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European Journal of Medical Research Oct 2023Patients with hypotension usually receive intravenous fluids, but only 50% will respond to fluid administration. We aimed to assess the intra and interobserver agreement...
BACKGROUND
Patients with hypotension usually receive intravenous fluids, but only 50% will respond to fluid administration. We aimed to assess the intra and interobserver agreement to evaluate fluid tolerance through diverse ultrasonographic methods.
METHODS
We prospectively included critically ill patients on mechanical ventilation. One trained intensivist and two intensive care residents obtained the left ventricular outflow tract velocity-time integral (VTI) variability, inferior vena cava (IVC) distensibility index, internal jugular vein (IJV) distensibility index, and each component of the venous excess ultrasound (VExUS) system. We obtained the intraclass correlation coefficient (ICC) and Gwet's first-order agreement coefficient (AC1), as appropriate.
RESULTS
We included 32 patients. In-training observers were unable to assess the VTI-variability in two patients. The interobserver agreement was moderate to evaluate the IJV-distensibility index (AC1 0.54, CI 95% 0.29-0.80), fair to evaluate VTI-variability (AC1 0.39, CI 95% 0.12-0.66), and absent to evaluate the IVC-distensibility index (AC1 0.19, CI 95% - 0.07 to 0.44). To classify patients according to their VExUS grade, the intraobserver agreement was good, and the interobserver agreement was moderate (AC1 0.52, CI 95% 0.34-0.69).
CONCLUSIONS
Point-of-care ultrasound is frequently used to support decision-making in fluid management. However, we observed that the VTI variability and IVC-distensibility index might require further training of the ultrasound operators to be clinically useful. Our findings suggest that the IJV-distensibility index and the VExUS system have acceptable reproducibility among in-training observers.
Topics: Humans; Reproducibility of Results; Point-of-Care Systems; Ultrasonography; Critical Care; Vena Cava, Inferior
PubMed: 37828607
DOI: 10.1186/s40001-023-01397-9 -
Clinical Cancer Research : An Official... Aug 2023GDC-0927 is a novel, potent, nonsteroidal, orally bioavailable, selective estrogen receptor (ER) degrader that induces tumor regression in ER+ breast cancer xenograft...
PURPOSE
GDC-0927 is a novel, potent, nonsteroidal, orally bioavailable, selective estrogen receptor (ER) degrader that induces tumor regression in ER+ breast cancer xenograft models.
PATIENTS AND METHODS
This phase I dose-escalation multicenter study enrolled postmenopausal women with ER+/HER2- metastatic breast cancer to determine the safety, pharmacokinetics, and recommended phase II dose of GDC-0927. Pharmacodynamics was assessed with [18F]-fluoroestradiol (FES) PET scans.
RESULTS
Forty-two patients received GDC-0927 once daily. The MTD was not reached. The most common adverse events (AE) regardless of causality were nausea, constipation, diarrhea, arthralgia, fatigue, hot flush, back pain, and vomiting. There were no deaths, grade 4/5 AEs, or treatment-related serious AEs. Two patients experienced grade 2 AEs of special interest of deep vein thrombosis and jugular vein thrombosis, both considered unrelated to GDC-0927. Following dosing, approximately 1.6-fold accumulation was observed, consistent with the observed half-life and dosing frequency. There were no complete or partial responses. Pharmacodynamics was supported by >90% reduction in FES uptake and an approximately 40% reduction in ER expression, suggesting ER degradation is not the mechanistic driver of ER antagonism. Twelve patients (29%) achieved clinical benefit; 17 patients (41%) showed a confirmed best overall response of stable disease. Baseline levels of ER and progesterone receptor protein and mutant ESR1 circulating tumor DNA did not correlate with clinical benefit.
CONCLUSIONS
GDC-0927 appeared to be well tolerated with pharmacokinetics supporting once-daily dosing. There was evidence of target engagement and preliminary evidence of antitumor activity in heavily pretreated patients with advanced/metastatic ER+/HER2- breast cancer with and without ESR1 mutations.
Topics: Humans; Female; Breast Neoplasms; Receptors, Estrogen; Postmenopause; Estrogen Receptor Antagonists; Positron-Emission Tomography
PubMed: 37261814
DOI: 10.1158/1078-0432.CCR-23-0011 -
European Journal of Case Reports in... 2023Seizure as a sole sign of Stanford Type A aortic dissection (AAD) is mentioned in the medical literature. In this case, AAD was manifested by external bilateral jugular...
INTRODUCTION
Seizure as a sole sign of Stanford Type A aortic dissection (AAD) is mentioned in the medical literature. In this case, AAD was manifested by external bilateral jugular vein distention and generalized seizure.
PATIENTS AND METHODS
A 47-year-old woman presented to the Emergency Department with convulsions in the upper and lower extremities. She was diagnosed with AAD and transferred to a hospital with cardio-thoracic capabilities for surgery.
CONCLUSION
Seizure resulting from aortic dissection has been explained by general cerebral hypoperfusion. However, jugular vein distention could be secondary to increased thoracic pressure, due to compression of the pulmonary artery by the ascending aorta.
LEARNING POINTS
To our knowledge, this is the first report of generalized seizure with the presence of bilateral jugular vein dilatation as a sign of aortic dissection.Medical staff should be aware of this unusual presentation.
PubMed: 37680777
DOI: 10.12890/2023_003996 -
Brazilian Journal of Cardiovascular... Aug 2023Homografts and bovine jugular vein are the most commonly used conduits for right ventricular outflow tract reconstruction at the time of primary repair of truncus... (Review)
Review
INTRODUCTION
Homografts and bovine jugular vein are the most commonly used conduits for right ventricular outflow tract reconstruction at the time of primary repair of truncus arteriosus.
METHODS
We reviewed all truncus patients from 1990 to 2020 in two mid-volume centers. Inclusion criteria were primary repair, age under one year, and implantation of either homograft or bovine jugular vein. Kaplan-Meier analysis was used to estimate survival, freedom from reoperation on right ventricular outflow tract, and freedom from right ventricular outflow tract reoperation or catheter intervention.
RESULTS
Seventy-three patients met the inclusion criteria, homografts were implanted in 31, and bovine jugular vein in 42. There was no difference in preoperative characteristics between the two groups. There were 25/73 (34%) early postoperative deaths and no late deaths. Follow-up for survivals was 17.5 (interquartile range 13.5) years for homograft group, and 11.5 (interquartile range 8.5) years for bovine jugular vein group (P=0.002). Freedom from reoperation on right ventricular outflow tract at one, five, and 10 years in the homograft group were 100%, 83%, and 53%; and in bovine jugular vein group, it was 100%, 85%, and 50% (P=0.79). There was no difference in freedom from reoperation or catheter intervention (P=0.32).
CONCLUSION
Bovine jugular vein was equivalent to homografts up to 10 years in terms of survival and freedom from right ventricular outflow tract reoperation or catheter intervention. The choice of either valved conduit did not influence the durability of the right ventricle-pulmonary artery conduit in truncus arteriosus.
Topics: Humans; Animals; Cattle; Infant; Heart Ventricles; Truncus Arteriosus; Jugular Veins; Treatment Outcome; Retrospective Studies; Allografts; Reoperation
PubMed: 37540653
DOI: 10.21470/1678-9741-2022-0341 -
Journal of Education & Teaching in... Jul 2023Emergency medicine residents and medical students on emergency medicine rotation.
AUDIENCE
Emergency medicine residents and medical students on emergency medicine rotation.
INTRODUCTION
Acute pulmonary edema is a common and potentially fatal presentation in the emergency department. More than 1 million patients are admitted annually with a diagnosis of pulmonary edema secondary to cardiac causes.1 Pulmonary edema is broadly split into two main categories: cardiogenic and noncardiogenic. Cardiogenic pulmonary edema is characterized by acute dyspnea caused by the accumulation of fluid within the lung's interstitial and/or alveolar spaces, which is the result of acutely elevated cardiac filling pressures.2 Noncardiogenic pulmonary edema is characterized by fluid accumulation within the alveolar space in the absence of elevated pulmonary capillary wedge pressure.2 These patients often present critically ill, and rapid identification and aggressive management is paramount in caring for patients with pulmonary edema. Dyspnea is the most common presentation with a sensitivity of 89% but a low specificity of 51%.3 Workup of pulmonary edema often includes laboratory testing, electrocardiogram (EKG), chest x-ray (CXR), and often bedside ultrasound (US) and echocardiography.4 Pulmonary edema management depends on the etiology but is often focused on preload and afterload reduction. Diuretics, nitrates, and optimizing ventilatory support through non-invasive and invasive strategies are the mainstay of treatment.
EDUCATIONAL OBJECTIVES
At the end of this practice oral boards case, the learner will:1) recognize unstable vital signs (VS) and intervene to stabilize ventilation and oxygenation, 2) demonstrate the ability to obtain a complete medical history including the important characteristics of chest pain, 3) demonstrate an appropriate exam on a patient, 4) order the appropriate evaluation studies for a patient with complaints of dyspnea, 5) interpret the results of diagnostic evaluation and diagnose Non- ST elevation myocardial infarction (NSTEMI) and pulmonary edema, 6) order appropriate management of pulmonary edema and NSTEMI, and 6) demonstrate effective communication with patient and family members.
EDUCATIONAL METHODS
Practice oral boards.
RESEARCH METHODS
Immediate Feedback was solicited from the learners and observers participating in the case both by verbal discussion and completion of a rating for the case following the debriefing. The efficacy of the educational content was assessed by comparing scoring measures across residents based on the training year. Scoring measures of the American College of Graduate Medical Education (ACGME) core competencies were performed using a scale from 1 - 8, 1-4 being unacceptable performance and 5 - 8 being acceptable. Efficacy was assumed based on full completion of the case by the residents who acted as practice oral board candidates, and a debriefing session followed to discuss the key components of the case.
RESULTS
This case was presented to twelve Emergency Medicine Residents, seven PGY 1 and five PGY 2 at a relatively new residency program. The overall average score for the residents was 5.62. The PGY 1 Residents' average on the case was 5.56, and the average for the PGY 2 Residents was slightly better at 5.70. The slight improvement noted by the PGY 2 Residents is likely attributable to more clinical experience; however, both classes did not have any prior exposure to the oral board format until this simulated experience. Six residents completed all critical actions in the case. Of those who missed a critical action, failing to diagnose NSTEMI and consulting cardiology were the most common. All learners found educational value in the case with an overall rating of 4.83 (1-5 Likert scale, 5 being excellent).
DISCUSSION
Acute pulmonary edema and NSTEMI are common diagnoses that will be frequently encountered for most emergency physicians. This case highlights the need for early identification and aggressive management of the patient presenting with respiratory distress. The differential for respiratory distress is large, but most learners were able to quickly identify pulmonary edema based on the exam findings of jugular vein distention (JVD), rales, and lower extremity edema. Most learners quickly escalated to a non-rebreather mask and ultimately to BPAP (bilevel positive airway pressure) without requesting to intubate the patient. There was notable variation in the approach to administering nitrates, but most ordered an intravenous (IV) nitroglycerin (NTG) drip and requested pharmacy assistance in dosing. Diuretics were ordered by all the learners, but some were hesitant to start early because they felt the effect would be delayed. Some of the residents did not identify ischemic changes on the EKG at first glance but did request to review a second time when the troponin result was positive. All residents gave aspirin after noting the positive troponin, but not all were able to make a clear diagnosis of NSTEMI or consult cardiology. Although the case was relatively straightforward, residents enjoyed early diagnosis and aggressive management of the patient with impending respiratory failure. Many residents are asking for an ultrasound early in the workup of this patient presenting in respiratory distress. Although not a critical action in this case, it highlights the emphasis placed on ultrasonography in the current emergency medicine curriculum.
TOPICS
Pulmonary Edema, Cardiovascular emergencies, NSTEMI.
PubMed: 37575411
DOI: 10.21980/J8CW67 -
BMC Surgery Jul 2023Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. This paper...
OBJECTIVE
Extracorporeal membrane oxygenation (ECMO) has been increasingly used for severe neonatal respiratory failure refractory to conventional treatments. This paper summarizes our operation experience of neonatal ECMO via cannulation of the internal jugular vein and carotid artery.
METHODS
The clinical data of 12 neonates with severe respiratory failure who underwent ECMO via the internal jugular vein and carotid artery in our hospital from January 2021 to October 2022 were collected.
RESULTS
All neonates were successfully operated on. The size of arterial intubation was 8 F, and the size of venous intubation was 10 F. The operation time was 29 (22-40) minutes. ECMO was successfully removed in 8 neonates. Surgeons successfully reconstructed the internal jugular vein and carotid artery of these neonates. Arterial blood flow was unobstructed in 5 patients, mild stenosis was present in 2 patients, and moderate stenosis was present in 1 patient. Venous blood flow was unobstructed in 6 patients, mild stenosis was present in 1 patient, and moderate stenosis was present in 1 patient. The complications were as follows: 1 case had poor neck incision healing after ECMO removal. No complications, such as incisional bleeding, incisional infection, catheter-related blood infection, cannulation accidentally pulling away, vascular laceration, thrombosis, cerebral haemorrhage, cerebral infarction, or haemolysis, occurred in any of the patients.
CONCLUSION
Cannulation of the internal jugular vein and carotid artery can quickly establish effective ECMO access for neonates with severe respiratory failure. Careful, skilled and delicate operation was essential. In addition, during the cannulation process, we should pay special attention to the position of cannulation, firm fixation and strict aseptic operation.
Topics: Infant, Newborn; Humans; Extracorporeal Membrane Oxygenation; Constriction, Pathologic; Catheterization; Jugular Veins; Respiratory Insufficiency
PubMed: 37415109
DOI: 10.1186/s12893-023-02094-4 -
Clinical Kidney Journal Nov 2023Goals of volume management are to accurately assess intravascular and extravascular volume and predict response to volume administration, vasopressor support or volume... (Review)
Review
Goals of volume management are to accurately assess intravascular and extravascular volume and predict response to volume administration, vasopressor support or volume removal. Data are reviewed that support the following: (i) Dynamic parameters reliably guide volume administration and may improve clinical outcomes compared with static parameters, but some are invasive or only validated with mechanical ventilation without spontaneous breathing. (ii) Ultrasound visualization of inferior vena cava (IVC) diameter variations with respiration reliably assesses intravascular volume and predicts volume responsiveness. (iii) Although physiology of IVC respiratory variations differs with mechanical ventilation and spontaneous breathing, the IVC collapsibility index (CI) and distensibility index are interconvertible. (iv) Prediction of volume responsiveness by IVC CI is comparable for mechanical ventilation and spontaneous breathing patients. (v) Respiratory variations of subclavian/proximal axillary and internal jugular veins by ultrasound are alternative sites, with comparable reliability. (vi) Data support clinical applicability of IVC CI to predict hypotension with anesthesia, guide ultrafiltration goals, predict dry weight, predict intra-dialytic hypotension and assess acute decompensated heart failure. (vii) IVC ultrasound may complement ultrasound of heart and lungs, and abdominal organs for venous congestion, for assessing and managing volume overload and deresuscitation, renal failure and shock. (viii) IVC ultrasound has limitations including inadequate visualization. Ultrasound data should always be interpreted in clinical context. Additional studies are required to further assess and validate the role of bedside ultrasonography in clinical care.
PubMed: 37915939
DOI: 10.1093/ckj/sfad156 -
Cureus Dec 2023Internal jugular vein (IJV) thrombosis, also known as Lemierre syndrome (LS), is a potentially dangerous complication that follows oropharyngeal infections. It has also...
Internal jugular vein (IJV) thrombosis, also known as Lemierre syndrome (LS), is a potentially dangerous complication that follows oropharyngeal infections. It has also been documented in individuals with cervical lymph node infection, thyroid abscess, and pharyngeal abscess. LS is potentially a catastrophic complication and, if not detected and treated early, can lead to mortality. This case report describes an older woman who presented with a history of fever, odynophagia, and swelling in the anterior aspect of her neck for 20 days. Examination revealed a severely congested posterior pharyngeal wall with bilateral tonsillitis and a tender goiter. Further investigations revealed a diagnosis of LS. The patient was appropriately managed with higher antibiotics and anticoagulation. This case report highlights the importance of IJV thrombosis, which can present as a thyroid swelling.
PubMed: 38264373
DOI: 10.7759/cureus.51023 -
Folia Morphologica Oct 2023Throughout the years, anatomic studies have demonstrated numerous variations in the course of the cephalic vein (CV). There are, however, very rare cases of uncommon...
Throughout the years, anatomic studies have demonstrated numerous variations in the course of the cephalic vein (CV). There are, however, very rare cases of uncommon formation, course or termination of the vein to which our attention should be drawn. During a routine dissections conducted in the Department of Anatomy and Neurobiology, in two formalin-fixed cadavers, the very rare anatomical variants were found. In 80 year-old Caucasian female the right cephalic vein, after crossing the clavipectoral triangle, ascended anterior and superior to the clavicle and drained into the lateral branch of the right external jugular vein, which in turn opened to the right subclavian vein. In the second case, the dissection of 83 year-old Caucasian male cadaver revealed that after passing through the deltopectoral groove, the left cephalic vein run between clavicle and subclavius muscle to terminate in the left subclavian vein. Understanding of the topography, morphology and anatomical variations of the cephalic vein is important not only for the anatomists but for the clinicians and nurses as well. Such knowledge can prevent multiple complications during many invasive procedures including implantation of Cardiac Implantable Electronic Devices, central venous access, arteriovenous fistula creation or even iatrogenic injuries during clavicle or glenohumeral joint surgery.
PubMed: 37889220
DOI: 10.5603/fm.96440