Comparison of noninvasive imaging modalities for stenosis grading in mesenteric arteries.

OBJECTIVE: To prospectively analyze duplex sonography, CTA, and MRA with respect to stenosis grading of the celiac trunk (TC) and the superior mesenteric artery (SMA), with DSA as the reference. MATERIALS AND METHODS: 52 subjects were enrolled (mean age: 71). The image quality was graded: 1-insufficient, 2-bad, 3-moderate, 4-good or 5-excellent. Stenosis was graded: 1 (< 25 %), 2 (25 - < 50 %), 3 (50 - 75 %) or 4 (75 %). Two-sided chi-square tests were used to check for correlation of stenosis grading between modalities. The weighted Cohen's kappa was calculated to assess the strength of correlation. With a threshold of 50 % for non-relevant stenosis vs. relevant stenosis, the sensitivity, specificity, PPV, NPV, and accuracy were calculated. RESULTS: The mean image quality was 3.8 ± 0.7, 3.1 ± 1.0, 4.4 ± 0.7, and 3.8 ± 0.9 for DSA, duplex sonography, CTA, and MRA, respectively. For both TC and SMA, stenosis grading reached a significant level of correlation between each noninvasive modality with DSA (p < 0.001, each). The weighted Cohen's kappa for duplex sonography/CTA/MRA was 0.94/0.93/0.74, respectively, for the TC and 0.64/0.91/0.56, respectively, for the SMA. Highest sensitivity/specificity/NPV/PPV/accuracy were found for CTA with 100 %/95 %/85 %/100 %/96 % for the TC and with na/98 %/na/100 %/98 %, respectively, for the SMA. CONCLUSION: CTA provided the best image quality, reached the highest level of agreement and significance in correlation in stenosis grading, and offered the best diagnostic accuracy.

Outcome of immediate interventions in acute dysfunctional hemodialysis fistulas.

PURPOSE: To analyze the efficacy of interventions in acute dysfunctional hemodialysis fistulas, if intervention is performed immediately as recommended by European Best Practice Guidelines for Hemodialysis. MATERIALS AND METHODS: Over 3 years, all (n = 280) patients with an acute dysfunctional hemodialysis fistula were immediately referred to angiography, irrespective of the time of day. Angiography and, if possible, interventional revision (n = 241) were performed. Three groups of interest were established: interventionalist's experience (high/low), time of day (routine hours: 7 am-4 pm/emergency hours: 4 pm-7 am), lesion type (stenosis/fibrosclerotic occlusion/thrombotic occlusion/combined stenosis+thrombotic occlusion). For statistical analysis corresponding success rates, chi-square tests (p < 0.025) and logistic regression analysis (p < 0.05) were calculated. RESULTS: The total success rate was 62 % (149/241). The success rates were: interventionalist experience high/low 71 % (79/111)/54 % (70/130), p = 0.022; time of day routine/emergency hours 68 % (93/136)/53 % (56/105), p = 0.017; lesion type stenosis/fibrosclerotic occlusion/thrombotic occlusion/combined stenosis+occlusion 82 % (94/104)/39 % (13/33)/18 % (6/33)/59 % (36/61), p < 0.001. Relevant variables due to logistic regression analysis were high experience and the lesion types stenosis and combined stenosis+occlusion with odds ratios 2.300 (p = 0.012), 12.053 (p < 0.001), 3.189 (p = 0.003). CONCLUSION: Unrestricted implementation of immediate interventions in acute dysfunctional hemodialysis fistulas requires permanent availability of experienced interventionalists. The lesion types fibrosclerotic occlusion and thrombotic occlusion offer poor success rates for interventional revision.

Electrophysiologic neuromonitoring during repair of the thoracoabdominal aorta by anesthesiologists.

BACKGROUND: Surgical repair of the thoracoabdominal aorta is associated with risk of spinal ischemia. Electrophysiologic neuromonitoring reduces this risk, but is usually performed by neurophysiologists not always available. In this study repair of the thoracoabdominal aorta monitored by anesthesiologists has been investigated. METHODS: Somatosensory and transcranial electrical motor evoked potentials were monitored in 20 patients. A lumbar intraspinal fluid drainage was inserted. Dacron graft replacement of the aorta was performed by sequentially clamping during partial cardiopulmonary bypass. Loss or decrease of amplitudes of evoked potentials of more than 50% prompted reinsertion of spinal arteries in the graft. RESULTS: One patient not monitored with motor evoked potentials due to indwelling cardiac pacemaker had postoperative paraplegia. Somatosensory and motor evoked potentials were recordable in all other patients. Two patients died during surgery, one patient died postoperatively. No surviving patient monitored with somatosensory and motor evoked potentials had neurologic deficits. CONCLUSION: Electrophysiologic neuromonitoring during surgical repair of the descending aorta can be successfully provided by anesthesiologists and should be predominately encouraged where neurophysiologists are not available due to organizational or financial shortcomings.

Development of education emergency medical staff in Sarajevo during period 1996.-1997.

The author gives out his experiences in EMS training in Sarajevo under the leadership of Johanniter-Unfall Hilfe, Hannover, Germany and also gives his suggestions for corporation of all Emergency Wards in Bosnia and Hercegovina. During the work there was a comparison for the experiences of the organisation of EM in North and Middle America.