 and 87.5% at Day9; in contrast, the Day2/Day9 accuracy were 62.5%/87.5% using tumor mean and its CV and were 50.0%/87.5% using tumor mean and its CV, respectively. These results suggest that the SS model parameters outperformed the Tofts model parameters in terms of capturing bevacizumab therapeutic effect in this longitudinal experiment.

SU‐F‐J‐155: Evaluation of Transcytolemmal Water Exchange Analysis For Therapeutic Response Assessment Using Dynamic Contrast‐Enhanced MRI

Purpose:To compare the performance of shutter‐speed(SS) model with transcytolemmal water exchange analysis against the Tofts model in the study of the efficacy of an anti‐angiogenesis drugMethods:16 mice with LS‐174T implanted were randomly assigned into treatment/control groups (n=8/group) and received bevacizumab/saline three times (Day1/Day4/Day8). All mice received one pre‐ (Day0) and two post‐treatment (Day2/Day9) DCE scans. For each scan, the CA extravasation rate constant KTtrans/KStrans from the Tofts/SS model were calculated. The intracellular water residence time τi which reflects limited transcytolemmal water exchange between cell and extravascular‐extracellular‐space were also analyzed using SS model. A biological subvolume(BV) within the tumor was automatically segmented based on the τi intensity distribution, and the SS model parameters within the BV (KS,BVtrans and τi, BV) were analyzed. Rank‐sum tests were conducted to assess the differences of each parameter's statistics (mean value/coefficient‐of‐variation (CV) /kurtosis/skewness/heterogeneity indices d1 and d2) between treatment/control groups. Experiment using support vector machine in a leave‐one‐out approach were performed to validate the use of the analyzed biomarkers for treatment/control classification.Results:The SS model was a better fit for all scans in terms of Bayesian information criterion. At Day9, the treatment group had significantly higher mean KTtrans(p=0.021), KStrans(p=0.021) and τi(p=0.045). In the identified BV, the treatment group had significantly higher mean KS,BVtrans at both Day2(p=0.038) and Day9(p=0.007). Additionally, at Day9, the treatment group had significantly higher mean τi, BV(p=0.045) and higher KS,BVtrans heterogeneity indices d1(p=0.010) and d2(p=0.021) values. When using KS,BVtrans statistics for treatment/control group classification, the highest accuracy was 68.8%/87.5% at Day2/Day9; this result was better than the result of 62.5%/87.5% using KStrans statistics and 50.0%/87.5% using KTtrans statistics.Conclusion:The SS model parameters may be more reliable than the Tofts model parameters for therapeutic assessment. The proposed biological subvolume in this work may be useful for early therapeutic effect monitoring.

Early removal of urinary catheter after excision and primary anastomosis in anterior urethral stricture.

To investigate the feasibility of removing the urinary catheter 7 days after excision and primary anastomosis (EPA) performed with the indication of anterior urethral stricture disease. Retrospective review of medical records of the patients who had undergone EPA between January 2005 and December 2010 was performed. These patients were divided into 2 groups: Group 1 (urethral catheter removed on or before 7. postoperative day) and Group 2 (urethral catheter removed on 8. postoperative day or later). We compared 2 groups as for the frequency of extravasation as detected on retrograde pericatheter urethrogram (PUG) and recurrence rate till the last follow-up. PUG was performed on an average day 7 and 14 in Groups 1 (n=102) and 2 (n=134), respectively followed by removal of the catheter. Extravasation on the first PUG was detected in 6.8% of the patients in Group 1, and in 4.5% of the cases in Group 2 had extravasation on the first PUG. Urethral catheter was left in situ in these patients and a repeat PUG after one week was performed which was normal in all cases. The incidence of extravasation and recurrence rate did not differ significantly whether catheter was removed on day 7 or 14 (6.8% vs. 4.5% and 4.9% vs. 5.2% respectively) (p>0.5). We conclude that removal of the catheter on postoperative day 7 after EPA does not increase the rate of extravasation and recurrence during long-term follow-up. Urethral catheter restricts physical activity in the postoperative period which is bothersome to the patient. Hence early removal of a catheter should be offered to men after EPA.

Quantification of cancer cell extravasation in vivo.

Cancer cell 'invasiveness' is one of the main driving forces in cancer metastasis, and assays that quantify this key attribute of cancer cells are crucial in cancer metastasis research. The research goal of many laboratories is to elucidate the signaling pathways and effectors that are responsible for cancer cell invasion, but many of these experiments rely on in vitro methods that do not specifically simulate individual steps of the metastatic cascade. Cancer cell extravasation is arguably the most important example of invasion in the metastatic cascade, whereby a single cancer cell undergoes transendothelial migration, forming invasive processes known as invadopodia to mediate translocation of the tumor cell from the vessel lumen into tissue in vivo. We have developed a rapid, reproducible and economical technique to evaluate cancer cell invasiveness by quantifying in vivo rates of cancer cell extravasation in the chorioallantoic membrane (CAM) of chicken embryos. This technique enables the investigator to perform well-powered loss-of-function studies of cancer cell extravasation within 24 h, and it can be used to identify and validate drugs with potential antimetastatic effects that specifically target cancer cell extravasation. A key advantage of this technique over similar assays is that intravascular cancer cells within the capillary bed of the CAM are clearly distinct from extravasated cells, which makes cancer cell extravasation easy to detect. An intermediate level of experience in injections of the chorioallantoic membrane of avian embryos and cell culture techniques is required to carry out the protocol.

Duration of urethral catheterization after urethroplasty: how long is enough?

To report the impact of duration of urethral catheterization (DUC) on the rate of extravasation on voiding cysto-urethrography (VCUG) and the subsequent need of catheter replacement in urethroplasty. Two hundred nineteen consecutive patients undergoing urethroplasty between October 2010 and November 2014 were evaluated for the impact of DUC. Patients were divided into 2 groups, based on the scheduled DUC≤10 days (group 1, N.=86) or >10 days (group 2, N.=133). Fourteen patients (6.4%) had extravasation on VCUG with an additional period of catheter usage. In 10 of the 14 patients (71.4%) clinical signs of impaired wound healing were present. In group 1 (median DUC 8 days) 3 patients (3.5%) needed an additional period of urethral catheterization, compared to 11 patients (8.3%) in group 2 (median DUC 14 days). Strictures in group 2 were longer (4 vs. 2 cm, P<0.001) and more complex. Redo urethroplasty was needed in 9 of the 14 patients with extravasation. In uncomplicated cases of urethroplasty, the urethral catheter can be safely removed after 8 to 10 days postoperatively. Extravasation on VCUG occurs in around 6% of urethroplasties and is a prognostic factor for stricture recurrence and reoperation.

Editorial Comment

The authors have put together a well-done retrospective review of men undergoing a bulbar urethroplasty over a 16-year time period. 1 Granieri M.A Webster G.D Peterson A.C. A critical evaluation of the utility of imaging after urethroplasty for bulbar urethral stricture disease. Urology. 2016; https://doi.org/10.1016/j.urology.2015.12.086 Abstract Full Text Full Text PDF Scopus (12) Google Scholar After analysis of their single-institution review, they concluded that increasing the urethral catheter drainage time by an additional week (3 weeks in total) decreased urinary extravasation rate in the excision and primary anastomosis (EPA) group (5% to < 1%). In a trade-off for the additional urethral catheter time, they are suggesting eliminating the use of pericatheter retrograde urethrogram prior to catheter removal in patients undergoing EPA.

Fluid filtration and vascular compliance during cardiopulmonary bypass: effects of two volatile anesthetics.

As intraoperative fluid accumulation may negatively impact post-operative organ function, strategies minimizing edema generation should be sought for. During general anesthesia, isoflurane in contrast to sevoflurane has been associated with increased fluid extravasation and edema generation. In this study, we tested sevoflurane against isoflurane with focus on vascular compliance and fluid shifts in an experimental cardiopulmonary bypass (CPB) model. Sixteen pigs underwent 120 min of cardiopulmonary bypass with isoflurane or sevoflurane anesthesia. Net fluid balance, plasma volume, serum-electrolytes, serum-albumin, serum-protein, colloid osmotic pressures in plasma and interstitial fluid, hematocrit levels, and total tissue water content were recorded. Intra-abdominal and intracranial pressures were measured directly, and fluid extravasation rates were calculated. Fluid extravasation rate increased dramatically in both groups during initiation of cardiopulmonary bypass, with no group differences. The animals of the sevoflurane group needed significantly more fluid supplementation to maintain a constant reservoir volume in the CPB circuit during bypass. Plasma volumes prior to bypass were 56.5 ± 7.9 ml/kg (mean ± SD) and 58.7 ± 3.8 ml/kg in the isoflurane group and sevoflurane group, respectively. During bypass, plasma volumes in the isoflurane group decreased about 25%, and remained significantly lowered when compared to the sevoflurane group, where the values remained stable. No differences in fluid extravasation rates were observed between sevoflurane and isoflurane. The increased net fluid balance in the sevoflurane group during cardiopulmonary bypass was not associated with edema generation. Plasma volume was retained in the sevoflurane group, in contrast to the isoflurane group.

A Critical Evaluation of the Utility of Imaging After Urethroplasty for Bulbar Urethral Stricture Disease

To determine the incidence of extravasation on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty and the relationship to repair type. We performed a retrospective review to collect stricture-related and postoperative information with emphasis on pcRUGs. All men had a pcRUG at the initial follow-up appointment. The Foley catheter was removed if no extravasation was seen and left in place for an extra week, with a repeat pcRUG if extravasation was noted. We limited our analysis to men who underwent bulbar urethroplasty from January 1996 to December 2012 (by two surgeons: GDW, ACP). We identified 437 patients and 407 (93%) had follow up data. The mean stricture length was 1.97 cm ± 1.2 cm. In those patients who underwent excision and primary anastomosis (EPA) (n = 232, 57%), we performed the1st pcRUG 1 week earlier compared to those who underwent augmented anastomotic repair (n = 150, 37%) or onlay repair (n = 25, 6%). There was no difference in extravasation rates among all repair types at first pcRUG. The overall rate of extravasation on the first postoperative pcRUG significantly decreased in all patients (0.98% vs 5%, P = .0008) and in those who underwent EPA (5.6% vs 0.4%, P = .0016) when the Foley catheter remained for an extra week. Men who undergo bulbar urethroplasty have a low extravasation rate (2.2%) 3 weeks postoperatively and those who underwent EPA benefited from an additional week of catheterization.

Ultrasound-Guided Glenohumeral Joint Injection Using the Posterior Approach.

This feature is a unique combination of text (voice) and video that more clearly presents and explains procedures in musculoskeletal medicine. These videos will be available on the journal’s Website. We hope that this new feature will change and enhance the learning experience. No caption available. Video Gallery: To view the online video of these procedures, use your smartphone camera QR Reader App to scan and capture this QR Code or visit www.AJPMR.com to locate this digital video content. URL: http://journals.lww.com/ajpmr/Pages/videogallery.aspx?videoId=22&autoPlay=true Injection treatment to the glenohumeral joint is often needed to treat shoulder problems such as adhesive capsulitis.1,2 This can be done through blind palpation technique and fluoroscopic or musculoskeletal ultrasound guidance.3 In recent years, ultrasound has been proven to increase the accuracy of needle placement into the glenohumeral joint.4 Ultrasound is radiation free and offers real-time images in performing needle-guided injection procedures.5 Glenohumeral joint injection can be done using the anterior rotator interval approach or the posterior approach technique.4 Both techniques are generally well tolerated by the patients. However, it was shown that the posterior injection technique offers an easier and a more effective approach to the glenohumeral joint with less extravasation rate as compared with the anterior approach.4 The posterior approach also avoids the potential risk of accidental puncture or injection into the axillary neurovascular structures. A linear transducer of 5–12 MHz is usually used.6 This technique is often applied to inject corticosteroid for the treatment of frozen shoulder or contrast medium for computed tomography or magnetic resonance shoulder arthrography.6

Metabolism Regulates Exposure of Pancreatic Islets to Circulating Molecules In Vivo.

Pancreatic β-cells modulate insulin secretion through rapid sensing of blood glucose and integration of gut-derived signals. Increased insulin demand during pregnancy and obesity alters islet function and mass and leads to gestational diabetes mellitus and type 2 diabetes in predisposed individuals. However, it is unclear how blood-borne factors dynamically access the islets of Langerhans. Thus, understanding the changes in circulating molecule distribution that accompany compensatory β-cell expansion may be key to developing novel antidiabetic therapies. Here, using two-photon microscopy in vivo in mice, we demonstrate that islets are almost instantly exposed to peaks of circulating molecules, which rapidly pervade the tissue before clearance. In addition, both gestation and short-term high-fat-diet feeding decrease molecule extravasation and uptake rates in vivo in islets, independently of β-cell expansion or islet blood flow velocity. Together, these data support a role for islet vascular permeability in shaping β-cell adaptive responses to metabolic demand by modulating the access and sensing of circulating molecules.

Evaluating the Evidence for Midline Catheter Use in the Newborn Intensive Care Unit.

When deciding which vascular access devices (VADs) are appropriate for patients in newborn intensive care units (NICUs), clinical providers may have difficulty reaching consensus because of a lack of evidence-based recommendations. The aim of this literature review is to evaluate current research and practice pertaining to midline catheter (MC) use in NICU patients. Discussion of the literature review includes information pertaining to the historical perspective of MC use, devices currently in use, common sites for placement, average dwell times, associated costs, and acceptable fluids and medications for infusion through MCs. Conclusive findings suggest that MCs are not an appropriate VAD for NICU patients because of insufficient high-level evidence demonstrating safety and efficacy. Randomized controlled trials are needed to evaluate current MC practice in the NICU and the rates of infection and extravasation associated with their use.

Rate of Contrast Extravasation on Computed Tomographic Angiography Predicts Hematoma Expansion and Mortality in Primary Intracerebral Hemorrhage.

In primary intracerebral hemorrhage, the presence of contrast extravasation after computed tomographic angiography (CTA), termed the spot sign, predicts hematoma expansion and mortality. Because the biological underpinnings of the spot sign are not fully understood, we investigated whether the rate of contrast extravasation, which may reflect the rate of bleeding, predicts expansion and mortality beyond the simple presence of the spot sign. Consecutive intracerebral hemorrhage patients with first-pass CTA followed by a 90-second delayed postcontrast CT (delayed CTA) were included. CTAs were reviewed for spot sign presence by 2 blinded readers. Spot sign volumes on first-pass and delayed CTA and intracerebral hemorrhage volumes were measured using semiautomated software. Extravasation rates were calculated and tested for association with hematoma expansion and mortality using uni- and multivariable logistic regressions. One hundred and sixty-two patients were included, 48 (30%) of whom had ≥1 spot sign. Median spot sign volume was 0.04 mL on first-pass CTA and 0.4 mL on delayed CTA. Median extravasation rate was 0.23 mL/min overall and 0.30 mL/min among expanders versus 0.07 mL/min in nonexpanders. Extravasation rates were also significantly higher in patients who died in hospital: 0.27 mL/min versus 0.04 mL/min. In multivariable analysis, the extravasation rate was independently associated with in-hospital mortality (odds ratio, 1.09 [95% confidence interval, 1.04-1.18], P=0.004), 90-day mortality (odds ratio, 1.15 [95% confidence interval, 1.08-1.27]; P=0.0004), and hematoma expansion (odds ratio, 1.03 [95% confidence interval, 1.01-1.08]; P=0.047). Contrast extravasation rate, or spot sign growth, further refines the ability to predict hematoma expansion and mortality. Our results support the hypothesis that the spot sign directly measures active bleeding in acute intracerebral hemorrhage.