The application experience of focused ultrasound heart examination in patients with COVID-19 in Prone-position.

Aim of the study. To study the experience of using focused transthoracic echocardiography in patients with COVID-19 in prone position (fEchoPr) in intensive care units (ICU). Materials and methods. The retrospective observational study included 53 patients (period from 15 April to 31 December 2020). Inclusion criteria: confirmed diagnosis of COVID-19, availability of fEchoPr data, outcome certainty (discharge/death). We analyzed electronic medical records. The fEchoPr was performed in patients in the prone position with a bolster under the left side of the chest and left arm raised ('swimmer's position'). We assessed the systolic function of the right ventricle (RV) (tricuspid annular plane systolic excursion (TAPSE)), RV size, RV/LV ratio, systolic function of the left ventricle (LV) (left ventricular outflow tract velocity time integral. (LVOT VTI)), and pulmonary hypertension (PH) (tricuspid regurgitation peak gradient (PGTR). Depending on the results, the patients were divided into 2 groups: informative (+fEchoPr) and non-informative (-fEchoPr) examinations. Results. There was no statistically significant difference in the groups (+fEcho n = 35 vs -fEcho n = 18) by age (65.6 +/- 15.3 vs 60.2 +/- 15.8, p > 0.05), by gender (male: 23 (65.7%) vs 14 (77.8%), p > 0.05), by body mass index (31.3 +/- 5.3 kg/m2 vs 29.5 +/- 5.4 kg/m2, p > 0.05), by mechanical ventilation support (24 (68.6%) vs 17 (94.4%), p = 0.074), by NEWS scale indicators (6.9 +/- 3.7 vs 8.5 +/- 3.5 points), by mortality (82.8% vs 94.4%, p > 0.05). Correlation analysis revealed a moderate inverse relationship between being on mechanical ventilation and the informative value of the study (Spearman's r = -0.30 at p = 0.033). In the +fEchoPr group, the correct measurement of TAPSE and RV/LV was carried out in 100%: a decrease in RV systolic function was recorded in 5 patients (14%), expansion of the RV in 13 patients (37%). Signs of PH were detected in 11 patients (31%), PGTR could not be measured in 10 patients (28%). LV systolic dysfunction was detected in 7 patients (20%). No pathology was detected in 16 patients (46%). One patient was diagnosed with infective endocarditis of native mitral valve, which was later confirmed by autopsy. Conclusion. In 66% of cases, fEchoPr examinations were informative, especially in terms of assessing the state of the right heart. fEchoPr examination is an affordable, valid and reproducible method to assess and monitor the state of the heart in ICU patients.Copyright © 2021 VIDAR Publishing House. All Rights Reserved.

Adverse events and complications after magnetic resonance-guided focused ultrasound (MRgFUS) therapy in uterine fibroids - a systematic review and future perspectives.

OBJECTIVES: The aim of this review was to analyze and summarize the most common adverse events (AEs) and complications after magnetic resonance-guided focused ultrasound (MRgFUS) therapy in uterine fibroids (UFs) and to establish the risk factors of their occurrence. METHODS: We searched for original research studies evaluating MRgFUS therapy in UFs with outcomes containing AEs and/or complications in different databases (PubMed/MEDLINE, SCOPUS, COCHRANE) until March 2022. Reviews, editorials, opinions or letters, case studies, conference papers and abstracts were excluded from the analysis. The systematic literature search identified 446 articles, 43 of which were analyzed. RESULTS: According to available evidence, the overall incidence of serious complications in MRgFUS therapy is relatively low. No AEs/complications were reported in 11 out of 43 analyzed studies. The mean occurrence of all AEs in the analyzed material was 24.67%. The most commonly described AEs included pain, skin burns, urinary tract infections and sciatic neuropraxia. Major AEs, such as skin ulcerations or deep vein thrombosis, occurred in 0.41% of cases in the analyzed material. CONCLUSION: MRgFUS seems to be safe in UF therapy. The occurrence of AEs, especially major ones, is relatively low in comparison with other methods. The new devices and more experience of their users seem to reduce AE rate. The lack of unification in AE reporting and missing data are the main issues in this area. More prospective, randomized studies with unified reporting and long follow-up are needed to determine the safety in a long-term perspective.

Recurrent intussusception with ileal perforation as a complication of Blue Rubber Bleb Nevus Syndrome in a pediatric patient

Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital condition, characterized by multiple venous malformations that may involve any organ system, most commonly the skin or the gastrointestinal tract. These lesions are often responsible for chronic blood loss and secondary anemia, and in rare situations may cause severe complications such as intussusception, volvulus, and intestinal infarction. Intussusception as a complication of BRBNS, although a known complication of the disease, has rarely been reported, especially in the Philippines. In the Philippine Society for Orphan Disorders, only 2 cases of BRBNS are currently included in the organization, including the patient presented in the case report. The treatment of BRBNS that involves the gastrointestinal tract depends on the extent of intestinal involvement and severity of the disease. The treatment aims to preserve the GI tract as much as possible due to the high recurrence in the disease. In this case report, we present a 13 year-old male with BRBNS with previous history of intussusception, successfully managed conservatively;however, upon recurrence, underwent exploratory laparotomy wherein a subcentimeter perforation in the antimesenteric border of the proximal ileum was noted, together with a gangrenous intussuscipiens, and multiple mulberry-like formations on the antimesenteric border of the small bowels. Histopathological findings of the resected bowels showed multiple cavernous hemangiomas consistent with BRBNS. The postoperative course of the patient was unremarkable.Copyright © 2023 The Authors

Awareness of Cosmetic Procedures among Adults Seeking to Enhance Their Physical Appearance: A Cross-Sectional Pilot Study in Central Jordan

The increase in urban society in the use of cosmetic practices to rejuvenate oneself or obtain a more appealing appearance has influenced the practices of cosmetic dermatologists, general medical practitioners, plastic surgeons, and dental practitioners, among others. The pharmaceutical industry has evolved to meet customers' desire to be more physically attractive irrespectively of age and gender. This study aimed to preliminarily explore Jordanian adults' awareness of dental, facial, and other cosmetic procedures. The reasons for undergoing such cosmetic procedures and self-reported knowledge of the side effects or risks associated with these interventions were also explored. The results show that the participants had undergone various procedures to enhance their looks, attractiveness, and confidence. None of the female participants wanted to emulate a celebrity. Most participants were aware of the side effects associated with cosmetic procedures, which may be attributed to their educational backgrounds, as the participants' minimum qualification was 12th grade and their easy access to information services such as electronic media. A multicenter, large-scale, regional study is required to determine the associations, correlations, and recommendations for individuals seeking cosmetic treatment, cosmetic health providers, and policymakers.

The utility of lung ultrasound in COVID-19: A systematic scoping review.

Introduction: Lung ultrasound (LUS) has an established evidence base and has proven useful in previous viral epidemics. An understanding of the utility of LUS in COVID-19 is crucial to determine its most suitable role based on local circumstances. Method: Online databases, specialist websites and social media platforms were searched to identify studies that explore the utility of LUS in COVID-19. Case reports and recommendations were excluded. Findings: In total, 33 studies were identified which represent a rapidly expanding evidence base for LUS in COVID-19. The quality of the included studies was relatively low; however, LUS certainly appears to be a highly sensitive and fairly specific test for COVID-19 in all ages and in pregnancy. Discussion: There may be LUS findings and patterns that are relatively specific to COVID-19; however, specificity may also be influenced by factors such as disease severity, pre-existing lung disease, operator experience, disease prevalence and the reference standard. Conclusion: LUS is almost certainly more sensitive than chest radiograph for COVID-19 and has several advantages over computed tomography and real-time polymerase chain reaction. High-quality research is needed into various aspects of LUS including: diagnostic accuracy in undifferentiated patients; triage and prognostication; monitoring progression and guiding interventions; the persistence of residual LUS findings; inter-observer agreement and the role of contrast-enhanced LUS.

Focused Ultrasound in Critical Care Outreach for acutely ill and deteriorating patients on the wards

Introduction: Focused Ultrasound in Intensive Care (FUSIC) refers to the use of ultrasound by a trained bedside clinician to guide patient management in real-time. Ultrasound is widely applied in practice and there is growing consensus that it is an essential tool for managing acutely ill patients in the intensive care unit (ICU). The Critical Care Outreach Team uses FUSIC as an additional assessment tool to guide management and decision-making plan for deteriorating patients on the wards. Objectives: To investigate whether how often information gained fromFUSICimaging had an impact on patient care and management decisions in a critical care outreach setting. Methods: A single-centre observational study at an academic tertiary referral institution. We included all patients reviewed by critical care outreach who were assessed by ultrasound during a 12-month period. Routine procedures for teaching purposes were not included. Results: Forty-six patients were assessed and supported by a combined focused lung and heart ultrasound performed at the patient bedside on the wards. In 46 patients FUSIC was instrumental in the differential diagnostic workup and in guiding the clinical management. In 32 (70%) patients FUSIC aided fluid therapy or diuresis (in case of pulmonary oedema) and helped targeting fluid balance. In three patients though to have consolidation on chest x-ray we were able to identify significant pleural effusions without needing an additional CT scan. In four patients with hypotension, an additional CT-PA was warranted due to dilated right ventricle (RV) with abnormal septal motion and decreased left ventricle (LV) size ratio (i.e. sign of right heart strain) as highly suspicious of pulmonary embolus. In two young patients with Coronavirus disease 2019 (COVID-19), using FUSIC we identified severe LV dysfunction which was subsequentially diagnosed as myocarditis and Angiotensin-converting enzyme (ACE) inhibitors therapy was commenced within 24 hours. Further diagnosis included cardiac tamponade (n = 2) requiring pericardiocentesis and pneumothorax (n =1). In all cases, the use of ultrasound helped in promptly referring patients to the specialist team (i.e. respiratory or cardiology) and to the ICU consultant. Conclusions: In our critical care outreach practice, FUSIC is considered an indispensable tool for safe and accurate management of acutely ill and deteriorating patients on the wards.

Nurse-led PoCUS in the Management of the Critically Ill COVID-19 Patient

Introduction: Point-of-Care Ultrasound (PoCUS) can rapidly diagnose presence and severity of COVID-19 disease and associated pathologies.1 PoCUS identifies life-threatening complications at the bedside, with the potential to reduce the need for out-of-department transfers for imaging, alongside associated radiation exposure and spread of infection.2 Use of PoCUS by doctors in the intensive care unit (ICU) is becoming increasingly widespread. However, uptake by ICU nurses is poor despite evidence to suggest comparable accuracy in acquiring and reporting PoCUS scans, and the potential benefit to patients as a result of an increased workforce of competent PoCUS clinicians.3-5 Objective: To report findings in critically ill COVID-19 patients identified through nurse-led cardiac and 6-point lung PoCUS. Method: This case series was part of the national service evaluation led by the Intensive Care Society, SAM, FUSIC, and FAMUS. Conduct was approved by the departmental lead for critical care ultrasound. An ICU nurse trained in Focused Intensive Care Echocardiography (FICE) and Focused Ultrasound in Intensive Care (FUSIC) performed cardiac and 6-point lung PoCUS scans on ICU patients with confirmed COVID-19 disease during the recovery phase. Severity of disease was scored between 0-3 (Table 1) in each lung region (upper anterior;mid-anterior;posterolateral) and a total score calculated (0-18). PoCUS scans were only performed on patients identified by the treating ICU consultant. Correlations between PoCUS findings and patient demographics, key clinical data, physiological parameters, and 30-day outcome were analysed using Pearson's coefficient. Descriptive statistics analysis (mean;standard deviation/ mode;interquartile range) were used to describe data. Results: A cardiac and 6-point lung PoCUS scan was performed on 15 patients. Fourteen (93%) scans were performed to answer lung-specific clinical questions including assessment of ventilation strategy (ventilation mode;PEEP level) in 5 (33%) patients, extravascular lung water assessment in 9 (60%), and lung assessment prior to tracheostomy decannulation in 1 (7%). Moderate to severe COVID-19 was apparent in all lung fields with severity scores from 6 to 14 (Figure 1). Left ventricular (LV) function was normal in 13 (87%) patients, 2 (13%) demonstrated signs of a dilated right ventricle (RV), and 1 (6%) had impaired LV and RV function (Figure 2). Ten scans identified pathologies that contributed to a change in clinical management immediately following the scan (Figure 3). Interventions included: (1) change in fluid management (increased fluid removal on renal filtration, new furosemide prescription) 4 (27%) patients) and a level 2 echo assessment due to identification of new cardiac pathologies (3 (20%) patients). Five patients had no change in care. We identified a moderate positive correlation between lung severity score and APACHE II (Pearson's coefficient: 0.69;p value <0.01). Weak correlation was found between lung severity score and white cell count, SOFA score, and PaO2/ FiO2. There was no difference in 30-day outcome in patients with a higher lung severity score or abnormal cardiac scan. Conclusion: Cardiac and lung PoCUS is a vital tool in the assessment of COVID-19 disease. The addition of ICU nurses to the growing workforce of PoCUS competent clinicians increases availability of real-time imaging.

First use of MRI-guided focused ultrasound to treat patients with essential tremor in Russia

Introduction. Treatment with MRI-guided focused ultrasound (MRgFUS) is a new, non-invasive surgical technique for treating extrapyramidal movement disorders. This article presents the first use of MRgFUS in Russia for treating patients with essential tremor (ET). Materials and methods. Patients (n = 26;17 men and 9 women) aged 21-82 years (median age 46.0 years) and with severe and refractory ET, underwent MRg- FUS thalamotomy (ExAblate 4000, Insightec). One side was treated in 22 patients (left thalamus in 18 and right thalamus in 6), both sides were treated concurrently in two patients, and both sides were treated consecutively in two patients. Tremor was assessed using the Clinical Rating Scale for Tremor (CRST). Because international clinical specialists could not visit Russia due to the COVID-19 pandemic, MRgFUS was performed via telehealth on May 5, 2020, in a world first. Results. A satisfactory result was achieved in 25 (96%) out of 26 patients. CRST scores improved by 64.7% on the side of the operation, by 10.2% on the control side, and by 37.5% overall. Intraoperative side effects included headache during sonication (42.3%), vertigo (15.4%), nausea (11.5%), vomiting (7.7%), numbness (3.8%), ataxia (3.8%), and pathological response to cold exposure (3.8%). The symptoms resolved immediately after surgery. Unstable gait was noted in five patients, which completely resolved two weeks after surgery. Median postoperative follow-up duration was 109 days [53;231], with a maximum of 625 days. No relapses (if the hyperkinesia had completely disappeared) or increased tremor (if reduced after surgery) were observed. Conclusion. The efficacy of MRgFUS for ET was 96%, with no long-term complications. Both bilateral concurrent and bilateral consecutive MRgFUS thalamotomy is possible, but its efficacy and safety should be assessed in a randomized study. In a world first, MRgFUS was successfully implemented using telehealth. © 2022, Annals of Clinical and Experimental Neurology.

Ultrasound combined with glial cell line-derived neurotrophic factor-loaded microbubbles for the targeted treatment of drug addiction.

Drug addiction is a serious problem globally, recently exacerbated by the COVID-19 pandemic. Glial cell-derived neurotrophic factor (GDNF) is considered a potentially effective strategy for the treatment of addiction. Previous animal experiments have proven that GDNF has a good therapeutic effect on drug addiction, but its clinical application is limited due to its poor blood-brain barrier (BBB) permeability. Low-frequency focused ultrasound, combined with microbubbles, is a non-invasive and reversible technique for locally-targeted BBB opening. In the present study, magnetic resonance imaging-guided low-frequency focused ultrasound, combined with GDNF microbubbles, was used to target BBB opening in the ventral tegmental area (VTA) region. The effects of GDNF on morphine-induced conditioned place preference (CPP) and acute withdrawal symptoms in rats after a partially opened BBB were evaluated by behavioral observation. Western blot was used to detect changes in tyrosine hydroxylase (TH) expression levels in the VTA region after different treatments, and high performance liquid chromatography was used to detect the changes in monoamine neurotransmitter content. The results showed that ultrasound combined with GDNF microbubbles targeted and opened the BBB in the VTA region, and significantly increased GDNF content, destroyed morphine-induced CPP, and reduced the withdrawal symptoms of morphine addiction in rats. Furthermore, the up-regulation of TH expression and the increase of norepinephrine and dopamine content induced by morphine were significantly reversed, and the increase of 5-hydroxytryptamine content was partially reversed. Therefore, ultrasound combined with GDNF microbubbles to target and open the BBB can effectively increase the content of central GDNF, thus playing a therapeutic role in morphine addiction. Our study provides a new approach to locally open the BBB and target delivery of neurotrophic factors, such as GDNF, to treat brain diseases like addiction.

One-year results of treatment of incompetent truncal veins and incompetent perforators using high intensity focused ultrasound (HIFU)

Introduction, Objectives, and/or Purpose: Incompetent truncal and perforating veins of the legs contribute to a variety of conditions collectively called chronic venous insufficiency (CVI). Symptoms and signs of CVI adversely affect patient's quality-of-life. These can range from tired and heavy legs, through varicose veins, swollen ankles, fasciocutaneous damage all the way to leg ulceration. International guidelines recommend the treatment of venous reflux using endovenous thermal ablation as a first-line, and foam sclerotherapy as a second-line treatment. Both of these ablate the incompetent vein. There has been a push towards less invasive techniques, but most of these still involve endovenous cannulation. High-Intensity Focused Ultrasound (HIFU) is a completely non-invasive ablative technique. The HIFU technique uses to ultrasound systems within one machine. The first, a greyscale ultrasound with a colour flow capability, is used to identify the target vein and to target the focused ultrasound. The second is a conical focused ultrasound beam, that focuses on a point approximately 5 mm high by 3.6 mm circumference. In this focus area, temperatures can rise to 70-90°C. This is sufficient to ablate biological tissue. Objectives: (1) To assess the success of using HIFU for the treatment of incompetent truncal veins (GSV, SSV, AASV). (2) To assess the success of using HIFU for the treatment of incompetent perforator veins. (3) To determine the success of adjuvant foam sclerotherapy with of after HIFU, as a treatment protocol. Methods: A retrospective audit of 55 patients treated with HIFU using the Sonovein device (Theraclion, Paris, France) between May 2019 and September 2020 was performed. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at the planned time intervals (1-2 weeks, 6- 8 weeks, 6 months, 1-year post-treatment). DUS outcome of the treated vein was graded: 1. complete success (complete atrophy of the target vein) 2. partial success (≥ 1 patent section;none giving rise to recurrent varicose veins / subclinical reflux not requiring treatment) 3. partial failure (≥ 1 patent section giving rise to significant recurrent varicose veins) 4. complete failure. Initially, we performed HIFU of incompetent veins and then completed the procedure with ultrasound-guided foam sclerotherapy. Later, the foamsclerotherapy was delayed and only used if required.We analysed the success rate of HIFU alone in those patients who had only HIFU treatment. In those who had additional foam sclerotherapy, we analysed the success rate of HIFU and foam sclerotherapy starting from the date of the foam sclerotherapy, regardless of whether it was performed on the same day as HIFU or subsequently. Results: Fifty patients (female:male 39:11) returned for at least one follow-up scan giving a 90.9% response rate for at least 1 scan. Due to the COVID-19 pandemic, and consequent travel restrictions and lockdowns, not all patients could return for follow-up DUS at planned time intervals (1-2 weeks, 6-8 weeks, 6 months, 1-year post-treatment). There were 78 legs treated, and 41 truncal veins and 146 incompetent perforator veins. Truncal veins: Twenty-nine patients (41 truncal veins in 35 legs) had at least one follow-up scan. Ten patients (15 truncal veins) had concurrent foam sclerotherapy, and nineteen patients (26 truncal veins) did not. Of these nineteen patients, seven patients (10 truncal veins) received foam sclerotherapy within one year of having HIFU treatment. Twelve patients (16 truncal veins) did not receive foam sclerotherapy at all. Those patients having HIFU only showed an 83.3% (15 out of 18) closure at 6- 8 weeks (Figure 1). The results for HIFU and foam sclerotherapy are shown in Figure 2. Despite difficulties in getting patients back for scans, closure rates of 83.3% and 100% were found between 9 and 12 months and over 12 months, respectively. Perforator veins: Forty-three patients (146 perforator veins in 68 legs) attended at least once. Suc essful ablation was seen in 88% at 6 months and 70% at one year in those not having foam sclerotherapy, and 83.3% and 100% in those having HIFU and foam sclerotherapy. Conclusions: High Intensity Focused Ultrasound (HIFU) is a new technique that can treat incompetent truncal and incompetent perforator veins extracorporeally. We have reported the one-year results of patients having either HIFU alone, or HIFU combined with ultrasound guided foam sclerotherapy. Allowances need to be made for the sporadic follow-up due to the COVID-19 pandemic, and also the fact that we changed our protocols of treatment as we got more experienced. Hence, even although we are reporting what is in effect the learning curve for this technique, the outcomes are not dissimilar from the early outcomes from endovenous thermal ablation. Increased speed of treatment with a corresponding reduction in the need of any local anaesthetic is being introduced, and further audits will be performed in the future to ensure the success rates are maintained or improved.