Clinician-performed ultrasound in hemodynamic and cardiac assessment: a synopsis of current indications and limitations.

Accurate hemodynamic and intravascular volume status assessment is essential in the diagnostic and therapeutic management of critically ill patients. Over the last two decades, a number of technological advances were translated into a variety of minimally invasive or non-invasive hemodynamic monitoring modalities. Despite the promise of less invasive technologies, the quality, reliability, reproducibility, and generalizability of resultant hemodynamic and intravascular volume status data have been lacking. Since its formal introduction, ultrasound technology has provided the medical community with a more standardized, higher quality, broadly applicable, and reproducible method of accomplishing the above-mentioned objectives. With the advent of portable, hand-carried devices, the importance of sonography in hemodynamic and volume status assessment became clear. From basic venous collapsibility and global cardiac assessment to more complex tasks such as the assessment of cardiac flow and tissue Doppler signals, the number of real-life indications for sonology continues to increase. This review will provide an outline of the essential ultrasound applications in hemodynamic and volume status assessment, focusing on evidence-based uses and indications.

Increasing the acceptance of internet-based mental health interventions in primary care patients with depressive symptoms. A randomized controlled trial.

BACKGROUND: Internet-based interventions (IBI) are effective in treating depression. However, uptake rates in routine care are still limited. Hence, this study aimed to (1) assess the acceptance of IBIs in primary care patients with depressive symptoms and to (2) examine the effects of a brief acceptance facilitating intervention in the form of an informational video on patients' acceptance of IBIs. METHODS: Primary care patients (N=128) with Minor or Major Depression were randomly assigned to an intervention (IG) or control group (CG). Patients in the IG were shown a brief informational video about IBIs before receiving a questionnaire that assessed their acceptance of IBIs and other secondary outcomes. Patients of the CG filled out the questionnaire immediately. RESULTS: Baseline acceptance of IBIs in the CG was high for 6.3%, moderate for 53.1% and low for 40.6% of patients. Acceptance of IBIs was significantly higher in the IG when compared to the CG (d=.71, 95%-CI:.09-2.91). Except for social influence and the general attitude towards psychological treatment, all secondary outcomes were also significantly improved (e.g. effort- (d=.40) and performance-expectancy: d=.65; knowledge about Internet interventions d=.35). LIMITATIONS: Depression of the participants was only assessed using a self-report measure (PHQ-9). CONCLUSION: Primary care patients' acceptance of IBIs for depressive symptoms was low but could be increased significantly using a brief acceptance facilitating intervention on the basis of an informational video. Future studies should further examine the potential of acceptance facilitating interventions for patients and health care providers to exploit the public health impact of IBIs.

Midazolam premedication improves tolerance of transesophageal echocardiography.

Patient premedication for transesophageal echocardiography (TEE) is still under debate, especially the use of sedatives. We performed a double-blind, placebo-controlled study to clarify the efficacy of low-dose intravenous midazolam as premedication for TEE. Placebo or midazolam (< or =50 kg, 2.0 mg intravenously; 50 to 80 kg, 2.5 mg; and > or =80 kg, 3.0 mg intravenously) was given in addition to topical anesthesia to 200 consecutive in- and outpatients. Blood pressure, heart rate, and oxygen saturation were monitored. Patients were interviewed immediately, and 2 to 10 days after TEE. Sixteen patients received an additional dose of midazolam, and in 12 follow-up was incomplete. Patients taking midazolam reported less gag reflex at probe introduction and during TEE, as did the examiners (p < 0.05 to 0.0001). Probe manipulations were found to produce less discomfort after midazolam administration (p < 0.005). Midazolam patients experienced less dyspnea (p < 0.01) despite a minimal decrease in oxygen saturation of 2% (p < 0.0001). The following day patients taking midazolam reported less sore throats, and painful swallowing was less frequent (p < 0.01 to 0.001). Systolic blood pressure decreased slightly in the midazolam group (132 +/- 24 to 121 +/- 20 mm Hg, p < 0.0001). The rate of minor complications showed no difference. Thus, TEE probe introduction and manipulation was tolerated better after low-dose midazolam premedication, and patients experienced less pharyngeal discomfort the day after. Midazolam was well tolerated and the complication rate did not increase. Thus low-dose, short-acting benzodiazepine premedication improves patient comfort during and after TEE and generous use can be recommended.

Expression, purification, and biochemical characterization of a recombinant lectin of Sarcocystis muris (Apicomplexa) cyst merozoites.

The mature major microneme protein of Sarcocystis muris cyst merozoites, which is known as a dimeric lectin with high affinity to galactose and some of its derivatives, was expressed in Escherichia colias a histidine-tagged fusion protein. The recombinant polypeptide, which was recognized by a monoclonal antibody directed against the native lectin, was purified from inclusion bodies after solubilization and refolding, using a combination of metal chelate and lactose affinity chromatography. The apparent molecular mass of the refolded polypeptide as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoreses was 16 kDa, whereas gel filtration chromatography clearly demonstrated that the recombinant protein, like its native counterpart, exists as a homodimer of two non-covalently associated subunits. Inhibition of haemagglutination suggests that the combining site of the recombinant lectin recognizes N-acetyl-galactosamine as the dominant sugar, thus confirming the correct folding of the monosaccharide combining site in the renatured lectin. To the best of our knowledge, this work represents the first reported detailed characterization of a recombinant lectin from apicomplexan parasites, and may contribute to a better understanding of the process of host cell recognition and invasion by these obligate intracellular protozoa.

A consensus on the normal characteristics of corpus cavernosum EMG.

Corpus cavernosum EMG (CC-EMG) has raised much controversy since its introduction. The first workshop on CC-EMG has resulted in acceptance of a standardized technique of recording. Using this technique 110 normal potent volunteers have been examined in different centres. One year later there is an agreement among participants that an analogous recording of CC-EMG during flaccidity in normal subject results in reproducible findings. CC-EMG is characterized by highly reproducible waveforms (potentials) within the individual subject and mostly of comparable shape interindividually. Maximum peak to peak amplitude lies between 75 and > 500 microV and potentials have a mean duration of 12 s.

[Progressive infantile spinal muscular atrophy. Report of 12 cases]. / Atrofia muscular espinhal infantil progressiva. Relato de 12 casos.

Twelve children with progressive spinal muscular atrophy were seen at Santo Antonio Children Hospital, Porto Alegre. Diagnosis was based on neurological evaluation, serum enzymes, electroneuromyography and muscle biopsy. Several aspects are discussed by the authors, especially those concerning the presentation mode of the illness and the laboratory investigation. Our results are reviewed under the light of the current literature.

Altered vascular reactivity in sickle hemoglobinopathy. A possible protective factor from hypertension.

Patients with sickle cell anemia have considerably less hypertension than the black population in general. Factor(s) offering "protection" from hypertension in these patients remain unknown. Hormonal and hemodynamic parameters involved in blood pressure regulation were evaluated in normotensive, stable sickle cell patients and black nonsickle normotensive controls. There was no difference in systolic, diastolic, or mean arterial blood pressure between the two groups. The characteristic hemodynamic findings of increased cardiac index, renal plasma flow, and plasma volume were observed in the sickle cell patients. Urinary sodium excretion was comparable on an ad libitum, high sodium, and low sodium diet. In contrast, plasma renin activity was greater in sickle cell patients at all levels of sodium intake in both supine and upright positions. These findings suggested possible altered vascular responsiveness to endogenous angiotensin II. Plethysmography revealed that sickle cell patients had greater forearm blood flow than normal controls and black nonsickle chronic anemic controls at rest, during cold stimulation, and during exercise. Forearm vascular resistance was significantly lower in the patients and did not increase with cold-induced, sympathetic-mediated stimulation. To assess these findings more directly, the pressor response to the exogenous administration of graded doses of angiotensin II and norepinephrine was measured. There was a marked decrease in the pressor response to angiotensin II but not to norepinephrine in the sickle cell patients. The findings in these studies indicate fundamental differences in blood pressure control in the sickle cell patient, probably at the vascular level.

[Pharmacokinetics of triamcinolone following oral administration]. / Pharmakokinetik von Triamcinolon nach oraler Verabreichung.

Plasma levels of triamcinolone were measured by RIA (radioimmunoassay) on 10 patients following oral application of 16 mg triamcinolone (Delphicort), the pharmacokinetic parameters were calculated. The terminal half-life of 2.7 +/- 1.3 h and tmax of 1.9 +/- 0.5 h are in agreement with corresponding data of other glucocorticoids, whereas the normalized plasma concentration and the volume of distribution are different. The normalized volume of distribution for triamcinolone is twice the value of prednisolone or methylprednisolone, cmax is about 2/3 of the values of these two other glucocorticoids.

Glucocorticoid receptors in human synovial tissue and relative receptor affinities of glucocorticoid-21-esters.

A dexamethasone binding protein was detected in cytosol of 11 human synovial tissues from patients with chronic polyarthritis. The apparent dissociation constant (KD) ranged from 3.3 to 17.1 (mean, 7.0 +/- 4.3) nmol/liter, and the receptor concentration (Ro) from 17 to 65 (mean, 42 + 15) fmol/mg protein. Results of competition assays with an excess of unlabeled aldosterone, estradiol, pregnenolone, and testosterone confirmed that the binding protein had characteristics of a glucocorticoid receptor. With the use of diisopropylfluorophosphate (DFP) for esterase inhibition, and considering the purity of the starting material and the hydrolysis products, we could determine the relative receptor affinities of glucocorticoid-21-esters. In contrast to the high affinity of the glucocorticoid-17-ester examined, esterification in position 21 abolishes binding affinities. Glucocorticoid-21-esters are true prodrugs for which the glucocorticoid action is caused only by the corresponding glucocorticoid alcohol.