Neck Veins Research Articles

1151

Case Reports: A 90 year old female presented with substernal chest pain and dyspnea. Pain was sudden onset and sharp with inspiration. Past medical history was significant for smoldering multiple myeloma, remote breast cancer, remote pulmonary embolism, and atrial fibrillation. Heart rate was irregularly irregular at 100-110 bpm and blood pressure was 133/88. Physical exam demonstrated markedly distended neck veins with accentuated x and y descent. Chest x ray demonstrated bilateral pleural effusions and cardiomegaly. ECG demonstrated atrial fibrillation, low voltage, and electrical alternans without ST elevation. Echocardiography (echo) demonstrated a moderate circumferential pericardial effusion, right ventricular diastolic collapse, and ventricular interdependence with accentuated transmitral inflow during respiration indicating early tamponade physiology. Echo-directed pericardiocentesis from the left parasternal position removed 700 cc of sanguineous fluid without complication. A pericardial catheter was placed draining 23 cc over a 24 hour period. Fluid analysis demonstrated hemoglobin of 2.3 and negative cytology. Symptoms resolved with drainage and repeat echocardiogram five days later showed a tiny insignificant pericardial effusion with no tamponade physiology. Hematology labs were unchanged from the previous three months and consistent with smoldering multiple myeloma. Differential diagnosis dyspnea and pericardial effusion includes tamponade. Diagnosis of tamponade can be made by a constellation of findings on physical exam and with the assistance of echo. Echocardiographic findings of tamponade include right or left chamber collapse during diastole, hepatic vein expiratory flow reversals, and mitral inflow variation > 25% with respiration (echo equivalent of pulsus paradoxus). Echo-guidance outlines the effusion size and location, defines the optimal needle angle to the pericardial space, and provides visualization of vital structures between the skin and pericardial space resulting in a high level of safety with minimal complications.

Ultrasound detection of septic jugular vein thrombosis

The two leading causes of IJVT are iatrogenic trauma secondary to jugular vein catheterization, and repeated IV injections by drug users. Lemierre syndrome is a complex and unusual clinical entity, characterized by septic thrombophlebitis of internal jugular vein. Lemierre syndrome was thought to be a rare and forgotten disease with suggested incidence of approximately one per million. However, an increase in frequency over the past years has been suggested due to changes in antibiotic usage. Unfortunately, wide spread antibiotic usage has also changed clinical picture of Lemierre syndrome and it is often difficult to recognize this unusual ilness in the Emergency Department (ED). Systemic septic complications may range from deep neck infection over septic arthritis to brain infections. Every organ system may be involved. Delays in diagnosis ranging up to 11 days after admission have been reported. When recognized and treated in early phase patients recover completely but other vise condition may be lethal. In emergency settings accurate and prompt diagnosis is crucial in satisfactory patient management. Diagnosis of Lemierre's syndrome is simple with Doppler ultrasonography but it mostly requires a high degree of clinical suspicion. It has been suggested that bedside ultrasound of the internal jugular vein in ED before other radiologic imaging, may lead to rapid diagnosis and treatment of Lemierre syndrome. In last two years we treated five patients with Lemierre’s syndrome in our department. In one case young woman died because of sepsis and multiorgan failure due to delayed diagnosis. Rapid ultrasound examination of neck veins is discussed as a part of ED evaluation of patients.

A right atrial mass—but where is it coming from?

We present a case of a 70-year-old male who attended our emergency department with prolonged weight loss and a 3-week history of progressive swelling of his lower limbs and scrotum with haematuria. On examination there was pitting oedema up to his sacral area, with significant scrotal enlargement. The abdomen was distended with a large left-sided abdominal mass extending across the midline. This was in addition to 5 cm of hepatomegaly. On auscultation a pansystolic murmur was noted, which was loudest over the cardiac apex, with bibasal lung crepitations. Engorged neck veins and goitre were also noted. Acute renal failure was diagnosed with a creatinine level of 171.

Predicting Venous Thromboembolism Recurrence Risk in Patients with Cancer: A Validation Study

AbstractAbstract 394 Background:Long-term low molecular weight heparin (LMWH) is the current standard for treatment of venous thromboembolism (VTE) in cancer patients. Whether treatment strategies should vary according to individual risk of VTE recurrence remains unknown. We have derived a clinical prediction rule that stratifies VTE recurrence risk in patients with cancer-associated VTE. The derivation model includes 4 independent predictors (sex, primary tumor site, stage and prior VTE). The score sum ranges between −3 and +3 points. Patients with a score ≤ 0 had low risk (≤4.5%) for recurrence and patients with a score above 1 had a high risk (≥ 19%) for VTE recurrence. Subsequently, we applied and validated the rule in an independent set of 819 patients from 2 randomized controlled trials comparing LMWH to warfarin for VTE treatment in cancer patients. In the current study we aim to externally validate our clinical prediction rule with an independent population of patients with cancer-associated VTE followed at the Thrombosis clinics of two tertiary Canadian centres. Methods:We conducted a retrospective cohort study of patients with cancer and VTE diagnosed and/or followed at the Thrombosis Clinic of the Victoria Hospital (London, Canada) from January 2006 to December 2010; and the Thrombosis Unit of the Ottawa Hospital (Ottawa, Canada) from January 2009 to December 2011. We included data from adult patients with active malignancy and objectively diagnosed acute pulmonary embolism (PE) or deep venous thrombosis (DVT) of the lower extremity (above knee), upper extremity and neck veins, or unusual site thrombosis. The primary outcome measure was VTE recurrence during the first six months of anticoagulation. Results:353 patients fulfilled our inclusion criteria and were included in the study. There were 149 males, and the overall population had a median age of 64 years (range: 18 – 95). One hundred and twenty-three patients had lower extremity DVT, 93 had PE and 57 had both. The remaining 80 patients had either upper extremity/neck DVT (n = 55) or unusual site thrombosis (n = 25). 77 patients had a prior history of VTE. The most common primary tumour site was gastrointestinal, followed by the lung. Of the 304 patients with solid tumours, 230 (75.7%%) had TNM greater than I.Two hundred and ninety-three (83.0%) patients were treated with longterm low molecular weight heparin (LMWH) only and 60 (17.0%) with warfarin (VKA). VTE recurrence occurred in 44 of 353 patients (12.4%). When we evaluated VTE recurrence risk per site, there was no significant difference: London 13 of 90 and Ottawa 31 of 263 [RR=1.23 (95%CI= 0.671 – 2.237; p=0. 507)]. In addition, there was no significant benefit with the use of LMWH (37 of 293) over VKA (7 of 60) in the risk of recurrence [RR=0.92 (95%CI= 0.433 – 1.973; p= 0.8379)]. When we applied our clinical prediction rule (Table 1) in the entire study population, recurrent VTE occurred in 12 of 204 (5.8%) patients stratified as low risk probability and in 32 of 149 (21.4%) patients stratified as high risk probability (Table 2). Conclusions:Our prediction rule has been adequately validated to now be used in prospective trials of treatment. Future trials evaluating novel treatment strategies for high risk patients are warranted.Table 1The Clinical prediction rule for risk stratification of VTE recurrence risk in patients with cancer- associated venous thrombosisPredictorPointsFemale1Lung cancer1Breast Cancer−1TNM$ Stage I−2Previous VTE**1Clinical ProbabilityLow risk of *rVTE (< or = 0)−3 to 0High risk of *rVTE (> or = 1)1 to 3*rVTE= recurrent venous thromboembolism.**VTE= venous thromboembolism.$TNM= tumour- node- metastasis classification of solid tumours.Table 2Results of the clinical prediction rule in the London-Ottawa retrospective studySum of PointsTotal Patients (n = 353)*rVTE (n = 44)Frequency of rVTE (%)-3100-24536.7-15658.9010243.91971616.52311342.038337.5Clinical ProbabilityLow Risk of rVTE (< or = 0)5.8%High Risk of rVTE (> or = 1)21.4%*rVTE= recurrent venous thromboembolism. Disclosures:No relevant conflicts of interest to declare.

Erythrocytosis as a cause of false increase in prothrombin time and activated partial thromboplastin time

Editor: Prothrombin time (PT) as an index of liver dysfunction is well-established. Abnormal PT in a patient with acute hepatitis alerts us to the possibility of impending liver failure and mandates much closer monitoring. We present a case where PT was falsely elevated. A 23-year-old gentleman, with ventricular septal defect, severe pulmonary hypertension, and reversal of shunt, was referred for opinion on deranged liver function. He had no jaundice, prodrome, ascites, or signs of liver decompensation. On examination, his vital parameters were normal. There was clubbing and cyanosis with normal neck veins. Abdominal examination showed no organomegaly or free fluid. He was on digoxin and diuretics and was not anticoagulated. He had erythrocytosis [hemoglobin of 23.3 g/dL (mean corpuscular volume, 92.6 fL; packed cell volume, 74 %)] with normal total white blood cell and platelet counts. He had mild indirect hyperbilirubinemia (serum total bilirubin, 1.6 mg/dL; direct fraction, 0.3 mg/dL), mildly elevated liver enzymes (serum alanine aminotransferase, 75 U/L; serum aspartate aminotransferase, 57 U/L), and normal serum albumin (5 g/dL). His PT was prolonged, 26.3 s, i.e. 14 s above the normal upper limit with an international normalized ratio (INR) of 2.37. Activated partial thromboplastin time (aPTT) was also prolonged, 58.9 s, i.e. 19 s above the normal upper limit. The PT and aPTT values were repeated on two different occasions with similar results. Etiological evaluation of liver disease, in the form of HBsAg, HCV antibody, serum ceruloplasmin, and serum ferritin, was unyielding. His liver on ultrasound appeared normal. The presence of coagulopathy was the only factor alarming in what looked like a nonspecific liver function abnormality. The tests were repeated on the same day after adding excess blood (7 mL) to the same amount of citrate thus maintaining the normal bloodto-anticoagulant ratio (Table 1). The corrected PT and aPTT were 11.6 s (INR, 1.08) and 29.4 s, respectively. The patient was reassured at that point and asked to review later. The patient was unable to come for reassessment, but on telephonic follow up at 6 months from the initial visit, he remained well and anicteric.

Massive and Severe Calcific Constrictive Pericarditis

41-year-old Nigerian woman was admitted to ourhospital complaining weakness, fatigue, chest pain,palpitations, gradual dyspnea on exertion, ascites, andpedal edema. There was no history of fever or cough.Routine blood examination results were normal, and atuberculin test result was negative. The physical exami-nation revealed peripheral edema, hepatomegaly, as-cites, and neck veins that were grossly distended. Thecardiac examination showed a normal heart size andvague distant heart sounds with a distinct pericardialknock. An electrocardiogram showed a normal sinusrhythm with a heart rate of 95 beats/min and an incom-plete left bundle branch block. A chest radiograph re-vealed diffuse and dense calcification of the pericardium(Fig 1A, arrows). A thoracic computed tomographic (CT)scan demonstrated a calcific pericardium surroundingthe entire heart (Fig 1B, arrow; Fig 1C, CT volumerendering showing calcific pericardium, arrow). Two-dimensional echocardiography confirmed severe peri-cardial calcification and revealed poor left ventricularejection fraction with pulmonary hypertension. Catheter-ization demonstrated rapid filling and elevation andequalization of left and right ventricular and diastolicpressures at a value of 18 mmHg. She underwent, viamedian sternotomy without cardiopulmonary bypass,pericardial resection with electrocauterization at 60 mVto avoid causing diathermal dysfunction of the rightventricle. Histologic examination showed fibrosis, mildchronic inflammation, and calcification. During the firstpostoperative month, the functional capacity of the pa-tient improved remarkably. Constrictive pericarditis, anuncommon entity, is characterized by an inflammatoryprocess that leads to progressive pericardial fibrosisencasing the heart in a thickened and fibrotic pericar-dium. The most common etiology in developing coun-tries is tuberculosis, but in industrialized nations theetiology is unclear in many cases (idiopathic constrictivepericarditis); the three most common identifiable causesare cardiac surgery, pericarditis, and mediastinal irradi-ation. Other possible causes include connective tissuediseases, malignancy, trauma and infections [1]. Todaypericardiectomy is generally a safe procedure, althoughthe early postoperative death risk is more than 2%.Survival rates vary from 55% to 90% on the basis of age,sex, and race [2].

A technical approach to dissecting and assessing cadaveric veins pertinent to chronic cerebrospinal venous insufficiency in multiple sclerosis

Objective: To establish a detailed technical procedure for studying the anatomical correlates of chronic cerebrospinal venous insufficiency in cadavers of multiple sclerosis and control subjects, and to present our findings of the normal anatomic venous structures, with reference to previous descriptions from the literature.Methods: This study examined the internal jugular veins (IJVs), the brachiocephalic veins, and the azygos vein from 20 cadavers (10 control and 10 multiple sclerosis). These veins were exposed, isolated by clamps from the rest of the venous system, flushed with water, and then injected with fluid silicone from the superior ends of both IJVs. After the silicone cured to its solid state, the venous tree was removed en bloc and dissected longitudinally to expose the luminal surface. All vein segments were analyzed for anatomic variation. Anatomical analysis for this manuscript focused on normal vein architecture and its variants.Results: Thirty-seven of 40 IJVs contained valves: 29 bicuspid, 6 tricuspid, and 2 unicuspid. The average circumferences of the right and left IJVs were 2·2 and 1·8 cm, respectively. Thirteen of 20 azygos veins contained a valve, located on average 3·6 cm away from the superior vena cava junction. Nine of the 13 azygos valves were bicuspid; four were tricuspid. Only one of the 40 brachiocephalic veins contained a valve.Discussion: We detailed a technical approach for harvesting cadaveric neck and thoracic veins with relevance to chronic cerebrospinal venous insufficiency. The anatomy of the venous system has significant variability, including differing number of valves in different regions and variable characteristics of the valves. Average vein circumference was less than that typically reported in imaging studies of live patients.

Simvastatin Induced Secretory Diarrhea: A Case Report

Purpose: A 74-year-old woman was admitted with unrelenting diarrhea and progressive malaise over a 2 week period. Stools were watery, voluminous, non-bloody and worsened after oral intake. She had associated abdominal cramping but denied fevers, chills, rashes, oral lesions, ill contacts, recent antibiotic use, travel or ingestion of raw or undercooked foods. Home medications included Prilosec, simvastatin, metoprolol, losartan-HCTZ, and aspirin. Physical exam revealed temperature 37.8 °C, pulse 90 bpm, respirations 13, BP 127/56 and oxygen saturation of 96% on ambient air. She appeared tired, weak, and with dry oral mucous membranes and depressed neck veins. The remainder of the exam was unremarkable. Initial lab studies showed albumin 2.4 gm/dL (3.4-5.0), total protein 5.3 gm/dL (6.4-8.2), potassium 3.3 mmol/L (3.4-5.1), chloride 109 mmol/L (98-107), magnesium 1.3 mg/dL (1.6-2.4), and phosphorus 1.9 mg/dL (2.4-4.7). CBC and CMP were otherwise unremarkable. Urinalysis was negative for protein. Her medications were held as she received supportive management and hydration. Clostridium difficile PCR, viral pathogens, ova and parasite, and enteric pathogens were negative. Colonic and terminal ileum biopsies were normal. Serology for celiac screening was negative. She improved quickly, tolerated general diet, and was discharged home. Within 24 hours, she was readmitted with recurrent symptoms. Given persistence and severity of symptoms, extensive workup ensued. Stool potassium was 12.5 mEq/L and sodium 142 mEq/L, consistent with secretory diarrhea. Fecal fat stain was negative. 24 hour urine 5HIAA level was 21 mg/g (< 14) and serum serotonin was 302 ng/mL (50-200). Chromogranin A and gastrin levels were normal. CT scan of the chest, abdomen and pelvis were negative. An octreotide scan showed soft tissue uptake in the left trochanteric region, however, MRI of the hip revealed this was due to degenerative changes. She again responded quickly to supportive care and was discharged home, only to return a third time, six days later, with profuse diarrhea. Clinical history was re-evaluated and patient remembered a recent medication change from atorvastatin to simvastatin 2 days before initial events. As before, symptoms abated when medications were held in the hospital. A medication challenge with simvastatin 20 mg was administered and four hours later, symptoms were reproduced with multiple, profuse, watery bowel movements. She has remained symptom free since discontinuation. Protein-losing enteropathy has been published in one patient, but generally transient diarrhea induced by simvastatin is <3%. This case represents a rare presentation of severe secretory diarrhea, which has not been previously reported.

Post-mortem development of conjunctival petechiae following temporary prone position

Conjunctival petechiae are an important diagnostic finding in external examination of forensic cases, being a sign of possible mechanical compression of the neck and jugular veins (e.g. choking, strangulation). Nevertheless, it is well known, that strong congestion of the conjunctival blood vessels might lead to the development of petechiae in the perimortal and early post mortem period, e.g. due to a head down position of the body. By now it remains unclear, whether a short term horizontal prone position of a body can lead to the development of conjunctival petechiae in the early post mortem period, a situation that might occur in everyday forensic casework. Therefore, we investigated the occurrence of conjunctival petechiae in 20 deceased at <12h after death following a prone position of 2h. Petechiae developed in 8 cases. Therefore, our results for the first time give evidence that conjunctival petechiae can be observed after a short-term horizontal prone position of a body in the early post mortem period, influencing the assessment of future forensic cases. Furthermore, statistical analysis revealed significant correlations with the examination method used to ectropionise the eyelids (forceps vs. cotton swab) and preceding resuscitation attempts. The latter observations should be considered in future research on the phenomenon.

Aneurysm of External Jugular Vein Mimicking Hemangioma of Neck

Venous aneurysms are one of the rare causes of neck swellings. Among neck veins, external jugular vein aneurysms are uncommon. We present a case of a woman who presented with a nontender compressible swelling in the left lower neck region, which initially thought to be hemangioma, was later found to be external jugular vein aneurysm on Doppler ultrasound and CT angiography.

Spontaneous Ear Hemorrhage During Cardiac Surgery

A 79-year-old patient who underwent mitral valve replacement experienced prolonged elevated central venous pressure associated with poor venous return during a cardiopulmonary bypass. After the procedure, the patient was noted to have spontaneous bleeding from the left ear. Otolaryngologic examination in the operating room showed no trauma in the exterior auditory canal and suggested that the hemorrhage was related to a superior vena cava syndrome and anticoagulation during the cardiopulmonary bypass. Determinants and management considerations of poor venous return, including maintenance of cerebral perfusion pressure, are discussed.

Spontaneous Fontan Physiology in Burnt-Out Endomyocardial Fibrosis

A 42-year-old man presented with congestive heart failure and atrial fibrillation. He had been diagnosed with endomyocardial fibrosis 8 years earlier and was stable on diuretics. He had congested neck veins, pedal edema, and massive ascites and a loud third heart sound. ECG confirmed atrial fibrillation. The chest radiograph showed massive cardiomegaly with a cardiothoracic ratio of 90%. Two-dimensional echocardiography revealed features of endomyocardial fibrosis with predominant right ventricular involvement (online-only Data Supplement Movie I; Figure, A). The right atrium was aneurysmally dilated with dense spontaneous echo contrast. The right ventricular cavity was obliterated. The inferior vena cava measured 28 mm with no respiratory variation, suggesting high systemic venous pressures. Hepatic vein flow showed loss of a wave reversal and increased antegrade flow in inspiration. Low-pressure tricuspid regurgitation was reflected in the …

Septic Pulmonary Embolism in a Patient with Defibrillator Lead Endocarditis

and a boil on his jaw. Computerized tomography (CT) scan of chest showed inflammatory changes along the pacemaker leads and thrombus in the left innominate and jugular veins (Figure 1a). Ultrasound of the left arm and neck veins showed venous thrombosis (Figure 1b). Transesophageal echocardiography showed a vegetation attached to the right atrial lead (Figure 1c). The ICD was explanted percutaneously. Four days later the patient developed fever with pleuritic chest pain. Follow-up CT angiography showed interval development of multiple pulmonary emboli (Figure 1d). The patient was treated with nafcillin, coumadin, and a life vest defibrillator until ICD re-implantation. The incidence of cardiac device endocarditis is 1–7% of those who receive a cardiac device, and 27% of cardiac device endocarditis is associated with septic pulmonary embolism. Both cardiac device endocarditis and septic pulmonary embolism have high morbidity and mortality (1). The risk factors for cardiac device endocarditis are recent device manipulation, diabetes mellitus, corticosteroid medication, anticoagulation, cancers, chronic renal failure, and bacteremia (2). Septic pulmonary embolism is a rare disorder associated with cardiac device implants, intravascular catheters, intravenous drug use, suppurative process in head and neck, thrombophlebitis, and immunocompromised state (3).

Pneumococcal Pyopericardium Masquerading as Acute Coronary Syndrome

A 54-year-old man was admitted with a one-week history of chest pain, increasing in severity and worsening dyspnoea. An ECG revealed changes consistent with an acute coronary syndrome (ACS) and a chest X-ray showed an enlarged cardiac shadow. Following admission to the coronary care unit for treatment of presumed ACS his condition deteriorated. A diagnosis of sepsis was made. A CT scan revealed a large pericardial and bilateral pleural effusions. Heart sounds were muffled and neck veins distended, suggesting pericardial tamponade. Echocardiography showed a global pericardial effusion ranging from 2–4 cm with haemodynamic compromise. Sub-xiphisternal pericardiocentesis revealed frank pus from the pericardial cavity and a total of 1,000 mL drained over 48 hours. Rapid haemodynamic improvement ensued. Streptococcus pneumoniae was isolated and the patient was successfully treated with intravenous antibiotics with no requirement for pericardial surgery. In the developed world acute purulent pericarditis is a rare entity with a high mortality rate. Only 10–20% of cases are diagnosed ante-mortem. The condition requires prompt recognition and immediate intervention. The diagnostic picture in this case was initially clouded by the suspicion of ischaemic coronary disease as well as the presence of sepsis. The presentation, management and risk factors associated with this unusual condition are discussed.

Does thoracic pump influence the cerebral venous return?

We assessed the hemodynamic effects induced by the thoracic pump in the intra- and extracranial veins of the cerebral venous system on healthy volunteers. Activation of the thoracic pump was standardized among subjects by setting the deep inspiration at 70% of individual vital capacity. Peak velocity (PV), time average velocity (TAV), vein area (VA), and flow quantification (Q) were assessed by means of echo color Doppler in supine posture. Deep respiration significantly increases PV, TAV, and Q, but it is limited to the extracranial veins. To the contrary, no significant hemodynamic changes were recorded at the level of the intracranial venous network. Moreover, at rest TAV in the jugular veins was significantly correlated with Q of the intracranial veins. We conclude that the modulation of the atmospheric pressure operated by the thoracic pump significantly modifies the hemodynamics of the jugular veins and of the reservoir of the neck and facial veins, with no effect on the vein network of the intracranial compartment.

M-010 SEVERE PULMONARY HYPERTENSION CAUSED BY PULMONARY ARTERY STENOSIS IN BEHÇET'S DISEASE

Background Pulmonary artery stenosis that causes pulmonary hypertension is rarely observed in adults. We have experienced a case of pulmonary hypertension with right side heart failure caused by pulmonary artery stenosis, which was treated with percutaneous angioplasty in Behçet's disease. Case presentation A 47-year-old female visited hospital for aggravated dyspnea and peripheral edema. In 2000, she was diagnosed with Behçet's disease and took prednisolone 5 mg after then. When visiting hospital, the patient showed neck vein engorgement, peripheral edema and S2 increment in stethoscope examination. On the Echocardiography, severe pulmonary hypertension (right ventricular systolic pressure = 97mmHg) was observed along with the dilation of MPA(main pulmonary artery = 36 mm) and alising flow was observed at bifurcation site of both pulmonary artery. Under the computed tomography angiography, 80∼90% of high grade stenosis accompanied without atherosclerotic plaque and thrombus was observed at the proximal pulmonary artery. We performed pulmonary artery angiography, and the pulmonary artery trunk pressure was 86/5mmHg. After balloon angioplasty treatment, the pulmonary artery trunk pressure was 67/3mmHg. After then, the patient's symptom was gone. Conclusion We report our experience in severe pulmonary hypertension caused by pulmonary artery stenosis, which was treated with percutaneous pulmonary angioplasty, in adult Behçet's.

Sodium and Its Multiorgan Targets

Case Presentation: A 66-year-old retired man presented to his physician with complaints of shortness of breath and weight gain over 1 week's time during a recent cruise. He was not short of breath in the supine position, although his neck veins were distended. The blood pressure was 196/104 mm Hg; his heart rate was 92 bpm; and his cardiac rhythm was normal. He had a large habitus and was 76 in tall and 248 lb, which was 27 lb heavier than when he was evaluated 6 weeks previously in the office. The lungs revealed fine crackling rales bilaterally and posteriorly, but no wheezes or other sounds were noted. A fourth heart sound was heard at the apex. The ECG revealed left atrial abnormality and left ventricular hypertrophy with a normal sinus rate and rhythm. The echocardiogram confirmed left ventricular hypertrophy, increased left atrial size, and evidence of impaired diastolic function, and the left ventricular ejection fraction was 32%. Pulse wave velocity and aortic distensibility were impaired. There was severe 4+ bilateral edema of both lower extremities to the knees. Although the hemogram was normal, his blood urea nitrogen and creatinine concentrations were 28 and 1.2 mg/dL, respectively. The urinalysis revealed 4+ proteinuria, and a 24-hour urine collection for sodium content (at the time when his appointment was made) was >13 g. The patient had been a long-time patient of ours, with well-controlled hypertension (receiving an angiotensin II receptor blocker, a calcium antagonist, a β-adrenergic receptor blocker, furosemide, spironolactone, and a statin). He controlled his diet at home, but always was tempted by the cuisine on his frequent vacation cruises. His dietary indiscretion actually produced his 27-lb weight gain within the first 3 days of his cruise and was lost 2 days after his office visit after a temporary increase in …

Cardiac and vascular responses to thigh cuffs and respiratory maneuvers on crewmembers of the International Space Station

The transition to microgravity eliminates the hydrostatic gradients in the vascular system. The resulting fluid redistribution commonly manifests as facial edema, engorgement of the external neck veins, nasal congestion, and headache. This experiment examined the responses to modified Valsalva and Mueller maneuvers measured by cardiac and vascular ultrasound (ECHO) in a baseline steady state and under the influence of thigh occlusion cuffs available as a countermeasure device (Braslet cuffs). Nine International Space Station crewmember subjects (expeditions 16-20) were examined in 15 experiment sessions 101 ± 46 days after launch (mean ± SD; 33-185). Twenty-seven cardiac and vascular parameters were obtained with/without respiratory maneuvers before and after tightening of the Braslet cuffs (162 parameter states/session). Quality of cardiac and vascular ultrasound examinations was assured through remote monitoring and guidance by investigators from the NASA Telescience Center in Houston, TX, and the Mission Control Center in Korolyov, Moscow region, Russia. 14 of 81 conditions (27 parameters measured at baseline, Valsalva, and Mueller maneuver) were significantly different when the Braslet was applied. Seven of 27 parameters were found to respond differently to respiratory maneuvers depending on the presence or absence of thigh compression. Acute application of Braslet occlusion cuffs causes lower extremity fluid sequestration and exerts commensurate measurable effects on cardiac performance in microgravity. Ultrasound techniques to measure the hemodynamic effects of thigh cuffs in combination with respiratory maneuvers may serve as an effective tool in determining the volume status of a cardiac or hemodynamically compromised patient at the "microgravity bedside."

Role of Surgery After Chemotherapy in B-Cell Lymphoma of Thymus Causing Airway Compression and Right Ventricle Outflow Tract Obstruction

Primary B-cell lymphoma of thymus is uncommon. We describe the case of a 23-year-old woman with a history of shortness of breath and distended neck veins of 1-month duration. A chest roentgenogram and computed tomographic chest scan of the showed a large anterior mediastinal mass. Tru-cut biopsy revealed primary B-cell lymphoma of thymus. She underwent chemotherapy with no symptomatic improvement. Post-chemotherapy computed tomographic scan of the chest showed no appreciable reduction in tumor size. Surgical excision was carried out with excellent results.

An elderly man with dyspnoea and engorged neck veins

An elderly man with dyspnoea and engorged neck veins