Multidisciplinary team management of patients with urological cancer.

Several specialist teams are involved in the management of patients with urological cancer. These specialists have been brought together as a multidisciplinary team to discuss, plan and deliver care to patients in an effective, patient-centred approach. This article discusses the benefits of this approach and ways in which multidisciplinary team working can be optimized.

Mannheim carotid intima-media thickness and plaque consensus (2004-2006-2011). An update on behalf of the advisory board of the 3rd, 4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg, Germany, 2011.

Intima-media thickness (IMT) provides a surrogate end point of cardiovascular outcomes in clinical trials evaluating the efficacy of cardiovascular risk factor modification. Carotid artery plaque further adds to the cardiovascular risk assessment. It is defined as a focal structure that encroaches into the arterial lumen of at least 0.5 mm or 50% of the surrounding IMT value or demonstrates a thickness >1.5 mm as measured from the media-adventitia interface to the intima-lumen interface. The scientific basis for use of IMT in clinical trials and practice includes ultrasound physics, technical and disease-related principles as well as best practice on the performance, interpretation and documentation of study results. Comparison of IMT results obtained from epidemiological and interventional studies around the world relies on harmonization on approaches to carotid image acquisition and analysis. This updated consensus document delineates further criteria to distinguish early atherosclerotic plaque formation from thickening of IMT. Standardized methods will foster homogenous data collection and analysis, improve the power of randomized clinical trials incorporating IMT and plaque measurements and facilitate the merging of large databases for meta-analyses. IMT results are applied to individual patients as an integrated assessment of cardiovascular risk factors. However, this document recommends against serial monitoring in individual patients.

Predictors of reduction in mitral regurgitation in patients undergoing cardiac resynchronisation treatment.

BACKGROUND: CRT causes reduction in MR due to left ventricular (LV) remodelling, but determinants of clinically meaningful MR reduction acutely after CRT have not been evaluated. OBJECTIVES: We evaluated echocardiographic predictors of significant reduction in functional mitral regurgitation (MR) by cardiac resynchronisation treatment (CRT). METHODS: 35 patients with >or= moderate to severe MR underwent CRT for presence of electrical and/or mechanical dyssynchrony. Significant reduction in MR post-CRT was defined as reduction to less than moderate MR (MR jet area/left atrial area <25%, group 1) on follow-up echocardiogram at 1.7 (SD 2.8) months post-CRT. RESULTS: Significant MR reduction of 62% (28%) from baseline MR occurred in 18 patients vs 22% (16%) in the remaining patients (group 2), p<0.01). Follow-up left ventricular ejection fraction (LVEF) was 0.43 (0.09) in group 1 patients vs 0.29% (0.1%) in group 2 patients (p<0.001). On multivariate analysis, time to peak strain in the mid inferior segment was the only significant predictor of MR reduction post-CRT (p = 0.008, OR = 1.023 (CI 1.006 to 1.041). The sensitivity and specificity of the combined variable of time to peak strain of >400 ms in the mid inferior segment and peak negative strain of >or=9% and 8% in the basal and mid posterior segments, respectively, to predict follow-up MR was 88% and 93% respectively and positive and negative predictive value was 94% and 87%. CONCLUSION: In patients with cardiomyopathy and significant MR, the presence of delayed longitudinal strain in the mid inferior LV segment along with preserved negative systolic strain in the basal and mid posterior segments predicts substantial reduction in MR post-CRT.

Novel method of biventricular pacemaker optimization by radial artery tonometer. A case report.

Echocardiographic guided pacemaker optimization leads to significant improvement in cardiac function among nonresponders to cardiac resynchronization treatment (CRT). Simpler, noninvasive determination of cardiac function during biventricular pacemaker programming may simplify this procedure. In this report we describe a 73 year old male patient who presented with recent onset NYHA class III symptoms 7 months post-CRT for ischemic cardiomyopathy. During pacemaker optimization using A-pacing at 60 bpm, optimal atrioventricular (AV) delay was found to be 290 ms by both pulsed wave (PW) echo Doppler as well as by the simultaneously measured radial artery pulse waveform analysis by tonometry. No discernable atrial mechanical activity was visible despite presence of sinus rhythm up to an AV delay of 190 ms. Further improvement in cardiac function and decrease in mechanical dyssynchrony was shown with VV optimization by tissue Doppler imaging (TDI). Our report emphasizes the need for individualized biventricular pacemaker optimization post-CRT and that concomitant assessment via radial artery pulse waveform analysis by tonometry along with PW and TDI may provide additional information during pacemaker programming to assist in pacemaker optimization.

Perioperative clinical decision-making in surgery for mitral valve repair.

Echocardiography has played a critical role in the progress in mitral valve reconstructive surgery which was revolutionized as ''the French correction'' by Alain Carpentier in the mid 1980s. Mitral regurgitation (MR) is the most challenging valvular heart disease throughout the world and is related to rheumatic etiology in the underdeveloped world and to degenerative etiology in the Western world. Echocardiography plays an integral role in the management of patients with significant MR. This includes evaluation and follow-up during the medical management phase of MR to intraoperative mitral valve repair and post operative follow-up, using a combination of transthoracic echocardiography and transesophageal echocardiography. Newer developments include evaluation by transthoracic and transesophageal three-dimensional echocardiography. This review summarizes role of echocardiography in diagnosis, therapy and follow-up of patients with clinically significant MR. Discussion will focus on mitral valve repair for degenerative MR of myxomatous etiology and functional and ischemic MR.

Ultrasound vascular screening for cardiovascular risk assessment. Why, when and how?

Carotid artery vessel wall assessment in the form of intima-media thickness (IMT) has been identified since the late 1970's as a sensitive tool to detect atherosclerosis, predict its sequelae and detect its progression and regression. Unfortunately the technique has remained confined to large multicenter clinical research trials and no consensus has been developed regarding methodology, analysis and interpretation and no agreed upon clinical protocol that could be used in clinical practice exists. The need for an accepted clinical protocol has become acute especially since the technique has been recommended by writing groups such as American Heart Association as a useful tool for risk stratification in those with unclear or intermediate risk of cardiovascular (CV) disease. The advent of automated edge detection software and a reimbursement of this technique by insurers make it compelling that clinical consensus is reached soon. Accurate data collection methodology and measurement precision are essential; as such a method that is sensitive yet not cumbersome is required for clinical utility. This review will give a short introduction to the studies that confirm value of IMT in detecting atherosclerosis and predicting its sequelae, followed by a discussion on the appropriate clinical method of imaging and reporting. Other controversial areas in methodology such as difference between plaque vs IMT in CV risk prediction will be discussed. Finally tools and skill a clinician will need to be able to do this technique will be discussed.

Thrombocytopenia due to hypotension unrelated to infection: shock marrow.

Although peripheral blood cytopenias are observed in clinical practice following hypotensive episodes unrelated to infection, there has previously been no formal description of this in the medical literature. We retrospectively reviewed all medical intensive care unit records from two hospitals over a 5-year period to identify cases in which sustained hypotension had occurred that was unrelated to infection. After initial review, 10 records were identified that met our criteria (systolic blood pressure < 90 mmHg for at least 6 h, with no evidence of sepsis or use of drugs commonly associated with suppression of haematopoiesis). All 10 of these patients were found to develop thrombocytopenia. The degree of thrombocytopenia correlated with the severity and duration of hypotension. Severe thrombocytopenia appeared to be associated with a poor outcome. Thrombocytopenia following shock unrelated to sepsis is common and is presumably related to hypoxic injury to haematopoietic progenitor cells.

Echocardiography in cardiac resynchronization therapy.

Cardiac resynchronization therapy (CRT) is a new treatment modality for eligible patients with congestive heart failure (CHF). The premise of CRT is that it decreases inter and intra ventricular inhomogeneity during systolic contraction thereby improving efficiency of cardiac pump function. Presence of cardiac dyssynchrony appears to be a prerequisite for a response to CRT. Traditionally this inhomogeneity in contraction has been determined by electrocardiographic QRS widening. More recently several echocardiographic methods of assessment of dyssynchrony have become available. These methods utilize conventional M-mode and pulsed wave (PW) Doppler as well tissue Doppler imaging (TDI) METHODS: These echocardiographic parameters have been shown to be more important predictors of response to CRT than conventional QRS widening. This article will discuss echocardiographic methods of assessment of dyssynchrony and their role in predicting response to CRT. In addition role of echocardiography in post CRT pacemaker programming will also be discussed.

Aortic root infection in a prosthetic valve demonstrated by gallium-67 citrate SPECT.

A 70-year-old man presented with 6 weeks of worsening low back pain, fever, sweating, and weight loss with known severe lumbosacral osteoarthritis. His history included CABG in 1992, porcine aortic valve replacement, and permanent pacemaker implantation in 2002. CT of the chest, abdomen, and pelvis did not demonstrate a cause for the symptoms. Blood cultures grew penicillin-sensitive enterococcus and he was referred for evaluation of possible osteodiskitis or epidural abscess. Gallium planar imaging demonstrated increased activity in the lumbar spine, suspicious for the presence of infection, and activity was noted in the mid mediastinum as well. SPECT clearly showed increased Ga-67 activity in the region of the aortic root, suspicious for infection. A perivalvular aortic root abscess was subsequently demonstrated by transesophageal echo. This case illustrates the value of Ga-67 chest SPECT in patients with prosthetic valves for detection of endocarditis.

Post-operative thrombotic thrombocytopenic purpura: a review.

Post-operative thrombotic thrombocytopenic purpura (TTP) is a recently recognised life-threatening clinical syndrome with considerable similarity to classic TTP in presentation and response to early treatment with plasma exchange. To date, 29 cases of TTP associated with surgery have been reported. The majority of cases have complicated vascular surgeries, with a few cases seen following gastrointestinal or orthopaedic procedures. Characteristically, patients develop microangiopathic haemolytic anaemia and consumptive thrombocytopenia 5 to 9 days following surgery with variable presence of fever, impaired renal function and altered mental status. The pathogenesis of post-operative TTP is speculative but may involve the release of large amounts of high-molecular-weight von Willebrand factor (vWF) multimers due to endothelial damage resulting from surgery in the setting of marginal levels of vWF-cleaving enzyme. The myriad of common post-surgical complications that may present with clinical manifestations similar to TTP may result in confusion with the potential for delay in the initiation of life-saving plasma-exchange therapy. It is important that physicians be alert to the phenomenon of post-operative TTP so that prompt recognition and treatment will prevent serious morbidity or mortality.

Myelofibrosis: response to busulfan after hydroxyurea failure.

We report a case of myelofibrosis with myeloid metaplasia (MMM) that responded dramatically to oral busulfan treatment after failure of hydroxyurea. Although busulfan treatment of this disease has fallen out of favour due to the favourable toxicity profile of hydroxyurea and reports of efficacy of interferon-alpha, our observation suggests there may still be a role for busulfan treatment of MMM in the setting of hydroxyurea or interferon failure or intolerance.

Comparison of myocardial tissue Doppler with transmitral flow Doppler in left ventricular hypertrophy.

We sought to determine the most useful echocardiographic measurements for assessment of diastolic function in patients with left ventricular hypertrophy (LVH) and normal systolic function. We compared myocardial Doppler velocities of the basal inferoposterior wall with mitral inflow pulsed wave Doppler velocities in 11 healthy volunteers (age, 36 +/- 6 years), 25 patients (age, 64 +/- 14 years) without LVH, and 37 patients (age, 67 +/- 14 years) with LVH and otherwise normal echocardiograms. The discriminatory measurements were myocardial A-wave duration (120 +/- 18 versus 98 +/- 20 and 92 +/- 12 ms, P <.0001), myocardial isovolumetric relaxation time (124 +/- 45 versus 95 +/- 48 and 78 +/- 25 ms, P =.0035), mitral A-wave velocity (0.98 +/- 0.37 versus 0.73 +/- 0.28 m/s and 0.61 +/- 0.22 m/s, P =.009), and mitral E-wave deceleration time (257 +/- 93 versus 201 +/- 85 ms and 184 +/- 83 ms, P =.015), which were significantly increased, and myocardial E-wave velocity (0.84 +/- 0.04 m/s versus 0.13 +/- 0.03 m/s and 0.14 +/- 0.03 m/s, P <.0001), which was significantly decreased, in patients with LVH compared with patients without LVH and normal volunteers, respectively. Left ventricular posterior wall thickness correlated with myocardial isovolumetric relaxation time (r = 0.52, P <.0001) and myocardial A-wave duration (r = 0.59, P <.0001), negatively with myocardial E wave (r = -0.43, P <.0001), and showed no correlation with mitral inflow parameters except mitral inflow A wave (r = 0.43, P =.002). On multivariate analysis using these variables, myocardial isovolumetric relaxation time (P =.0014) and A-wave duration (P =.001) were the only 2 variables that correlated with posterior wall thickness (multiple R = 0.71). In the presence of LVH and preserved left ventricular systolic function, myocardial relaxation time and velocities are more sensitive than mitral Doppler inflow parameters in detecting abnormal left ventricular relaxation.

Association of mitral annulus calcification, aortic valve sclerosis and aortic root calcification with abnormal myocardial perfusion single photon emission tomography in subjects age < or =65 years old.

OBJECTIVES: We examined the hypothesis that mitral annulus calcification (MAC), aortic valve sclerosis (AVS) and aortic root calcification (ARC) are associated with coronary artery disease (CAD) in subjects age < or =65 years. BACKGROUND: Mitral annulus calcification, AVS and ARC frequently coexist and are associated with coronary risk factors and CAD in the elderly. METHODS: We studied 338 subjects age < or =65 years who underwent evaluation of chest pain with myocardial perfusion single photon emission computed tomography (SPECT) and a two-dimensional transthoracic echocardiogram for other indications. The association of MAC, AVS and ARC with abnormal SPECT was evaluated by using chi-square analyses and logistic regression analyses. RESULTS: Compared with no or one calcium deposit and no or one coronary risk factor other than diabetes, multiple (> or =2) calcium (or sclerosis) deposits with diabetes or multiple (> or =2) coronary risk factors were significantly associated with abnormal SPECT in women age < or =55 years old (odds ratio [OR], 20.00), in women age >55 years old (OR, 10.00) and in men age < or =55 years old (OR, 5.55). Multivariate analyses identified multiple calcium deposits as a significant predictor for an abnormal SPECT in women (p < 0.001), younger subjects age < or =55 years (p < 0.05) and the total group of subjects (p < 0.01). CONCLUSIONS: When coronary risk factors are also taken into consideration, the presence of multiple calcium deposits in the mitral annulus, aortic valve or aortic root appears to be a marker of CAD in men < or =55 years old and women.

Myocardial Doppler tissue imaging: findings in inferior myocardial infarction and left ventricular hypertrophy--wall motion assessment.

BACKGROUND: Because of the geometry of the basal inferior wall and its relation with the posterior medial papillary muscle, differentiating abnormal from normal basal inferior wall motion can be challenging. METHODS: We performed pulsed wave Doppler echocardiography of the basal inferior wall and basal interventricular septum in 26 patients (63 +/- 14 years) with a normal echocardiogram, 33 patients (67 +/- 14 years) with inferior myocardial infarction (MI) associated with hypokinesis to dyskinesis of the basal inferior wall, and 38 patients (67 +/- 14 years) with left ventricular hypertrophy (LVH). RESULTS: Systolic velocity was significantly lower in the basal interventricular septum (0.071 +/- 0.013 m/s versus 0.084 +/- 0.023 m/s) and basal inferior wall (0.075 +/- 0.014 m/s versus 0.085 +/- 0.019 m/s) in the MI group compared with the LVH group, and both were significantly lower compared with normal values at the interventricular septum (0.090 +/- 0.023 m/s, P <.001, analysis of variance) and basal inferior wall (0.095 +/- 0.014 m/s, P <.0001, analysis of variance). The sum of the systolic (S), early diastolic (E'), and late diastolic (A') velocities of 0.30 m/s at the basal inferior wall had 91%, 76%, and 84% sensitivity, specificity, and accuracy, respectively, for the differentiation of a normal wall from an infarcted basal inferior wall, and 76%, 73%, and 75% sensitivity, specificity, and accuracy, respectively, for the differentiation of a normal wall from a hypertrophied basal inferior wall. The sum of systolic and diastolic velocities of 0.25 m/s at the basal interventricular septum had 70%, 66%, and 68% sensitivity, specificity, and accuracy, respectively, for the differentiation of an infarcted from a hypertrophied basal interventricular septum. Mitral inflow early-filling wave deceleration time by pulsed wave Doppler was the most sensitive parameter for the differentiation of LVH from MI (P <.0001). CONCLUSION: Doppler tissue imaging velocities of the basal inferior wall and basal interventricular septum may help differentiate normal from infarcted and hypertrophied myocardium.

Synergistic effects of tumor necrosis factor-alpha and thrombin in increasing endothelial permeability.

Because activation of the coagulation cascade and the generation of thrombin coexist with sepsis and the release of tumor necrosis factor (TNF)-alpha, we determined the effects of TNF-alpha on the mechanism of thrombin-induced increase in endothelial permeability. We assessed Ca(2+) signaling in human umbilical vein endothelial cells. In human umbilical vein endothelial cells exposed to TNF-alpha for 2 h, thrombin produced a rise in the intracellular Ca(2+) concentration ([Ca(2+)](i)) lasting up to 10 min. In contrast, thrombin alone produced a rise in [Ca(2+)](i) lasting for 3 min, whereas TNF-alpha alone had no effect on [Ca(2+)](i.) Thrombin-induced inositol 1,4,5-trisphosphate generation was not different between control and TNF-alpha-exposed cells. In the absence of extracellular Ca(2+), thrombin produced similar increases in [Ca(2+)](i) in both control and TNF-alpha-exposed cells. In TNF-alpha-exposed cells, the thrombin-induced Ca(2+) influx after intracellular Ca(2+) store depletion was significantly greater and prolonged compared with control cells. Increased Ca(2+) entry was associated with an approximately fourfold increase in Src activity and was sensitive to the Src kinase inhibitor PP1. After TNF-alpha exposure, thrombin caused increased tyrosine phosphorylation of junctional proteins and actin stress fiber formation as well as augmented endothelial permeability. These results suggest that TNF-alpha stimulation of endothelial cells results in amplification of the thrombin-induced Ca(2+) influx by an Src-dependent mechanism, thereby promoting loss of endothelial barrier function.

Differential atrial stunning after electrical cardioversion: an echo tissue Doppler case study.

Left atrial stunning after cardioversion is a well-known phenomenon. It has been associated with higher risk of postcardioversion thromboemboli and increased risk of recurrence of atrial fibrillation. We present a case of differential atrial stunning after electrical cardioversion for atrial fibrillation. Diagnosis was made by pulsed wave Doppler of mitral, tricuspid, and pulmonary vein inflow and mitral and tricuspid annuli. Differential mechanical atrial stunning may be a common phenomenon after cardioversion and may suggest difference in right and left atrial transport function. Its prevalence needs to be determined by a large study. Doppler tissue imaging might be routinely used in patients after cardioversion for atrial fibrillation to detect atrial stunning.

Milrinone echocardiographic viability test: a pilot study.

We assessed the utility of milrinone to predict recovery of function after surgical myocardial revascularization in patients with severe baseline left ventricular systolic dysfunction caused by coronary artery disease (CAD). Prediction of viable myocardial segments that will regain function after revascularization may help in the selection of patients who will benefit from coronary artery bypass graft surgery (CABG) as well as aid in the choice of target sites for coronary revascularization. We investigated 20 consecutive patients with CAD and left ventricular ejection fraction < or = 40% who had evidence of myocardial viability by either thallium scan or dobutamine viability test and were candidates for elective CABG. Left ventricular regional wall motion and global ejection fraction were assessed by transesophageal echocardiography in the operating room. Measurements were done before and 10 minutes after milrinone infusion, and immediately after CABG. Left ventricular wall motion score was derived by means of a 12-segment model. Functional improvement for each segment was defined as a wall motion change > 1. Baseline ejection fraction was 27% +/- 5% (mean +/- SD). Ejection fraction increased to 35% +/- 5% after milrinone infusion (P < .0001) and to 36% +/- 6% after CABG (P < .0001). Post-CABG ejection fraction was significantly correlated with postmilrinone ejection fraction (r = 0.65, P < .0001). Milrinone infusion resulted in augmentation of contraction in 98 of the 209 abnormal segments (wall motion score > or = 2); 91 (92.9%) of these improved after CABG. One hundred nine of the 111 segments that showed no improvement with milrinone did not improve after revascularization (98.2%). Seventy-three segments were akinetic or dyskinetic at baseline; 46 (63.0%) of these improved with milrinone. Improvement in regional wall motion after revascularization was detected in 84.8% of the segments that improved with milrinone versus only 3.7% of the segments that did not improve with milrinone. In patients with ischemic cardiomyopathy, improvement in left ventricular function (segmental wall motion and global ejection fraction) during milrinone infusion is highly predictive of improvement after CABG.

Requirement for Ca2+ signaling in the mechanism of thrombin-induced increase in endothelial permeability.

We compared the thrombin-activated responses in human umbilical vein endothelial cells (HUVECs) and a HUVEC-derived cell line, ECV304. Thrombin induced a 40-50% decrease in transendothelial monolayer electrical resistance and a twofold increase in 125I-albumin permeability in HUVECs, whereas it failed to alter the endothelial barrier function in ECV304 cells. Thrombin produced a brisk intracellular Ca2+ concentration transient and phosphorylation of 20-kDa myosin light chain in HUVECs but not in ECV304 cells. Thrombin-induced phosphoinositide hydrolysis was comparable in ECV304 cells and HUVECs, indicating the activation of thrombin receptors in both cell types. La3+ reduced both the thrombin-induced decrease in endothelial monolayer electrical resistance and the increase in 125I-albumin permeability in HUVECs. Because the absence of Ca2+ signaling could explain the impairment in the permeability response in ECV304 cells, we studied the effect of increasing intracellular Ca2+ concentration in ECV304 cells with thapsigargin. Exposure of ECV304 cells to thapsigargin caused decreased endothelial monolayer electrical resistance and increased 125I-albumin permeability. These results indicate that Ca2+ influx and activation of Ca2+-dependent signaling pathways are important determinants of the thrombin-induced increase in endothelial permeability.

Pacing stress echocardiography: an alternative to pharmacologic stress testing.

OBJECTIVES: We sought to evaluate the diagnostic accuracy and feasibility of bedside pacing stress echocardiography (PASE) as a potential substitute for pharmacologic stress echocardiography in patients admitted to the hospital with new-onset chest pain or worsening angina pectoris. BACKGROUND: Accurate and rapid noninvasive identification and evaluation of the extent of coronary artery disease (CAD) is essential for optimal management of these patients. METHODS: Bedside transthoracic stress echocardiography was performed in 54 consecutive patients admitted to a community hospital with new-onset chest pain, after acute myocardial infarction had been excluded. We used 10F transesophageal pacing catheters and a rapid and modified pacing protocol. The PASE results were validated in all patients by coronary angiography performed within 24 h of the test. Significant CAD was defined as > or =75% stenosis in at least one major epicardial coronary artery. RESULTS: The sensitivity of PASE for identifying patients with significant CAD was 95%, specificity was 87% and accuracy was 92%. The extent of significant CAD (single- or multivessel disease) was highly concordant with coronary angiography (kappa = 0.73, p<0.001). Pacing stress echocardiography was well tolerated, and only 4% of the patients had minor adverse events. The mean rate-pressure product at peak pacing was 22,313+/-5,357 beats/min per mm Hg, and heart rate >85% of the age-predicted target was achieved in 94% of patients. The average duration of the bedside PASE test, including image interpretation, was 38+/-6 min. CONCLUSIONS: Bedside PASE is rapid, tolerable and accurate for identification of significant CAD in patients admitted to the hospital with new-onset chest pain or worsening angina pectoris.