Ultrasound identification of nerve cords in the infraclavicular fossa: a clinical study.

BACKGROUND: This study aimed to analyze nerve trunk anatomy in the infraclavicular fossa and to correlate these data with the most common anthropometric parameters. METHODS: A Mylab 30 Gold (Esaote) and the linear transducer LA523 (7.5 MHz frequency) were used. The probe was oriented according to a parasagittal plane, parallel to the lateral chest wall and immediately medial to the coracoid process underneath the clavicle. Measurements included the distance between the artery and the cutaneous surface (mm) and the apical corner of the ultrasound image (mm), the number of identified nervous cords and their position related to the axillary artery, and the position and number of axillary veins. Sex, age, height, weight, body mass index (BMI), biceps girth, and breast size were recorded. Statistical analysis included calculation of linear Pearson correlation coefficient and Student's t test. RESULTS: Two hundred and two consecutive patients were enrolled. The position of the three cords was highly variable around the artery. In a small but significant percentage of patients (8.9%), the medial and the lateral cords were located together at the top of the artery. The visibility of the trunks and the distance between the upper part of the artery and the apical corner of the ultrasound image correlated with anthropometric characteristics. The vein position with respect to the artery and nerves was markedly variable. CONCLUSION: Sono-anatomic study of the infraclavicular region adds important data that is useful when conducting nerve blocks to improve safety and likelihood of success.

Fenoldopam to prevent renal replacement therapy after cardiac surgery. Design of the FENO-HSR study.

INTRODUCTION: Acute kidney injury requiring renal replacement therapy is a serious complication following cardiac surgery associated with poor clinical outcomes. Until now no drug showed nephroprotective effects. Fenoldopam is a dopamine-1 receptor agonist which seems to be effective in improving postoperative renal function. The aim of this paper is to describe the design of the FENO-HSR study, planned to assess the effect of a continuous infusion of fenoldopam in reducing the need for renal replacement therapy in patients with acute kidney injury after cardiac surgery. METHODS: We're performing a double blind, placebo-controlled multicentre randomized trial in over 20 Italian hospitals. Patients who develop acute renal failure defined as R of RIFLE score following cardiac surgery are randomized to receive a 96-hours continuous infusion of either fenoldopam (0.025-0.3 µg/kg/min) or placebo. RESULTS: The primary endpoint will be the rate of renal replacement therapy. Secondary endpoints will be: mortality, time on mechanical ventilation, length of intensive care unit and hospital stay, peak serum creatinine and the rate of acute renal failure (following the RIFLE score). CONCLUSIONS: This trial is planned to assess if fenoldopam could improve relevant outcomes in patients undergoing cardiac surgery who develop acute renal dysfunction. Results of this double-blind randomized trial could provide important insights to improve the management strategy of patients at high risk for postoperative acute kidney injury.

Antioxidant supplements for non-alcoholic fatty liver disease and/or steatohepatitis.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is characterised by fatty deposition in the hepatocytes of patients with minimal or no alcohol intake and without other known cause. NAFLD includes a wide spectrum of histologic abnormalities ranging from hepatic steatosis to non-alcoholic steatohepatitis (NASH), or even cirrhosis. Antioxidant supplements, therefore, could potentially protect cellular structures against oxidative stress and the resulting lipid peroxidation. OBJECTIVES: To systematically evaluate the beneficial and harmful effects of antioxidant supplements versus no intervention, placebo, or other interventions for patients with NAFLD or NASH. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (June 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2006), MEDLINE (1966 to June 2006), EMBASE (1980 to June 2006), and the Chinese Biomedical Database (1978 to June 2006). No language restrictions were applied. SELECTION CRITERIA: Randomised clinical trials evaluating any antioxidant supplements versus no intervention, placebo, or other interventions in patients with NAFLD or NASH. Our inclusion criteria for NAFLD or NASH were based on history of minimal or no alcohol intake, imaging techniques showing hepatic steatosis, and/or histological evidence of hepatic damage (including simple steatosis, fatty infiltration plus nonspecific inflammation, steatohepatitis, fibrosis, and cirrhosis), and by exclusion of other causes of hepatic steatosis. DATA COLLECTION AND ANALYSIS: We extracted data from the identified trials and contacted authors. We used a random-effects model and fixed-effect model with the significant level set at P = 0.05. We evaluated the methodological quality of the randomised trials by looking at how the generation of allocation sequence, allocation concealment, blinding, and follow-up were performed. We made our analyses following the intention-to-treat method by imputing missing data. MAIN RESULTS: We identified six trials: two were regarded of high methodological quality and four of low methodological quality. None of the trials reported any deaths. Treatment with antioxidant supplements showed a significant, though not clinically relevant, amelioration of aspartate aminotransferase levels, but not of alanine aminotransferase levels, as compared to placebo or other interventions. Gamma-glutamyl-transpeptidase was decreased, albeit not significantly, in the treatment arm. Radiological and histological data were too limited to draw any definite conclusions on the effectiveness of these agents. Adverse events were non-specific and of no major clinical relevance. AUTHORS' CONCLUSIONS: There is insufficient data to either support or refute the use of antioxidant supplements for patients with NAFLD. It may be advisable to carry out large prospective randomised clinical trials on this topic.

Bile acids for non-alcoholic fatty liver disease and/or steatohepatitis.

BACKGROUND: Non-alcoholic fatty liver disease is a condition characterised by fatty deposition in the hepatocytes of patients in patients with minimal or no alcohol intake. Some patients develop non-alcoholic steatohepatitis. Bile acids may potentially protect cellular structures and may be of benefit in patients with non-alcoholic fatty liver or steatohepatitis. OBJECTIVES: To systematically evaluate the beneficial and harmful effects of bile acids versus no intervention, placebo, or other interventions for patients with non-alcoholic fatty liver or steatohepatitis. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (July 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005), and The Chinese Biomedical Database (1978 to July 2005). No language restrictions were applied. SELECTION CRITERIA: Randomised clinical trials evaluating any bile acids versus no intervention, placebo, or other interventions in patients with NAFLD. DATA COLLECTION AND ANALYSIS: We extracted data from the identified trials as well as contacted authors. We evaluated the methodological quality of the randomised trials by assessing the generation of allocation sequence, allocation concealment, blinding, and follow-up. We made our analyses following the intention-to-treat method by imputing missing data. MAIN RESULTS: We identified four randomised clinical trials randomising 279 patients. Only one of the trials was considered a low-bias risk trial. One of the trials reported a non-liver-related death in the bile acid group. No significant differences were found regarding mortality or improvement in liver function tests observed after treatment with ursodeoxycholic acid. Data on the radiological and histological responses were too scant to draw any definite conclusions. Adverse events were non-specific and considered of no major clinical relevance. AUTHORS' CONCLUSIONS: Presently, there are insufficient data to support or refute the use of ursodeoxycholic acid for patients with non-alcoholic fatty liver or steatohepatitis. It may be advisable to carry out large randomised clinical trials on this topic.

Probiotics for non-alcoholic fatty liver disease and/or steatohepatitis.

BACKGROUND: Non-alcoholic fatty liver disease comprises a spectrum of diseases ranging from simple steatosis to non-alcoholic steatohepatitis, fibrosis, and cirrhosis. Probiotics have been proposed as a treatment option because of their modulating effect on the gut flora that could influence the gut-liver axis. OBJECTIVES: To evaluate the beneficial and harmful effects of probiotics for non-alcoholic fatty liver disease and/or steatohepatitis. SEARCH STRATEGY: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (July 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2006), MEDLINE (1966 to May 2006), and EMBASE (1980 to May 2006). No language restrictions were applied. SELECTION CRITERIA: Randomised clinical trials evaluating probiotic treatment in any dose, duration, and route of administration versus no intervention, placebo, or other interventions in patients with non-alcoholic fatty liver disease. The diagnosis was made by history of minimal or no alcohol intake, imaging techniques showing hepatic steatosis and/or histological evidence of hepatic damage, and by exclusion of other causes of hepatic steatosis. DATA COLLECTION AND ANALYSIS: We had planned to extract data in duplicate and analyse results by intention-to-treat. MAIN RESULTS: No randomised clinical trials were identified. Preliminary data from two pilot non-randomised studies suggest that probiotics may be well tolerated, may improve conventional liver function tests, and may decrease markers of lipid peroxidation. AUTHORS' CONCLUSIONS: The lack of randomised clinical trials makes it impossible to support or refute probiotics for patients with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis.