Exploring the impact of indication on variation in rates of intrapartum caesarean section in six Palestinian hospitals: a prospective cohort study.

BACKGROUND: Caesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5 to 35.6%. Our aim was to assess whether variation in odds for intrapartum caesarean section in six Palestinian government hospitals can be explained by differences in indications. METHODS: Data on maternal and fetal health were collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by the hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for intrapartum caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square. RESULTS: Out of 51,041 women, 4724 (9.3%) underwent intrapartum caesarean section. The prevalence of intrapartum caesarean section varied across hospitals; from 7.6 to 22.1% in nulliparous, and from 5.8 to 14.1% among parous women. The most common indications were fetal distress and failure to progress in nulliparous, and previous caesarean section with an additional obstetric indication among parous women. Adjusted ORs for intrapartum caesarean section among nulliparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40-0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58 and 66% of the variation in intrapartum caesarean section among nulliparous and parous women, respectively. CONCLUSION: The differences in odds for intrapartum caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary.

Robot-assisted magnetic capsule endoscopy; navigating colorectal inclinations.

Purpose: To investigate the interaction of a robot assisted magnetically driven wireless capsule endoscope (WCE) with colonic tissue, as it traverses the colorectal bends in the dorsal and ventral directions, relying only on the feedback from a 3D accelerometer. We also investigate the impact of shell geometry and water insufflation on WCE locomotion.Methods: A 3D printed incline phantom, lined with porcine colon, was used as the experimental platform, for controlled and repeatable results. The tilt angle of WCE was controlled to observe its influence on WCE locomotion. The phantom was placed underwater to observe the effects of water insufflation. The experiments were repeated using the two capsule shell geometries to observe the effect of shell geometry on WCE locomotion.Results: Friction between WCE and intestinal tissue increased when the tilt angle of the WCE was lower than the angle of the incline of the phantom. Increasing the WCE tilt angle to match the angle of the incline reduced this friction. Water insufflation and elliptical capsule shell geometry reduced the friction further.Conclusion: Tilting of the WCE equal to, or more than the angle of the incline improved the WCE locomotion. WCE locomotion was also improved by using elliptical capsule shell geometry and water insufflation.Abbreviations: CRC: colorectal cancer; GI: gastrointestinal; MRI: magnetic resonance imaging; WCE: wireless capsule endoscope.

Open chest and pericardium facilitate transpulmonary passage of venous air emboli.

BACKGROUND: Transpulmonary passage of air emboli can lead to fatal brain- and myocardial infarctions. We studied whether pigs with open chest and pericardium had a greater transpulmonary passage of venous air emboli than pigs with closed thorax. METHODS: We allocated pigs with verified closed foramen ovale to venous air infusion with either open chest with sternotomy and opening of the pleura and pericardium (n = 8) or closed thorax (n = 16). All pigs received a five-hour intravenous infusion of ambient air, starting at 4-6 mL/kg/h and increased by 2 mL/kg/h each hour. We assessed transpulmonary air passage by transesophageal M-mode echocardiography and present the results as median with inter-quartile range (IQR). RESULTS: Transpulmonary air passage occurred in all pigs with open chest and pericardium and in nine pigs with closed thorax (56%). Compared to pigs with closed thorax, pigs with open chest and pericardium had a shorter to air passage (10 minutes (5-16) vs. 120 minutes (44-212), P < .0001), a smaller volume of infused air at the time of transpulmonary passage (12 mL (10-23) vs.170 mL (107-494), P < .0001), shorter time to death (122 minutes (48-185) vs 263 minutes (248-300, P = .0005) and a smaller volume of infused air at the time of death (264 mL (53-466) vs 727 mL (564-968), P = .001). In pigs with open chest and, infused air and time to death correlated strongly (r = 0.95, P = .001). CONCLUSION: Open chest and pericardium facilitated the transpulmonary passage of intravenously infused air in pigs.

Evaluation of Image Quality for 7 Iterative Reconstruction Algorithms in Chest Computed Tomography Imaging: A Phantom Study.

OBJECTIVES: This study aimed to evaluate the image quality of 7 iterative reconstruction (IR) algorithms in comparison to filtered back-projection (FBP) algorithm. METHODS: An anthropomorphic chest phantom was scanned on 4 computed tomography scanners and reconstructed with FBP and IR algorithms. Image quality of anatomical details-large/medium-sized pulmonary vessels, small pulmonary vessels, thoracic wall, and small and large lesions-was scored. Furthermore, general impression of noise, image contrast, and artifacts were evaluated. Visual grading regression was used to analyze the data. Standard deviations were measured, and the noise power spectrum was calculated. RESULTS: Iterative reconstruction algorithms showed significantly better results when compared with FBP for these criteria (regression coefficients/P values in parentheses): vessels (FIRST: -1.8/0.05, AIDR Enhanced: <-2.3/0.01, Veo: <-0.1/0.03, ADMIRE: <-2.1/0.04), lesions (FIRST: <-2.6/0.01, AIDR Enhanced: <-1.9/0.03, IMR1: <-2.7/0.01, Veo: <-2.4/0.02, ADMIRE: -2.3/0.02), image noise (FIRST: <-3.2/0.004, AIDR Enhanced: <-3.5/0.002, IMR1: <-6.1/0.001, iDose: <-2.3/0.02, Veo: <-3.4/0.002, ADMIRE: <-3.5/0.02), image contrast (FIRST: -2.3/0.01, AIDR Enhanced: -2.5/0.01, IMR1: -3.7/0.001, iDose: -2.1/0.02), and artifacts (FIRST: <-3.8/0.004, AIDR Enhanced: <-2.7/0.02, IMR1: <-2.6/0.02, iDose: -2.1/0.04, Veo: -2.6/0.02). The iDose algorithm was the only IR algorithm that maintained the noise frequencies. CONCLUSIONS: Iterative reconstruction algorithms performed differently on all evaluated criteria, showing the importance of careful implementation of algorithms for diagnostic purposes.

Impact of animated instruction on tablets and hands-on training in applying bimanual perineal support on episiotomy rates: an intervention study.

INTRODUCTION AND HYPOTHESIS: In Palestine, episiotomy is frequently used among primiparous women.This study assesses the effect of training birth attendants in applying bimanual perineal support during delivery by either animated instruction on tablets or hands-on training on episiotomy rates among primiparous women. METHODS: An interventional cohort study was performed from 15 October 2015 to 31 January 2017, including all primiparous women with singletons and noninstrumental vaginal deliveries at six Palestinian hospitals. Intervention 1 (animated instructions on tablets) was conducted in Hospitals 1, 2, 3, and 4. Intervention 2 (bedside hands-on training) was applied in Hospitals 1 and 2 only. Hospitals 5 and 6 did not receive interventions. Differences in episiotomy rates in intervention and nonintervention hospitals were assessed before and after the interventions and presented as p values using chi-square test, and odds ratios (OR) with 95% confidence intervals (CI). Differences in the demographic and obstetric characteristics were presented as p values using the Kruskal-Wallis test. RESULTS: Of 46,709 women, 12,841 were included. The overall episiotomy rate in the intervention hospitals did not change significantly after intervention 1, from 63.1 to 62.1% (OR = 0.96, 95% CI 0.84-1.08), but did so after intervention 2, from 61.1 to 38.1% (OR = 0.39, 95% CI 0.33-0.47). Rates after Intervention 2 changed from 65.0 to 47.3% (OR = 0.52, 95% CI 0.40-0.67) in Hospital 1 and from 39.4 to 25.1% (OR = 0.49, 95% CI 0.35-0.68) in Hospital 2. CONCLUSIONS: Hands-on training of bimanual perineal support during delivery of primiparous women was significantly more effective in reducing episiotomy rates than animated instruction videos alone.

Reduced inflammatory response by transcatheter, as compared to surgical aortic valve replacement.

OBJECTIVES: The inflammatory response to on-pump cardiac surgery is well known. Systemic inflammatory response syndrome after transcatheter valve implantation (TAVI) has been reported. The objective of this study was to study the inflammatory response during TAVI, and compare with the response during surgical aortic valve replacement. METHODS: Eighteen patients undergoing transcatheter implantation, either by a transfemoral (n = 9) or transaortal (n = 9) approach were compared with eighteen patients admitted for surgical replacement. Blood samples per- and postoperatively were analysed for C3bc, terminal complement complex, myeloperoxidase, macrophage inflammatory protein-1ß, monocyte chemo-attractant peptide-1, eotaxin, IL-6 and troponin-T. All markers were measured at defined time points and the areas under the curve were compared. RESULTS: Activation of complement, granulocytes, monocytes and eosinophils were significantly lower in the transcatheter group as compared to the surgical group (<0.01). There was no difference in generation of troponin T and IL-6. A small difference in complement activation was observed between the transfemoral and transaortal placement of TAVI. There was no significant difference in clinical outcomes between the TAVI and surgical groups. DISCUSSION: Activation and release of inflammatory markers was significantly less during with TAVI as compared to SAVR, particularly for markers associated with extracorporeal circulation. TAVI and SAVR generated the same degree of IL-6 and troponin T, indicating that the burden on the myocardial tissue was the same. Clinical Trials: Gov ID: NCT03074838 Unique protocol ID: 2012/7919.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence. METHODS: This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ2-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis. RESULTS: A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3. CONCLUSION: The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities. STUDY REGISTRATION NUMBER: ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.

Examining participant perceptions of an interprofessional simulation-based trauma team training for medical and nursing students.

High quality care relies on interprofessional teamwork. We developed a short simulation-based course for final year medical, nursing and nursing anaesthesia students, using scenarios from emergency medicine. The aim of this paper is to describe the adaptation of an interprofessional simulation course in an undergraduate setting and to report participants' experiences with the course and students' learning outcomes. We evaluated the course collecting responses from students through questionnaires with both closed-ended and open-ended questions, supplemented by the facilitators' assessment of students' performance. Our data is based on responses from 310 students and 16 facilitators who contributed through three evaluation phases. In the analysis, we found that students reported emotional activation and learning outcomes within the domains self-insight and stress management, understanding of the leadership role, insight into teamwork, and skills in team communication. In subsequent questionnaire studies students reported having gained insights about communication, teamwork and leadership, and they believed they would be better leaders of teams and/or team members after having completed the course. Facilitators' observations suggested a progress in students' non-technical skills during the course. The facilitators observed that nursing anaesthesia students seemed to be more comfortable in finding their role in the team than the two other groups. In conclusion, we found that an interprofessional simulation-based emergency team training course with a focus on leadership, communication and teamwork, was feasible to run on a regular basis for large groups of students. The course improved the students' team skills and received a favourable evaluation from both students and faculty.

Building a research registry for studying birth complications and outcomes in six Palestinian governmental hospitals.

BACKGROUND: Electronic-health (e-health) provides opportunities for quality improvement of healthcare, but implementation in low and middle income countries is still limited. Our aim was to describe the implementation of a registration (case record form; CRF) for obstetric interventions and childbirth events using e-health in a prospective birth cohort study in Palestine. We also report the completeness and the reliability of the data. METHODS: Data on maternal and fetal health was collected prospectively for all women admitted to give birth during the period from 1st March 2015 to 31st December 2015 in three governmental hospitals in Gaza and three in the West Bank. Essential indicators were noted in a case registration form (CRF) and subsequently entered into the District Health Information Software 2 (DHIS 2) system. Completeness of registered cases was checked against the monthly hospital birth registries. Reliability (correct information) of DHIS2 registration and entry were checked for 22 selected variables, collected during the first 10 months. In the West Bank, a comparison between our data registration and entry and data obtained from the Ministry of Health patient electronic records was conducted in the three hospitals. RESULTS: According to the hospital birth registries, a total of 34,482 births occurred in the six hospitals during the study period. Data on the mothers and children registered on CRF was almost complete in two hospitals (100% and 99.9%); in the other hospitals the completeness ranged from 72.1% to 98.7%. Eighty birth events were audited for 22 variables in the three hospitals in the West Bank. Out of 1760 registrations in each hospital, the rates of correct data registration ranged from 81% to 93.2% and data entry ranged from 84.5% to 93.1%. CONCLUSIONS: The registered and entered data on birth events in six hospitals was almost complete in five out of six hospitals. The collected data is considered reliable for research purposes.

Does therapeutic hypothermia during extracorporeal cardiopulmonary resuscitation preserve cardiac function?

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (E-CPR) is increasingly used as a rescue method in the management of cardiac arrest and provides the opportunity to rapidly induce therapeutic hypothermia. The survival after a cardiac arrest is related to post-arrest cardiac function, and the application of therapeutic hypothermia post-arrest is hypothesized to improve cardiac outcome. The present animal study compares normothermic and hypothermic E-CPR considering resuscitation success, post-arrest left ventricular function and magnitude of myocardial injury. METHODS: After a 15-min untreated ventricular fibrillation, the pigs (n = 20) were randomized to either normothermic (38 °C) or hypothermic (32-33 °C) E-CPR. Defibrillation terminated ventricular fibrillation after 5 min of E-CPR, and extracorporeal support continued for 2 h, followed by warming, weaning and a stabilization period. Magnetic resonance imaging and left ventricle pressure measurements were used to assess left ventricular function pre-arrest and 5 h post-arrest. Myocardial injury was estimated by serum concentrations of cardiac TroponinT and Aspartate transaminase (ASAT). RESULTS: E-CPR resuscitated all animals and the hypothermic strategy induced therapeutic hypothermia within minutes without impairment of the resuscitation success rate. All animals suffered a severe global systolic left ventricular dysfunction post-arrest with 50-70% reductions in stroke volume, ejection fraction, wall thickening, strain and mitral annular plane systolic excursion. Serum concentrations of cardiac TroponinT and ASAT increased considerably post-arrest. No significant differences were found between the two groups. CONCLUSIONS: Two-hour therapeutic hypothermia during E-CPR offers an equal resuscitation success rate, but does not preserve the post-arrest cardiac function nor reduce the magnitude of myocardial injury, compared to normothermic E-CPR. Trial registration FOTS 4611/13 registered 25 October 2012.

Image Quality in Oncologic Chest Computerized Tomography With Iterative Reconstruction: A Phantom Study.

OBJECTIVE: The purpose of this study was to validate iterative reconstruction technique in oncologic chest computed tomography (CT). METHODS: An anthropomorphic thorax phantom with 4 simulated tumors was scanned on a 64-slice CT scanner with 2 different iterative reconstruction techniques: one model based (MBIR) and one hybrid (ASiR). Dose levels of 14.9, 11.1, 6.7, and 0.6 mGy were used, and all images were reconstructed with filtered back projection (FBP) and both iterative reconstruction algorithms. Hounsfield units (HU) and absolute noise were measured in the tumors, lung, heart, diaphragm, and muscle. Contrast-to-noise ratios (CNRs) and signal-to-noise ratios (SNRs) were calculated. RESULTS: Model-based iterative reconstruction (MBIR) increased CNRs of the tumors (21.1-192.2) and SNRs in the lung (-49.0-165.6) and heart (3.1-8.5) at all dose levels compared with FBP (CNR, 1.1-23.0; SNR, -7.5-31.6 and 0.2-1.1) and with adaptive statistical iterative reconstruction (CNR, 1.2-33.2; SNR, -7.3-37.7 and 0.2-1.5). At the lowest dose level (0.6 mGy), MBIR reduced the cupping artifact (HU range: 17.0 HU compared with 31.4-32.2). An HU shift in the negative direction was seen with MBIR. CONCLUSIONS: Quantitative image quality parameters in oncologic chest CT are improved with MBIR compared with FBP and simpler iterative reconstruction algorithms. Artifacts at low doses are reduced. A shift in HU values was shown; thus, absolute HU values should be used with care.

Myocardial Function by Two-Dimensional Speckle Tracking Echocardiography and Activin A May Predict Mortality in Patients with Carcinoid Intestinal Disease.

OBJECTIVES: Myocardial fibrosis causes deterioration of myocardial function in carcinoid intestinal disease (CID). We assessed the ability of myocardial function and various biomarkers to predict mortality in patients with CID. METHODS: A total of 71 patients with small intestinal carcinoid tumours were included, and underwent echocardiography at baseline. Systolic function was assessed by two-dimensional speckle tracking echocardiography as left ventricular (LV) and right ventricular (RV) strain, and as mitral annular displacement (MAD), by tissue Doppler imaging. Parameters of diastolic function, the amount of liver metastases, and various biomarkers were also analysed. RESULTS: During 1,274 ± 368 days of follow-up, 18 patients (25%) died. Of the 53 survivors, 46 patients (87%) were available for follow-up echocardiography. Baseline LV strain and MAD was reduced in those who died compared to those who survived (p < 0.001). Baseline plasma levels of activin A were markedly higher in patients who died during follow-up than those who survived (p = 0.001). In multivariate Cox hazard models (A, B, C and D), LV strain, age, the amount of liver metastases, MAD, and activin A were independent predictors of mortality. CONCLUSION: Assessment of myocardial function by echocardiography, and the biomarker activin A, can be very useful in the risk stratification of patients with CID. © 2015 S. Karger AG, Basel.

Transcatheter aortic valve implantation and intraoperative left ventricular function: a myocardial tissue Doppler imaging study.

OBJECTIVE: Transcatheter aortic valve implantation in patients turned down for surgical aortic valve replacement is a high-risk procedure. Severe aortic stenosis is associated with impaired left ventricular longitudinal motion, and myocardial peak systolic velocity is a measure of left ventricular function in these patients. The present study aimed to quantify the acute changes in left ventricular function during the procedure by using myocardial tissue Doppler imaging and transthoracic cardiac output measurements. DESIGN: Prospective observational study. SETTING: Tertiary care university hospital. PARTICIPANTS: 40 patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation. INTERVENTIONS: Transesophageal 4-chamber and 2-chamber echocardiograms were performed immediately before and ~15 minutes after valve implantation. Longitudinal myocardial peak systolic velocity was obtained by tissue Doppler imaging from 8 basal segments and averaged. Cardiac output was measured by the lithium dilution method, and systemic vascular resistance index and stroke volume were calculated. MEASUREMENTS AND MAIN RESULTS: Longitudinal myocardial peak systolic velocity improved immediately after valve implantation, from -2.3±0.8 to -3.0±1.1 cm/sec (p<0.001); this represented an average increase of 31%±33%. Cardiac output increased from 3.2±0.8 L/min to 3.6±0.9 L/min (15%±33%; p = 0.04). This was due to increased heart rate (59±9 beats/min to 72±12 beats/min; p<0.001) and not to an improved stroke volume. Systemic vascular resistance index was reduced from 2,937±984 dynes*sec/cm(5)/m(2) to 2,436±730 dynes*sec/cm(5)/m(2) (p = 0.003). CONCLUSION: Intraoperative echocardiography tissue Doppler imaging detected immediate improvement in left ventricular long-axis motion after transcatheter aortic valve implantation. The method provided detailed information not obtainable by routine hemodynamic monitoring.

Review of the endovascular approach to mitral valve disease.

The first interventional attempts at relieving mitral valve disease were in a sense minimally invasive, using relatively small incisions and introduction of instruments or a finger to open stenotic valves on the beating heart. The development of reliable cardiopulmonary bypass (CPB) made exact anatomic repair of mitral pathology possible with improved results. Mitral valve surgery on an arrested heart has been the mainstay of treatment for decades. Modifications and minimalization of the surgical approach using videoscopic or robotic instruments have made less invasive procedures possible. Such procedures demand excellent technical skills and are still not widely adopted. More recently, attempts have been made to repair mitral valves using endovascular access on the beating heart, guiding the repair process with real-time imaging. We are presenting a review of available and developing techniques for endovascular repair of the mitral valve. A device developed by our group will be briefly described.

Advantages of strain echocardiography in assessment of myocardial function in severe sepsis: an experimental study.

OBJECTIVES: Cardiovascular failure is an important feature of severe sepsis and mortality in sepsis. The aim of our study was to explore myocardial dysfunction in severe sepsis. DESIGN: Prospective experimental study. SETTING: Operating room at Intervention Centre, Oslo University Hospital. SUBJECTS: Eight Norwegian Landrace pigs. INTERVENTIONS: The pigs were anesthetized, a medial sternotomy performed and miniature sensors for wall-thickness measurements attached to the epicardium and invasive pressure monitoring established, and an infusion of Escherichia coli started. Hemodynamic response was monitored and myocardial strain assessed by echocardiography. MEASUREMENTS AND MAIN RESULTS: Left ventricular myocardial function was significantly reduced assessed by longitudinal myocardial strain (-17.2% ± 2.8% to -12.3% ± 3.2%, p = 0.04), despite a reduced afterload as expressed by the left ventricular end-systolic meridional wall stress (35 ± 13 to 18 ± 8 kdyn/cm, p = 0.04). Left ventricular ejection fraction remained unaltered (48% ± 7% to 49% ± 5%, p = 0.4) as did cardiac output (6.3 ± 1.3 to 5.9 ± 3 L/min, p = 0.7). The decline in left ventricular function was further supported by significant reductions in the index of regional work by pressure-wall thickness loop area (121 ± 45 to 73 ± 37 mm × mm Hg, p = 0.005). Left ventricular myocardial wall thickness increased in both end diastole (11.5 ± 2.7 to 13.7 ± 2.4 mm, p = 0.03) and end systole (16.1 ± 2.9 to 18.5 ± 1.8 mm, p = 0.03), implying edema of the left ventricular myocardial wall. Right ventricular myocardial function by strain was reduced (-24.2% ± 4.1% to -16.9% ± 5.7%, p = 0.02). High right ventricular pressures caused septal shift as demonstrated by the end-diastolic transseptal pressure gradient (4.1 ± 3.3 to -2.2 ± 5.8 mm Hg, p = 0.01). CONCLUSIONS: The present study demonstrates myocardial dysfunction in severe sepsis. Strain echocardiography reveals myocardial dysfunction before significant changes in ejection fraction and cardiac output and could prove to be a useful tool in clinical evaluation of septic patients.

Comparing five different iterative reconstruction algorithms for computed tomography in an ROC study.

OBJECTIVES: The purpose of this study was to evaluate lesion conspicuity achieved with five different iterative reconstruction techniques from four CT vendors at three different dose levels. Comparisons were made of iterative algorithm and filtered back projection (FBP) among and within systems. METHODS: An anthropomorphic liver phantom was examined with four CT systems, each from a different vendor. CTDIvol levels of 5 mGy, 10 mGy and 15 mGy were chosen. Images were reconstructed with FBP and the iterative algorithm on the system. Images were interpreted independently by four observers, and the areas under the ROC curve (AUCs) were calculated. Noise and contrast-to-noise ratios (CNR) were measured. RESULTS: One iterative algorithm increased AUC (0.79, 0.95, and 0.97) compared to FBP (0.70, 0.86, and 0.93) at all dose levels (p < 0.001 and p = 0.047). Another algorithm increased AUC from 0.78 with FBP to 0.84 (p = 0.007) at 5 mGy. Differences at 10 and 15 mGy were not significant (p-values: 0.084-0.883). Three algorithms showed no difference in AUC compared to FBP (p-values: 0.008-1.000). All of the algorithms decreased noise (10-71%) and improved CNR. CONCLUSIONS: Only two algorithms improved lesion detection, even though noise reduction was shown with all algorithms. KEY POINTS: Iterative reconstruction algorithms affected lesion detection differently at different dose levels. One iterative algorithm improved lesion detectability compared to filtered back projection. Three algorithms did not significantly improve lesion detectability. One algorithm improved lesion detectability at the lowest dose level.

Wireless vital signs from a life-supporting medical device exposed to electromagnetic disturbance.

OBJECTIVES: To evaluate the level of agreement of simulated wired and Wi-Fi vital signs output from an intra-aortic balloon pump during exposure to electromagnetic interference from frequency overlapping ZigBee sensors. MATERIAL AND METHODS: A series of experiments with interference from single and multiple ZigBee sensors were benchmarked with wired and Wi-Fi output. Tests included single ZigBee sensor adjacent and co-channel interference, and multiple ZigBee interferences towards the Wi-Fi receiver and transmitter. RESULTS: Interference-free differences between wired and wireless aortic blood pressure and electrocardiogram were very small, verified by time domain and Bland - Altman plots. Bland - Altman plots comparing level of agreement in wired and wireless aortic blood pressure and ECG output during interference experiments showed a difference from 0.2 to 0.3 mmHg for blood pressure, and from 0.001 to 0.004 mV for electrocardiogram. CONCLUSIONS: Level of agreement in wired and wireless (Wi-Fi) arterial blood pressure and electrocardiogram during single or multiple sensor interference was high. No clinically relevant degradation of Wi-Fi transmission of aortic blood pressure or ECG signals was observed.

Volumetric ablation of uterine fibroids using Sonalleve high-intensity focused ultrasound in a 3 Tesla scanner--first clinical assessment.

INTRODUCTION: The purpose of this study was to evaluate the feasibility and safety of the Sonalleve high-intensity focused ultrasound (HIFU; Philips Healthcare, Vantaa, Finland) system in ablating uterine fibroids in a 3T magnet. MATERIAL AND METHODS: Seven women were included in this study. Treatment was performed according to the manufacturer's recommendation. Technical data describing the HIFU procedures were collected. On MR images at baseline, immediately and 30 days after ablation, we evaluated the volumes of the uterus, the dominant fibroid and the ablation zone. The Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire was used to assess potential clinical response. RESULTS: The procedure was technically feasible in all patients. The median number of sonications performed during each procedure was 20 (range 2-27) per patient, the maximum temperature in all sonication cells was about 68°C. The median procedure time was 156 minutes (range 95-164). The non-perfused volume after treatment ranged from 1 to 27 ml and was unchanged or decreased in all but one patient at 30 days follow-up. There were no major adverse events. DISCUSSION: In our 3T magnet the system was able to heat tissue and induce areas of non-enhancement within uterine fibroids without major complications. Clinical benefit remains to be proven.