Postextubation Dysphagia in Critical Patients: A First Report From the Largest Step-Down Intensive Care Unit in Greece.

PURPOSE: This study provided preliminary data on the occurrence and impact of postextubation dysphagia in the largest Greek step-down intensive care unit (ICU) over 2 years. METHOD: A retrospective observational cohort study of patients referred for swallowing assessment postextubation was conducted from November, 2011, to August, 2013. RESULTS: Of the 357 patients admitted to the unit during this period, 87, aged 55.8 ± 18.1 years (61 male, 26 female), were referred and evaluated. Of these, 2.3% were found to have no dysphagia, and 21.8% and 75.9% were diagnosed with mild and moderate/severe dysphagia, respectively. Across severity levels, 23% of patients in the unit were found to have dysphagia. Patients with moderate/severe dysphagia were more likely to have had prolonged intubation (> 48 hr; p = .02) and exhibit signs of aspiration (p = .002) than those with no or mild dysphagia. Prolonged intubation was associated with increased likelihood of moderate/severe dysphagia by a factor of 12 (p = .042, odds ratio = 12.355) compared to short intubation. Moderate/severe dysphagia was correlated with pneumonia (p = .02), feeding tube placement (p = .004) and in-hospital mortality (p = .034). CONCLUSION: In this sample, moderate/severe dysphagia was correlated with prolonged intubation, and was found to increase the risk for pneumonia and in-hospital mortality. Our results suggest the importance of early dysphagia management in critical patients in Greece and globally.

Non-coronary myocardial infarction in myasthenia gravis: Case report and review of the literature.

Cardiovascular adverse events in patients with myasthenia gravis (MG) are rare, but the early recognition of such events is crucial. We describe a case of a non-coronary myocardial infarction (MI) during the initial treatment period with pyridostigmine bromide in a female patient with MG. Clinicians should be cautious about the appearance of potential MI in patients with MG. A baseline electrocardiogram is advocated, when the early recognition of the MI clinical signs and the laboratory findings (myocardial markers) are vital to the immediate and appropriate management of this medical emergency, as well as to prevent future cardiovascular events. In this case report possible causes of myocardial adverse events in the context of MG, which may occur during the ongoing treatment and the clinical course of the disease, are discussed.

An international pilot study of asynchronous teleconsultation for oropharyngeal dysphagia.

We investigated whether an expert's consultation provided via telemedicine could improve the quality of care for patients with dysphagia. A trained clinician completed videofluoroscopic swallowing studies (VFSS) of 17 consecutive patients in a Greek hospital. The videofluoroscopic images were then stored on a website for independent review by an expert Speech and Language Pathologist in the US. An extra Rater evaluated 20% of all data for additional reliability testing. Eight diagnostic indicators of swallowing impairment and an overall subjective severity index were recorded for each study. Clinicians were also asked to choose from ten common treatment options for patients with dysphagia. There was good inter-rater agreement for most of the diagnostic indicators examined (ranging from 78% to 90%; kappa = 0.52-0.71) between all three Raters. Agreement on overall severity ratings was exact for more than half of the patients and within one-point on the 4-point scale for all other patients except one. However, the quality of care would have been substandard for more than half of the patients if teleconsultation had not been employed. In settings where a swallowing expert is not available and real-time telemedicine is not feasible, the use of asynchronous teleconsultation can produce better quality of care for patients with dysphagia.

End-of-life decisions in Greek intensive care units: a multicenter cohort study.

INTRODUCTION: Intensive care may prolong the dying process in patients who have been unresponsive to the treatment already provided. Limitation of life-sustaining therapy, by either withholding or withdrawing support, is an ethically acceptable and common worldwide practice. The purpose of the present study was to examine the frequency, types, and rationale of limiting life support in Greek intensive care units (ICUs), the clinical and demographic parameters associated with it, and the participation of relatives in decision making. METHODS: This was a prospective observational study conducted in eight Greek multidisciplinary ICUs. We studied all consecutive ICU patients who died, excluding those who stayed in the ICU less than 48 hours or were brain dead. RESULTS: Three hundred six patients composed the study population, with a mean age of 64 years and a mean APACHE II score on admission of 21. Of study patients, 41% received full support, including unsuccessful cardiopulmonary resuscitation (CPR); 48% died after withholding of CPR; 8%, after withholding of other treatment modalities besides CPR; and 3%, after withdrawal of treatment. Patients in whom therapy was limited had a longer ICU (P < 0.01) and hospital (P = 0.01) length of stay, a lower Glasgow Coma Scale score (GCS) on admission (P < 0.01), a higher APACHE II score 24 hours before death (P < 0.01), and were more likely to be admitted with a neurologic diagnosis (P < 0.01). Patients who received full support were more likely to be admitted with either a cardiovascular (P = 0.02) or trauma diagnosis (P = 0.05) and to be surgical rather than medical (P = 0.05). The main factors that influenced the physician's decision were, when providing full support, reversibility of illness and prognostic uncertainty, whereas, when limiting therapy, unresponsiveness to treatment already offered, prognosis of underlying chronic disease, and prognosis of acute disorder. Relatives' participation in decision making occurred in 20% of cases and was more frequent when a decision to provide full support was made (P < 0.01). Advance directives were rare (1%). CONCLUSIONS: Limitation of life-sustaining treatment is a common phenomenon in the Greek ICUs studied. However, in a large majority of cases, it is equivalent to the withholding of CPR alone. Withholding of other therapies besides CPR and withdrawal of support are infrequent. Medical paternalism predominates in decision making.

Electrical muscle stimulation prevents critical illness polyneuromyopathy: a randomized parallel intervention trial.

INTRODUCTION: Critical illness polyneuromyopathy (CIPNM) is a common complication of critical illness presenting with muscle weakness and is associated with increased duration of mechanical ventilation and weaning period. No preventive tool and no specific treatment have been proposed so far for CIPNM. Electrical muscle stimulation (EMS) has been shown to be beneficial in patients with severe chronic heart failure and chronic obstructive pulmonary disease. Aim of our study was to assess the efficacy of EMS in preventing CIPNM in critically ill patients. METHODS: One hundred and forty consecutive critically ill patients with an APACHE II score >or= 13 were randomly assigned after stratification to the EMS group (n = 68) (age:61 +/- 19 years) (APACHE II:18 +/- 4, SOFA:9 +/- 3) or to the control group (n = 72) (age:58 +/- 18 years) (APACHE II:18 +/- 5, SOFA:9 +/- 3). Patients of the EMS group received daily EMS sessions. CIPNM was diagnosed clinically with the medical research council (MRC) scale for muscle strength (maximum score 60, <48/60 cut off for diagnosis) by two unblinded independent investigators. Duration of weaning from mechanical ventilation and intensive care unit (ICU) stay were recorded. RESULTS: Fifty two patients could be finally evaluated with MRC; 24 in the EMS group and 28 in the control group. CIPNM was diagnosed in 3 patients in the EMS group as compared to 11 patients in the control group (OR = 0.22; CI: 0.05 to 0.92, P = 0.04). The MRC score was significantly higher in patients of the EMS group as compared to the control group [58 (33 to 60) vs. 52 (2 to 60) respectively, median (range), P = 0.04). The weaning period was statistically significantly shorter in patients of the EMS group vs. the control group [1 (0 to 10) days vs. 3 (0 to 44) days, respectively, median (range), P = 0.003]. CONCLUSIONS: This study suggests that daily EMS sessions prevent the development of CIPNM in critically ill patients and also result in shorter duration of weaning. Further studies should evaluate which patients benefit more from EMS and explore the EMS characteristics most appropriate for preventing CIPNM. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT00882830.

Short-term systemic effect of electrical muscle stimulation in critically ill patients.

BACKGROUND: Our study assessed the short-term effect of electrical muscle stimulation (EMS) of the lower extremities on the thenar muscle microcirculation of patients who are critically ill. METHODS: Twenty-nine hospital ICU patients (19 men; mean [+/- SD] age, 58 +/- 19 years; mean acute physiology and chronic health evaluation score, 17 +/- 5; mean sequential organ failure assessment score, 9 +/- 3) underwent a 45-min session of EMS of the lower extremities. BP and heart rate were measured, and blood samples were retrieved. Tissue oxygen saturation (Sto(2)) was assessed with near infrared spectroscopy at the thenar muscle with a vascular occlusion before and after EMS. A control group of six patients who were critically ill (4 men; mean age, 50 +/- 19 years) also were included in the study. RESULTS: The mean Sto(2) did not differ significantly before and after the EMS session (81 +/- 16% vs 83 +/- 16%, respectively). The oxygen consumption rate during vascular occlusion differed significantly before the beginning and at the end of the session (20 +/- 9%/min vs 22 +/- 9%/min, respectively; p < 0.05). The reperfusion rate differed significantly before the beginning and at the end of the session (299 +/- 177%/min vs 375 +/- 182%/min, respectively; p < 0.05). Heart rate increased significantly at the end of the session (94 +/- 16 beats/min vs 99 +/- 16 beats/min, respectively; p < 0.05) as did systolic BP (127 +/- 21 mm Hg vs 133 +/- 23 mm Hg; p < 0.05, respectively). The Sto(2) value did not differ between the two measurements in control patients. CONCLUSION: The data suggest that EMS has a systemic effect on microcirculation. These results suggest that further studies are needed to explore the potential use of EMS as a preventive and rehabilitation tool in critically ill patients.

Application of Kohonen network for automatic point correspondence in 2D medical images.

In this paper, a generalized application of Kohonen Network for automatic point correspondence of unimodal medical images is presented. Given a pair of two-dimensional medical images of the same anatomical region and a set of interest points in one of the images, the algorithm detects effectively the set of corresponding points in the second image, by exploiting the properties of the Kohonen self organizing maps (SOMs) and embedding them in a stochastic optimization framework. The correspondences are established by determining the parameters of local transformations that map the interest points of the first image to their corresponding points in the second image. The parameters of each transformation are computed in an iterative way, using a modification of the competitive learning, as implemented by SOMs. The proposed algorithm was tested on medical imaging data from three different modalities (CT, MR and red-free retinal images) subject to known and unknown transformations. The quantitative results in all cases exhibited sub-pixel accuracy. The algorithm also proved to work efficiently in the case of noise corrupted data. Finally, in comparison to a previously published algorithm that was also based on SOMs, as well as two widely used techniques for detection of point correspondences (template matching and iterative closest point), the proposed algorithm exhibits an improved performance in terms of accuracy and robustness.

An iterative point correspondence algorithm for automatic image registration: an application to dental subtraction radiography.

In this paper, an Automatic Iterative Point Correspondence (AIPC) algorithm towards image registration is presented. Given an image pair, distinctive points are extracted only in one of the images (reference image), and the corresponding points in the other image are obtained automatically by maximizing a similarity measure between regions of the two images with respect to the parameters of a local transformation. The maximization is accomplished by means of an iterative procedure, in which candidate solutions for the transformation parameters are tested at each iteration; these solutions are evaluated by the similarity measure between image regions. The detected point pairs by the application of the AIPC algorithm are then used to estimate the parameters of a global projective transformation for the registration of the image pair. The proposed AIPC algorithm was applied on 113 in vitro and in vivo dental image pairs providing improved registration accuracy against three widely used registration methods.