ultrasound guided technique of central venous catheterization versus anatomical landmark guided technique in medical intensive care patients

Background: Central venous catheterization [CVC] is an important procedure in the practice of emergency medicine. Insertion of CVC is amongst the most frequently performed invasive procedures in ICU. In severely ill and long-stay patients, inserted CVCs enable relatively safe and painless application of parenteral nutrition, long-term antibiotics, chemotherapy, intravenous fluids, and blood components and are also used for repetitive blood sampling. Furthermore, CVCs are used for invasive hemodynamic monitoring, hemodialysis, plasmapheresis and in case of shortage of a peripheral access. With the increasing availability of bedside ultrasound, emergency physicians have begun to incorporate this new technology to reduce error and improve patient care

Objective: To compare the outcome of an ultrasound guided technique versus an anatomical landmark guided technique for central venous catheterization

Patients and methods: The present study was performed on one hundred patients of both sexes; the study was conducted at El-Hussein University Hospital. They were scheduled for insertion of central venous line for various purposes. The patients were assigned into two groups each group formed of fifty patients [n=50]. Group [A]: Anatomical guided technique for insertion of CVC, Group [B]: Ultrasound guided technique for insertion of CVC. Patients with local infection, known vascular abnormalities, untreated coagulopathy [INR more than 1.5, platelets less than 50000/mm3 ] and age less than 16 years old were excluded from the study

Results: A total of 100 patients were included. The outcome of each group was recorded regarding success rate, number of attempts and access time in seconds. The use of ultrasound guided central venous catheterization has better outcome and higher-safety in comparison to anatomical landmark-based technique. Ultrasound guidance elevated significantly the success rate of central venous catheterization than anatomical landmark-based technique. In addition, the access time was reduced in a significant trend by using ultrasound guidance. In the same manner the average number of attempts needed for accessing the vein was limited significantly when Ultrasound guidance was applied. The incidence of hematoma formation, arterial puncture and malposition was reduced in a significant trend by using ultrasound guidance in comparison to landmark-based techniques. When comparing ultrasound guidance to anatomical landmark-based guidance we found that all mechanical complications were significantly lower when central venous catheterization was carried out by means of ultrasound guidance

Conclusion: Ultrasound examination of the region of interest offers some additional information compared to clinical examination as Position of the vessel, Patency of the vessel, Size of the vessel and Stenosis or hematoma. The implementation of ultrasound guidance improves success and reduces complication rate during central venous catheterization

Diaphragmatic excursion assessment by ultrasound versus volume associated weaning parameters as a prediction in extubation in critically Ill patients

Background: Liberating a patient from ventilator is a continuous process as with any disease condition which starts with recognition of patient being ready to be weaned from ventilator by letting the patient breathe on T-piece and, if successful proceeding to SBT followed by extubation, if it is tolerated well [simple weaning]. Otherwise letting patient on ventilator till next such trial being successful. Difficulty in weaning from mechanical ventilation is one of the most frequently encountered problems in MICU. An estimated 20% of mechanically ventilated patients face failed extuabtion [requiring reintubation within 48 h of extuabtion]

Aim of the study: This study was designed to assess the value of the excursion of diaphragm tested by ultrasonography to predict weaning from mechanical ventilation versus volume associated weaning parameters in medical intensive unit's patients

Patients and Methods: A prospective study was carried out on 30 patients ready for weaning. All patients were divided into two equal groups.Group A [successful weaning group] and Group B [failed weaning group]

Results: Of the entire group of 30 patients, 21 patients [70%] had succeeded extubation and 9 patients [30%] failed. By applying cut-off level 1cm determined in our study the sensitivity and specificity of mean liver and spleen displacement were 95.2% and 88.9% respectively, which is higher than Pi max [85.7% and 77.8%] by cut-off level

Conclusions: The present study concluded that ultrasonographic measurement of liver and spleen displacement during SBT before extubation is a good method for predicting extubation outcome

Role of Fas [CD95] in T lymphocytes Apoptosis in malnourished children

Apoptosis is programmed cell death. Lymphocyte apoptosis was described in peripheral blood and lymphatic organs in malnutrition. Little has been done to explore Fas [CD95] function in apoptosis of lymphocyte populations in malnourished children. To address this issue, we studied the apoptosis in T lymphocytes in different types of malnutrition. We also aimed to assess the role of Fas in this apoptosis in relation to clinical and laboratory parameters in the studied patients. Sixty three malnourished infants and children were compared to 27 healthy controls. Beside thorough history and clinical examination, laboratory investigation and evaluation of flow cytometry assessment of T lymphocytes was done to all cases and controls. The viability of T lymphocytes was determined by anti CD3 combined with anti CD95 and fluorescence dye 7-amino actinomycin D [7AAD]. There was a decrease in the percentage and absolute lymphocyte count [CD3[+]], with increased apoptosis in these cells compared with the controls. There was up-regulation of Fas expression in CD3[+] cells. Furthermore CD3[+]/CD95[+] cells were highly less viable, more apoptotic than CD3[+]/CD95[-] in the patients with malnutrition and than CD3[+]/CD95[+] cells in donors. The differences were highly significant. All the clinical and laboratory parameters of the studied patients showed no significant correlation with any of the apoptotic indices. We concluded that the increased apoptosis of T lymphocytes in malnourished children may be the cause of the decreased lymphocyte count in peripheral blood in these cases. This intern may be related to the decreased cell mediated immunity and the more common occurrence of infection in such cases. Furthermore the up-regulation of Fas may be the molecular basis for apoptosis in T lymphocytes in these malnourished children

Plasma/urine glucose ratio (P/U-GR) as a tool for monitoring hyperglycaemia in diabetic patients

The present study was undertaken to evaluate the validity of glucosuria measurements by double voided technique to monitor plasma glucose level, and use of plasma/urine glucose ratio [P/U-GR] changes as a sign of development of diabetic nephropathy. The study was conducted at AI-Azher University Hospitals between March to November 2002 on 200 diabetic patients [72 type 1 and 128 type 2] who had inadequate glucose control. It has been found that urine glucose levels was correlated significantly with blood sugar levels in uncontrolled diabetic patients. Sensitivity, specificity and negative prediction value were 96.5%, 89.5% and 79% respectively. Glucosuria was significantly higher in diabetic hypertensive patients than diabetic alone and in diabetic hypertensive patients treated by ACE inhibitors than those treated by other lines of antihypertensives. On other hand, glucosuria was significantly lower in patients with proteinuria than the rest of patients and in macroalbuminuria than those with microalbuminuria. P/U-GR which was found to be fixed and individualized for each patient, correlated with age, duration of disease, hypertension, serum creatinine, creatinine clearance, HbA1c and proteinuria but not correlated with blood urea and type of diabetes. P/U-GR was significantly lower in diabetic patients with hypertension than those without hypertension and in patients treated by ACE inhibitors than those treated by other lines of antihypertensive agents. On the other hand, P/U-GR was significantly higher in diabetic patients with proteinuria than the rest of diabetic patients and in diabetic patients with macroalbuminuria than those with microalbumrnuna. Our results recommend that the use of urine testing by double voided technique is reliable and accurate method in more than 79% of diabetic patients and could be used as a guide for detection of plasma glucose level in non emergency conditions

Insulin and glutamic acid decarboxylase antibodies in chronic hepatitis [C] patients with diabetes mellitus

Diabetes mellitus is associated more with HCV chronic liver disease than in the general population and in the other types of chronic liver disease. The increased incidence of diabetes in HCV patients might be related to an autoimmune process produced by the virus or the virus itself has a cytopathic effect on the pancreatic beta clells. The aim of this work was to study the plasma basal insulin level and the seropositivity against glutamic acid decarboxylase [GADA] - an islet cell cytoplasmic antigen. Patients: the study was carried out on 45 patients categorized into 3 equal groups. Group I included 15 diabetic patient with HCV chronic liver disease, Group II included 15 diabetic patients with chronic liver disease which is not related to HCV, Group III included 15 non diabetic patients with HCV chronic liver disease. All patients were selected to be matched regarding age, sex and sevirity of liver disease. The results showed that basal insulin level [22.4 +/- 23.1 micro IU/ml in group I, 21.6 +/- 23.8 micro IU/ml in group II, and 8.8 +/- 6.4 micro IU/ml in group III] were significantly higher in the diabetic patients [GI and GII] compared to the non diabetic [GIII] [P<0.01]. The insulin resistance index as calculated by HOMA equation [9.6 +/- 7.9 in group I, 9.2 +/- 10.3 in group II and 2.4 +/- 1.2 in group III], were also significantly higher in the diabetic groups [p < 0.01]. Seropositivity for [GADA] was 9/15 [60%] of patients of groups I and III and 3/15 [20%] of patients of group II. We concluded that diabetes mellitus associated with HCV chronic liver disease in characterized hyperinsulinaemia and increased insulin resistance. There may be a role of autoimmunity in the pathogenesis of diabetes in HCV chronic liver disease. Follow up of the non diabetic HCV patients with positive GADA for development of diabetes is recommended

Retinopathies following psychological stress

This study was conducted on 36 patients with different forms of retinopathies that following psychological stressors. A comprehensive ophthalmological and psychiatric evaluation was done for all patients. It was found that a very disturbing psychological event had preceded the onset of retinopathies in 88% of the cases. The psychological disturbance preceded the first visual symptoms by an average of ten days. The pathophysiology was nonspecific, but a stress-induced etiology was highly suggestive. Also, it was noticed that the personality traits increased the severity of the individual's daily tensions, emotional distress and psychological arousal. The results showed that patients needed psychological stability to regain mind- body harmony, beside the routine management of these diseases

role of ultrasonography to discriminate between schistosomiasis and virus-related chronic liver disease

The aim of our study was to assess the role of ultrasonography in patients with chronic liver diseases in discriminating between schistosomiasis and viral hepatitis infections in Egypt, an area where these infections are endemic. We assessed 114 patients with chronic liver disease, clinically, ultrasonographically, biochemically, virologically, parasitologically and by liver biopsy. According to histological diagnosis; 7.9% of patients had portal fibrosis, 43% chronic hepatitis, 47.4% cirrhosis and 1.8% hepatic malignancies. Patients with cirrhosis 44 [49.4%] of them had pure HCV infection. The longitudinal diameter of the spleen was significantly higher in patients with cirrhosis- virus related liver disease than those with pure schistosomiasis, while no significant differences were found in the degree of periportal thickening between the two groups. This study shows that ultrasonography alone can not be used as a screening procedure to discriminate between schistosomiasis and viral hepatitis infections in areas where these infections are highly associated, such as in Egypt