Longitudinal Assessment of Left Ventricular Function in Patients with Myopericarditis After mRNA COVID-19 Vaccination.

BACKGROUND: Multiple reports have described myopericarditis following mRNA COVID-19 vaccination. However, data on the persistence of subclinical myocardial injury assessed by left ventricular (LV) longitudinal strain (LVLS) is limited. OBJECTIVES: Our aim was to assess LV function longitudinally in our cohort of COVID-19 vaccine-related myopericarditis using ejection fraction (EF), fractional shortening (FS), LVLS, and diastolic parameters. METHODS: Retrospective, single-center review of demographic, laboratory, and management data was performed on 20 patients meeting diagnostic criteria for myopericarditis after mRNA COVID-19 vaccination. Echocardiographic images were obtained on initial presentation (time 0), at a median of 12 days (7.5, 18.5; time 1), and at a median of 44 days (29.5, 83.5; time 2). FS was calculated by M-mode, EF by 5/6 area-length methods, LVLS by utilization of TOMTEC software, and diastolic function by tissue Doppler. All parameters were compared across pairs of these time points using Wilcoxon signed-rank test. RESULTS: Our cohort consisted predominantly of adolescent males (85%) with mild presentation of myopericarditis. The median EF was 61.6% (54.6, 68.0), 63.8% (60.7, 68.3), 61.4% (60.1, 64.6) at times 0, 1, and 2, respectively. Upon initial presentation, 47% of our cohort had LVLS < -18%. The median LVLS was -18.6% (-16.9, -21.0) at time 0, -21.2% at time 1 (-19.4, -23.5) (p = 0.004) and -20.8% (-18.7, -21.7) at time 2 (p = 0.004, as compared to time 0). CONCLUSIONS: Though many of our patients had abnormal strain during acute illness, LVLS improved longitudinally, indicating myocardial recovery. LVLS can be used as marker of subclinical myocardial injury and risk stratification in this population.

Nanostructured materials for water desalination.

Desalination of seawater and brackish water is becoming an increasingly important means to address the scarcity of fresh water resources in the world. Decreasing the energy requirements and infrastructure costs of existing desalination technologies remains a challenge. By enabling the manipulation of matter and control of transport at nanometer length scales, the emergence of nanotechnology offers new opportunities to advance water desalination technologies. This review focuses on nanostructured materials that are directly involved in the separation of water from salt as opposed to mitigating issues such as fouling. We discuss separation mechanisms and novel transport phenomena in materials including zeolites, carbon nanotubes, and graphene with potential applications to reverse osmosis, capacitive deionization, and multi-stage flash, among others. Such nanostructured materials can potentially enable the development of next-generation desalination systems with increased efficiency and capacity.

[Flying fitness of patients with cardiovascular diseases]. / Flugfähigkeit bei kardialen Erkrankungen.

Air travel of persons with coronary heart disease, heart failure and cyanotic congenital heart disease will be without complications and problems in the most cases. Prerequisite for an uneventful flight are stable cardiac conditions and an extensive cardiac examination including echocardiography and exercise testing before starting the journey. Careful travel planning and timing to reduce travel stress is mandatory. To determine fitness for air travel left heart catheterization is required in most patients with acute coronary syndrome. Patients with an acute coronary syndrome may repatriated with medical escort within the first 2 weeks after the acute event. Patients with a low risk profile can fly with reasonable safety 14 to 21 days after the acute event without medical escort. Fitness to travel may be given within a few days after successful percutaneous coronary intervention in individual cases. Patients with severe acute cardiovascular diseases and an appropriate medical indication may be transferred by air ambulance after acute local medical care and pretransfer stabilisation with ambulance jet under intensive care conditions. In these cases close cooperation between the doctor in charge, cardiologist and cardiologic department respectively and air ambulance is mandatory.

Outcome in patients with intracerebral hemorrhage: predictors of survival.

BACKGROUND AND PURPOSE: The aim of this retrospective study was to determine in-hospital mortality and morbidity secondary to intracerebral hemorrhage and to analyse variables considered to be significantly associated with survival in these patients. PATIENTS AND METHODS: The study cohort consisted of 135 consecutive patients with intracerebral hemorrhage, admitted to a large community hospital in the urban area of Vienna. The diagnosis of intracerebral hemorrhage was established in all cases with axial computed tomography. The following variables were analysed: age, sex, Glasgow coma score on admission, location of hematomas, intraventricular hemorrhage, neurosurgical interventions and medical complications. RESULTS: Sixty-seven (49.6%) of the 135 patients died, 50 (37%) of them during the first 4 days after the acute event, 13 within the 1st week and 4 within one month. In a multivariate analysis the risk of death was significantly increased by the presence of intraventricular hemorrhage (p < 0.01), a Glasgow coma score of 6 or less (p < 0.0001) and age greater than 60 years (p < 0.001). Gender, medical complications and surgical removal of hemorrhage with or without additional ventriculostomy did not correlate significantly with outcome while an infratentorial location of hematoma showed a trend (p < 0.15) towards a higher mortality. CONCLUSION: A Glasgow coma score of 6 or less on admission, age greater than 60 years and the presence of intraventricular hemorrhage appear to be predictors of mortality in patients with intracerebral hemorrhage.

Fulminant septic melioidosis after a vacation in Thailand.

Severe infection with Burkholderia pseudomallei (formerly Pseudomonas pseudomallei), the bacterium causing melioidosis, is a common cause of acquired septicaemia in south-east Asia and northern Australia. A few cases of infected travellers returning to European countries have been reported. Melioidosis is a tropical disease, the clinical presentation ranging from asymptomatic infection to fulminant sepsis. Predisposing conditions such as impaired cellular immunity, preexisting renal failure or diabetes mellitus seem to enhance the severity of the disease. For a definite diagnosis the bacterium has to be isolated. The antimicrobial treatment of choice is ceftazidime in combination with co-trimoxazole or doxycycline. Even with correct antibiotic treatment the mortality rate is high in cases of fulminant sepsis. We report a 29-year old man with Type I diabetes who acquired melioidosis during a vacation in Thailand. After returning to Austria he was admitted to the intensive care unit with multiple organ failure. Despite intensive care treatment the patient's infection proved lethal. Burkholderia pseudomallei was isolated from the blood and bronchoalveolar lavage.

Coil embolization of coronary supply to a cardiac metastasis.

Coil embolization of tumor-related coronary arteries was successful in interrupting coronary supply to a cardiac metastasis from uterine leiomyosarcoma. In patients with cardiac metastases of highly malignant tumors this may be a palliative therapeutic approach.

Transcranial Doppler for early identification of potential organ transplant donors.

BACKGROUND: Encouraging results in transplant medicine create a growing demand for organ transplant donors. Transcranial Doppler (TCD) has been used by several investigators to assess arrest of the cerebral circulation in brain dead patients. We report on TCD as a monitoring tool for early identification of potential organ transplant donors. DESIGN: A prospective clinical study. SETTING: Intensive care unit (ICU) of a 900-bed community hospital (primary and tertiary care center) in Vienna, Austria. SUBJECTS AND METHODS: All patients with acute intracranial lesions admitted to our intensive care unit underwent TCD examination at least once daily. In patients with Glasgow Coma Scores < 7, TCD waveforms with high resistance profiles unchanged by therapeutic attempts to lower intracranial pressure indicated the need for repeated TCD up to four times a day. TCD waveform abnormality consisting of absent or reversed diastolic flow or small early systolic spikes in at least two intracranial arteries was considered to constitute intracranial circulatory arrest. Brain death was confirmed by clinical criteria, an isoelectric electroencephalography (EEG) or non filling of the intracerebral arteries on arteriography. RESULTS: From January 1994 to July 1996 we identified 11 comatose patients as potential organ transplant donors with typical TCD findings indicating intracranial circulatory arrest. Diagnosis was subarachnoid hemorrhage in 7 and intracerebral hemorrhage in 4 patients. Brain death diagnosis according to the criteria of Austrian law was initiated immediately after the TCD findings suggested intracranial circulatory arrest. Confirmation of brain death was obtained by clinical criteria and either EEG (6 patients) or cerebral angiography (5 patients). CONCLUSION: TCD examinations on a daily routine basis offer a noninvasive monitoring method for early assessment of intracranial circulatory arrest. TCD enables quick identification and further diagnosis of candidates for organ transplant donation.

L-selectin expression affects T-cell circulation following isoproterenol infusion in humans.

beta-Adrenergic receptor agonists have been shown to affect leukocyte migration. This study examined the expression of cellular adhesion molecules on lymphocyte, monocyte, and granulocyte distribution following an infusion of isoproterenol (20 and 40 ng/kg/min for 15 min each) in 12 healthy subjects. Leukocyte populations and adhesion molecule expression were determined via flow cytometry. Isoproterenol led to an expected lymphocytosis and leukocytosis. L-selectin expression varied across leukocytes and influenced cell trafficking in response to isoproterenol. Approximately 60% of CD8+ T-cells expressed L-selectin (CD8+CD62L+) and these cells showed no appreciable response to isoproterenol. In contrast, CD8+CD62L- cells showed a robust increase in number and distribution of approximately 100% over baseline (p's < .001). Across CD4+ T-helpers, L-selectin was expressed on approximately 86% of cells. CD4+CD62L+ cells decreased in number and distribution (p's < .001) with isoproterenol, while CD4+CD62L- cells showed a modest increase (p's < or = .05). In contrast to lymphocytes, nearly all monocytes and granulocytes expressed L-selectin; these cells increased and decreased respectively in response to isoproterenol (p's < or = .05). CD11a (the beta 2-integrin LFA-1) was expressed on > 95% of all leukocytes and these data were thus similar to the overall leukocytosis data. CD54 (ICAM-1) was expressed on approximately 60% of mixed lymphocytes and was unchanged in response to isoproterenol. The findings indicate that L-selectin expression influences T-cell trafficking in response to beta-adrenergic stimulation and help further illuminate catecholamine-mediated sympathetic and immune interactions.

Sex-related differences in acetazolamide-induced cerebral vasomotor reactivity.

BACKGROUND AND PURPOSE: Cerebral vasomotor reactivity can easily be assessed reliably by measuring vasodilatory response to acetazolamide by transcranial Doppler sonography. The aim of this study was to confirm the hypothesis that female sex is associated with an increased cerebrovascular flow reserve. METHODS: Blood flow velocity of the middle cerebral artery was measured by transcranial Doppler sonography in 36 healthy sex- and age-matched subjects. After the initial blood flow velocities were recorded, the subjects received 14.3 mg/kg body wt acetazolamide, ie, 1 g/70 kg, intravenously. The measurements were repeatedly performed at 5-minute intervals starting 10 minutes after injection and lasting for 30 minutes. The highest measured flow velocities were used for further analysis. RESULTS: In both groups mean blood flow velocity increased significantly after acetazolamide (women, from 60.2 +/- 12.5 to 89.9 +/- 14.4 cm/s, P < .006; men, from 54.5 +/- 18.8 to 75.7 +/- 24.5 cm/s, P < .02). The difference in mean blood flow velocity after acetazolamide between groups of women and men was statistically significant (P < .02). CONCLUSIONS: Female subjects show an increased vasodilatory response to the acetazolamide test compared with men.

False diagnosis of myocardial infarction due to an extreme left sided cardiac rotation in two patients.

We present two patients with an extremely rare condition: abnormal cardiac levoposition. Alterations in the ECG caused by this congenital abnormality and additional chest symptoms led to the false diagnosis of previous myocardial infarction. Chest X-ray and echocardiography suggested cardiac malformation. Correct diagnosis of cardiac levoposition was established by magnetic resonance imaging.

[Syringomyelia as a rare cause of respiratory insufficiency requiring ventilation]. / Syringomyelie als seltene Ursache einer beatmungspflichtigen respiratorischen Insuffizienz.

For 17 years a now 45-year-old man had suffered from progressively more severe flaccid paresis of the arms and thoracic muscles, spastic paralysis of the legs and kyphoscoliosis. Artificial ventilation was required when he contracted pneumonia. Although it was being treated with antibiotics, frequent bronchoalveolar lavage had to be done because of repeated atelectases. After 6 weeks clonuses developed in the legs, predominantly on the right, stretch synergisms and opisthotonos. The pupils were small with sluggish reaction to light, and there was a positive "doll's head" phenomenon. The level of consciousness alternated between somnolence and sleepiness. Magnetic resonance imaging demonstrated cavities in cervical and thoracic spinal cord, supporting the diagnosis of an abnormal cerebrospinal circulation due to gliosis in syringomyelia. To secure cerebrospinal fluid drainage, the cerebellar tonsils were resected, together with a duraplasty and partial resection of the atlas. Following this he became fully conscious and the spastic state improved. During the following 8 weeks it became possible gradually to wean him from the artificial ventilation and achieve satisfactory mobilization so that he could be discharged to domiciliary care.

Treatment of exudative fibrinous pericarditis with intrapericardial urokinase.

Three male patients with purulent pericarditis, in whom complete drainage could not be obtained by pericardiocentesis, were treated with transcatheter intrapericardial urokinase to prevent the development of chronic constrictive pericarditis. As shown by echocardiography, the intrapericardial fibrin layers disappeared in two cases and were reduced by more than half in the third. Effects on systemic coagulation indices and complications related to intrapericardial lysis were not observed.

Bedside percutaneous dilational tracheostomy with endoscopic guidance: experience with 71 ICU patients.

OBJECTIVE: To assess the value of endoscopic guidance in bedside percutaneous dilational tracheostomy. DESIGN: The medical critical care unit of a large community hospital. SETTING: 71 consecutive adult patients who required prolonged mechanical ventilation. INTERVENTIONS: 72 elective percutaneous dilational tracheostomies using the Ciaglia technique were performed under view of a flexible fiberoptic bronchoscope. MEASUREMENTS AND RESULTS: Patients were examined during tracheostomy and on days 2 and 7 after the procedure, at discharge and after half a year if they were still alive. A correct median puncture was observed by endoscopic control in 59 interventions. An initial paramedian puncture was detected in 13/72 (18%) procedures and was corrected by renewed insertion in all cases. No severe complications related to percutaneous dilational tracheostomy were noticed. Minor complications occurred in 4/71 (5.6%) patients including minor bleeding in 2, inflammatory infiltration in 1 and one superficial lesion of the posterior tracheal mucosa. Long-term follow-up revealed stomal granulation in 3 patients including one at the tracheal site. At the end of the observation period the tracheostomy still was in use in 14/71 (20%) patients and 12/71 (17%) patients were decannulated. Due to their severe underlying diseases 45/71 (63%) patients had died. To facilitate weaning from the tracheostomy a minitracheostomy tube was used in 3 patients. CONCLUSION: Percutaneous dilational tracheostomy is a simple bedside procedure associated with a low complication rate. We recommend the use of endoscopic guidance to increase the safety of tracheal puncture and dilation procedure.

Embolic stroke by compression maneuver during transcranial Doppler sonography.

BACKGROUND AND PURPOSE: Embolic complications during ultrasound examinations are a rare cause of neurological deficits. The present case documents the occurrence of embolism by a nonobstructive compression maneuver during transcranial Doppler examination, resulting in a minor stroke. CASE DESCRIPTION: A 63-year-old man suffered from recurrent transient ischemic attacks. Duplex sonography showed a small echogenic plaque at the right carotid bifurcation. During transcranial Doppler studies with a reverberating compression maneuver of the right common carotid artery low in the neck, multiple emboli signals were detected, and the patient developed a left-sided hemiparesis with slurred speech. Funduscopy revealed cholesterol emboli in the inferior temporal arteriole of the right eye. These findings suggested embolization as the cause of the stroke. CONCLUSIONS: Compression maneuvers should not be performed in patients with recent neurological symptoms, even in the case of only small lesions in the extracranial carotid territory.

[Complications of routine intensive care interventions]. / Komplikationen intensivmedizinischer Routineinterventionen.

The frequent use of invasive procedures for diagnosis, monitoring, and treatment in intensive care units engenders often underestimated dangers due to human error or complications which are to some extent inherent. A brief survey is given of adverse events in connection with central venous catheters, Swan-Ganz catheters, arterial lines, endotracheal intubation, gastric tubes, and cardiopulmonary resuscitation. Strategies to reduce the risks are outlined. Documentation of adverse events and near misses, along with an analysis of their causes constitute indispensable elements of quality control in intensive care medicine. Policies to avoid adverse events, as well as guidelines to recognize and treat them promptly should be regularly scrutinized.

Initial experience with intravascular ultrasound imaging during carotid endarterectomy.

BACKGROUND AND PURPOSE: To assess the feasibility of intravascular ultrasound imaging during carotid endarterectomy. METHODS: Intravascular ultrasound imaging was performed during carotid endarterectomy in eight patients using an over-the-wire catheter system with a 30-MHz ultrasound probe. In vitro studies were carried out before the intraoperative application, paying special attention to visualization of the wall layers of normal carotid arteries, structures of more or less diseased vessels, and surgically placed materials such as patch, suture material, and fibrin glue. Although intravascular ultrasound failed to distinguish between intima and media in areas of normal intima, fibrotic and calcified plaques were detected clearly. Dacron patch as well as sutures were identified as highly reflective structures. RESULTS: In seven of the eight patients studied, intravascular ultrasound yielded cross-sectional images of good quality allowing identification of the vessel layers and the structures at the endarterectomy site. In all patients the three layers of the vessel wall were clearly differentiated and the transition zone between the site of endarterectomy and the genuine vessel appeared smooth without intimal flaps or residual arteriosclerotic plaques. In one patient severe eccentric thickening of the media was detected in the distal internal carotid artery. Neither damage of the vessel layers by the shunt nor thrombus formation in the operating area and the internal carotid artery were detected. CONCLUSIONS: Intravascular ultrasound lends itself as a potentially valuable method of quality control during carotid endarterectomy. The method seems to enable an accurate evaluation of the endarterectomy site and the search for residual plaques.

The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism.

OBJECTIVE: To determine the prevalence of venous thrombosis in patients with suspected paradoxical embolism. DESIGN: Observational study. PATIENTS: Two hundred sixty-four patients with clinically suspected embolic events underwent contrast transesophageal echocardiographic evaluation. Forty-nine patients (24 women, 25 men) had a patent foramen ovale. Forty-one patients had acute stroke, and 8 had acute limb ischemia. SETTING: Echocardiography laboratory of a community hospital. MEASUREMENTS: The presence of a patent foramen ovale was assessed by transesophageal contrast echocardiography. Forty-two patients had venographic evaluation of the lower-extremity venous system. RESULTS: Venous thrombosis was clinically suspected in 6 patients and documented in 24 of the 42 patients with patent foramen ovale who underwent venographic study (57%; 95% Cl, 41% to 72%). Venous thrombosis was confined to calf or popliteal veins in 15 cases. Fifteen of 17 patients who had venographic evaluation within 7 days of the index event had thrombosis compared with 9 of 25 patients who had later evaluations (P = 0.001). More patients with venous thrombosis than without venous thrombosis had a history of previous thromboembolism (13 of 24 compared with 1 of 18 [corrected], respectively; P = 0.001). CONCLUSION: When a patent foramen ovale is detected in a patient with embolism, occult leg vein thrombosis is frequently present.