Transthoracic Echocardiography: Beginner's Guide with Emphasis on Blind Spots as Identified with CT and MRI.

Transthoracic echocardiography (TTE) is the primary initial imaging modality in cardiac imaging. Advantages include portability, safety, availability, and ability to assess the morphology and physiology of the heart in a noninvasive manner. Because of this, many patients who undergo advanced imaging with CT or MRI will have undergone prior TTE, particularly when cardiac CT angiography or cardiac MRI is performed. In the modern era, the increasing interconnectivity of picture archiving and communication systems (PACS) has made these images more available for comparison. Therefore, radiologists who interpret chest imaging studies should have a basic understanding of TTE, including its strengths and limitations, to make accurate comparisons and assist in rendering a diagnosis or avoiding a misdiagnosis. The authors present the standard TTE views along with multiplanar reformatted CT images for correlation. This is followed by examples of limitations of TTE, focusing on potential blind spots, which have been placed in seven categories on the basis of the structures involved: (a) pericardium (thickening, calcification, effusions, cysts, masses), (b) aorta (dissection, intramural hematoma, penetrating atherosclerotic ulcer), (c) left ventricular apex (infarcts, aneurysms, thrombus, apical hypertrophic cardiomyopathy), (d) cardiac valves (complications of native and prosthetic valves), (e) left atrial appendage (thrombus), (f) coronary arteries (origins, calcifications, fistulas, aneurysms), and (g) extracardiac structures (primary and metastatic masses). Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article . ©RSNA, 2021.

Droplet Coalescence is Initiated by Thermal Motion.

The classical notion of the coalescence of two droplets of the same radius R is that surface tension drives an initially singular flow. In this Letter we show, using molecular dynamics simulations of coalescing water nanodroplets, that after single or multiple bridges form due to the presence of thermal capillary waves, the bridge growth commences in a thermal regime. Here, the bridges expand linearly in time much faster than the viscous-capillary speed due to collective molecular jumps near the bridge fronts. Transition to the classical hydrodynamic regime only occurs once the bridge radius exceeds a thermal length scale l_{T}∼sqrt[R].

Mechanical Stability of Surface Nanobubbles.

Bubble cavitation is important in technologies such as noninvasive cancer treatment and diagnosis, surface cleaning, and waste-water treatment. The cavitation threshold is the critical external tensile pressure that induces unstable growth of the bubble. Surface nanobubbles have been previously shown experimentally to be stable down to -6 MPa, in disagreement with the Blake threshold, which is the classical cavitation model that predicts bulk bubbles with radii ∼100 nm should be unstable below -0.6 MPa. Here, we use molecular dynamics to simulate quasi-two-dimensional (2D) and three-dimensional (3D) nitrogen surface nanobubbles immersed in water, subject to a range of pressure drops until unstable growth is observed. We propose and assess new cavitation threshold models, derived from mechanical equilibrium analyses for both the quasi-2D and 3D cavitating bubbles. The discrepancies from the Blake threshold are attributed to the pinned contact line, within which the surface nanobubbles grow with constant lateral contact diameter, and consequently a reduced radius of curvature. We conclude with a critical discussion of previous experimental results on the cavitation of relatively large surface nanobubbles.

Acoustothermal Atomization of Water Nanofilms.

We report nonequilibrium molecular simulations of the vibration-induced heating of nanoscale-thick water layers on a metal substrate. In addition to experimentally confirmed acoustothermal evaporation, we observe hitherto unmapped nucleate and film boiling regimes, accompanied by the generation of unprecedented heat fluxes [∼O(10^{9}) W/m^{2}]. We develop a universal scaling parameter to classify the heat-transfer regimes and to predict the thickness of the residual nonevaporating liquid layer. The results find broad application to systems involving drying, coatings, and sprays.

Dynamics of Nanodroplets on Vibrating Surfaces.

We report the results of molecular dynamics investigations into the behavior of nanoscale water droplets on surfaces subjected to cyclic-frequency normal vibration. Our results show, for the first time, a range of vibration-induced phenomena, including the existence of the following different regimes: evaporation, droplet oscillation, and droplet lift-off. We also describe the effect of different surface wettabilities on evaporation. The outcomes of this work can be utilized in the design of future nanoengineered technologies that employ surface/bulk acoustic waves, such as water-based cooling systems for high-heat-generating processor chips, by tuning the vibration frequency and amplitude, as well as the surface wettability, to obtain the desired performance.

A Non-Comparative Prospective Pilot Study of Ketamine for Sedation in Adult Septic Shock.

Introduction: Sedation and analgesia in the intensive care unit (ICU) for patients with sepsis can be challenging. Opioids and benzodiazepines can lower blood pressure and decrease respiratory drive. Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist that provides both amnesia and analgesia without depressing respiratory drive or blood pressure. The purpose of this pilot study was to assess the effect of ketamine on the vasopressor requirement in adult patients with septic shock requiring mechanical ventilation. Materials and Methods: We conducted a two-phase study in a multi-disciplinary adult ICU at a tertiary medical center. The first phase was a retrospective chart review of patients admitted with septic shock between July 2010 and July 2011; 29 patients were identified for a historical control group. The second phase was a prospective, non-randomized, open-label pilot study. Patients were eligible for inclusion if they were 18-89 yr of age with a diagnosis of septic shock, who also required mechanical ventilation for at least 24 h, concomitant sedation, and vasopressor therapy. Pregnant patients, patients in the peri-operative timeframe, and patients with acute coronary syndrome were excluded. Patients enrolled in the phase two pilot study received ketamine as the primary sedative. Ketamine was administered as a 1-2 mg/kg IV bolus, then as a continuous infusion starting at 5 mcg/kg/min, titrated 2 mcg/kg/min every 30 min as needed to obtain a Richmond Agitation Sedation Scale (RASS) goal of -1 to -2. If continuous sedation was still required after 48 h, patients were transitioned off ketamine and sedative strategy reverted to usual ICU sedation protocol. The primary outcome was the dose of vasopressor required at 24, 48, 72 and 96 h after enrollment. Secondary outcomes included cumulative ketamine dose, additional sedative and analgesics used, cumulative sedative and analgesic dosing at all time periods, corticosteroid use, days of mechanical ventilation, ICU LOS, hospital LOS, and mortality. Contiguous data were analyzed with unpaired t-tests and categorical data were analyzed with two-tailed, Fisher's exact test. This study was approved by our Institutional Review Board. Results: From January 2012 to April 2015, a total of 17 patients were enrolled. Patient characteristics were similar in the control and study group. Ketamine was discontinued in one patient due to agitation at 36 h. There was a trend towards decreased norepinephrine and vasopressin use in the study group at all time periods. Regarding secondary outcomes, the study group received less additional analgesia with fentanyl at 24 and 48 h (p < 0.001), and less additional sedation with lorazepam, midazolam or dexmedetomidine at 24 h (p = 0.015). Conclusion: This pilot study demonstrated a trend towards decreased vasopressor dose, and decreased benzodiazepine and opiate use when ketamine is used as the sole sedative. The limitations to our study include a small sample size and those inherent in using a retrospective control group. Our findings should be further explored in a large, randomized prospective study.

Electrowetting Controls the Deposit Patterns of Evaporated Salt Water Nanodroplets.

So-called "coffee-ring" stains are the deposits remaining after complete evaporation of droplets containing nonvolatile solutes. In this paper we use molecular dynamics to simulate the evaporation of salt water nanodroplets in the presence of an applied electric field. We demonstrate, for the first time, that electrowetted nanodroplets can produce various deposit patterns, which vary substantially from the original ringlike deposit that occurs when there is no electric field. If a direct current (dc) electric field with strength greater than 0.03 V/Å is imposed parallel to the surface, after the water evaporates the salt crystals form a deposit on the substrate in a ribbon pattern along the field direction. However, when an alternating current (ac) electric field is applied the salt deposit patterns can be either ringlike or clump, depending on the strength and frequency of the applied ac field. We find that an ac field of high strength and low frequency facilitates the regulation of the deposit patterns: the threshold electric field strength for the transition from ringlike to clump is approximately 0.006 V/Å. These findings have potential application in fabricating nanostructures and surface coatings with desired patterns.

Electric fields can control the transport of water in carbon nanotubes.

The properties of water confined inside nanotubes are of considerable scientific and technological interest. We use molecular dynamics to investigate the structure and average orientation of water flowing within a carbon nanotube. We find that water exhibits biaxial paranematic liquid crystal ordering both within the nanotube and close to its ends. This preferred molecular ordering is enhanced when an axial electric field is applied, affecting the water flow rate through the nanotube. A spatially patterned electric field can minimize nanotube entrance effects and significantly increase the flow rate.

Wetting and evaporation of salt-water nanodroplets: A molecular dynamics investigation.

We employ molecular dynamics simulations to study the wetting and evaporation of salt-water nanodroplets on platinum surfaces. Our results show that the contact angle of the droplets increases with the salt concentration. To verify this, a second simulation system of a thin salt-water film on a platinum surface is used to calculate the various surface tensions. We find that both the solid-liquid and liquid-vapor surface tensions increase with salt concentration and as a result these cause an increase in the contact angle. However, the evaporation rate of salt-water droplets decreases as the salt concentration increases, due to the hydration of salt ions. When the water molecules have all evaporated from the droplet, two forms of salt crystals are deposited, clump and ringlike, depending on the solid-liquid interaction strength and the evaporation rate. To form salt crystals in a ring, it is crucial that there is a pinned stage in the evaporation process, during which salt ions can move from the center to the rim of the droplets. With a stronger solid-liquid interaction strength, a slower evaporation rate, and a higher salt concentration, a complete salt crystal ring can be deposited on the surface.

Cardiovascular Imaging for the Primary Prevention of Atherosclerotic Cardiovascular Disease Events.

Traditional cardiovascular risk factors have well-known limitations for the accurate assessment of individual cardiovascular risk. Unlike risk factor-based scores which rely on probabilistic calculations derived from population-based studies, coronary artery calcium (CAC) scoring, and carotid ultrasound allow for the direct visualization and quantification of subclinical atherosclerosis with the potential for a more accurate, personalized risk assessment and treatment approach. Among strategies used to guide preventive management, CAC scoring has consistently and convincingly outperformed traditional risk factors for the prediction of adverse cardiovascular events. Moreover, several studies have demonstrated the potential of CAC testing to improve precision for the use of more intensive pharmacologic therapies, such as aspirin and statins, in patients most likely to derive benefit, as compared to atherosclerotic cardiovascular disease risk calculators. By comparison to CAC, the role of carotid ultrasound for the measurement of carotid intima-media thickness (CIMT) remains less well-elucidated but may be significantly improved with the inclusion of plaque screening and novel three-dimensional measurements of plaque volume and morphology. Despite significant evidence supporting the ability of non-invasive atherosclerosis imaging (particularly CAC) to guide preventive management, imaging remains an under-utilized strategy among current guidelines and clinical practice. Herein, we review evidence regarding CAC and carotid ultrasound for patient risk classification, with a comparison of these techniques to currently advocated traditional risk factor-based scores.

Breakdown parameter for kinetic modeling of multiscale gas flows.

Multiscale methods built purely on the kinetic theory of gases provide information about the molecular velocity distribution function. It is therefore both important and feasible to establish new breakdown parameters for assessing the appropriateness of a fluid description at the continuum level by utilizing kinetic information rather than macroscopic flow quantities alone. We propose a new kinetic criterion to indirectly assess the errors introduced by a continuum-level description of the gas flow. The analysis, which includes numerical demonstrations, focuses on the validity of the Navier-Stokes-Fourier equations and corresponding kinetic models and reveals that the new criterion can consistently indicate the validity of continuum-level modeling in both low-speed and high-speed flows at different Knudsen numbers.

The FADE mass-stat: a technique for inserting or deleting particles in molecular dynamics simulations.

The emergence of new applications of molecular dynamics (MD) simulation calls for the development of mass-statting procedures that insert or delete particles on-the-fly. In this paper we present a new mass-stat which we term FADE, because it gradually "fades-in" (inserts) or "fades-out" (deletes) molecules over a short relaxation period within a MD simulation. FADE applies a time-weighted relaxation to the intermolecular pair forces between the inserting/deleting molecule and any neighbouring molecules. The weighting function we propose in this paper is a piece-wise polynomial that can be described entirely by two parameters: the relaxation time scale and the order of the polynomial. FADE inherently conserves overall system momentum independent of the form of the weighting function. We demonstrate various simulations of insertions of atomic argon, polyatomic TIP4P water, polymer strands, and C60 Buckminsterfullerene molecules. We propose FADE parameters and a maximum density variation per insertion-instance that restricts spurious potential energy changes entering the system within desired tolerances. We also demonstrate in this paper that FADE compares very well to an existing insertion algorithm called USHER, in terms of accuracy, insertion rate (in dense fluids), and computational efficiency. The USHER algorithm is applicable to monatomic and water molecules only, but we demonstrate that FADE can be generally applied to various forms and sizes of molecules, such as polymeric molecules of long aspect ratio, and spherical carbon fullerenes with hollow interiors.

Flow enhancement in nanotubes of different materials and lengths.

The high water flow rates observed in carbon nanotubes (CNTs) have previously been attributed to the unfavorable energetic interaction between the liquid and the graphitic walls of the CNTs. This paper reports molecular dynamics simulations of water flow in carbon, boron nitride, and silicon carbide nanotubes that show the effect of the solid-liquid interactions on the fluid flow. Alongside an analytical model, these results show that the flow enhancement depends on the tube's geometric characteristics and the solid-liquid interactions.

Dynamics of nanoscale droplets on moving surfaces.

We use molecular dynamics (MD) simulations to investigate the dynamic wetting of nanoscale water droplets on moving surfaces. The density and hydrogen bonding profiles along the direction normal to the surface are reported, and the width of the water depletion layer is evaluated first for droplets on three different static surfaces: silicon, graphite, and a fictitious superhydrophobic surface. The advancing and receding contact angles, and contact angle hysteresis, are then measured as a function of capillary number on smooth moving silicon and graphite surfaces. Our results for the silicon surface show that molecular displacements at the contact line are influenced greatly by interactions with the solid surface and partly by viscous dissipation effects induced through the movement of the surface. For the graphite surface, however, both the advancing and receding contact angles values are close to the static contact angle value and are independent of the capillary number; i.e., viscous dissipation effects are negligible. This finding is in contrast with the wetting dynamics of macroscale water droplets, which show significant dependence on the capillary number.

Exertional rhabdomyolysis: attrition through exercise, a case series and review of the literature.

Rhabdomyolysis is a common syndrome that can range from asymptomatic to a severe life-threatening condition. It is the result of acute muscle fiber necrosis leading to cell lysis and subsequent transfer of those byproducts into the circulatory system.1-3 The most significant constituent of these byproducts is myoglobin, which has been known to cause renal failure in 10?50% of patients that develop rhabdomyolysis.4,5 In addition, the electrolytes contained within these cells are leached into the blood stream, which can lead to significant electrolyte abnormalities. The etiology of rhabdomyolysis is broad and includes inherited diseases, drugs, toxins, muscle compression or overexertion, infections, and more. This syndrome may carry a mortality rate ranging from 7?80%.3,6 We describe five patients assigned to various companies within 160th Special Operations Aviation Regiment (Airborne) that developed exertional rhabdomyolysis of the bilateral upper extremities between June 2011 and January 2012. In this case series we will describe the events leading up to the diagnosis, lack of risk factors or family history, diagnostic criteria, treatment, and future concerns related to the condition.

Analysis of the thermomechanical inconsistency of some extended hydrodynamic models at high Knudsen number.

There are some hydrodynamic equations that, while their parent kinetic equation satisfies fundamental mechanical properties, appear themselves to violate mechanical or thermodynamic properties. This paper aims to shed some light on the source of this problem. Starting with diffusive volume hydrodynamic models, the microscopic temporal and spatial scales are first separated at the kinetic level from the macroscopic scales at the hydrodynamic level. Then, we consider Klimontovich's spatial stochastic version of the Boltzmann kinetic equation and show that, for small local Knudsen numbers, the stochastic term vanishes and the kinetic equation becomes the Boltzmann equation. The collision integral dominates in the small local Knudsen number regime, which is associated with the exact traditional continuum limit. We find a subdomain of the continuum range, which the conventional Knudsen number classification does not account for appropriately. In this subdomain, it is possible to obtain a fully mechanically consistent volume (or mass) diffusion model that satisfies the second law of thermodynamics on the grounds of extended non-local-equilibrium thermodynamics.

Critical care management of major disasters: a practical guide to disaster preparation in the intensive care unit.

Recent events and regulatory mandates have underlined the importance of medical planning and preparedness for catastrophic events. The purpose of this review is to provide a brief summary of current commonly identified threats, an overview of mass critical care management, and a discussion of resource allocation to provide the intensive care unit (ICU) director with a practical guide to help prepare and coordinate the activities of the multidisciplinary critical care team in the event of a disaster.

Achromobacter xylosoxidans infection presenting as a pulmonary nodule mimicking cancer.

Achromobacter xylosoxidans is typically isolated from pulmonary sources, presenting as pneumonia in immunosuppressed individuals. We describe a novel clinical presentation of A. xylosoxidans infection presenting as multiple spiculated, pulmonary nodules mimicking cancer for which the patient underwent a wedge resection of the lung for diagnosis and staging of presumptive cancer.

Velocity boundary condition at solid walls in rarefied gas calculations.

Maxwell's famous slip boundary condition is often misapplied in current rarefied gas flow calculations (e.g., in hypersonics, microfluidics). For simulations of gas flows over curved or moving surfaces, this means crucial physics can be lost. We give examples of such cases. We also propose a higher-order boundary condition based on Maxwell's general equation and the constitutive relations derived by Burnett. Unlike many other higher-order slip conditions these are applicable to any form of surface geometry. It is shown that these "Maxwell-Burnett" boundary conditions are in reasonable agreement with the limited experimental data available for Poiseuille flow and can also predict Sone's thermal-stress slip flow-a phenomenon which cannot be captured by conventional slip boundary conditions.

New directions in fluid dynamics: non-equilibrium aerodynamic and microsystem flows.

Fluid flows that do not have local equilibrium are characteristic of some of the new frontiers in engineering and technology, for example, high-speed high-altitude aerodynamics and the development of micrometre-sized fluid pumps, turbines and other devices. However, this area of fluid dynamics is poorly understood from both the experimental and simulation perspectives, which hampers the progress of these technologies. This paper reviews some of the recent developments in experimental techniques and modelling methods for non-equilibrium gas flows, examining their advantages and drawbacks. We also present new results from our computational investigations into both hypersonic and microsystem flows using two distinct numerical methodologies: the direct simulation Monte Carlo method and extended hydrodynamics. While the direct simulation approach produces excellent results and is used widely, extended hydrodynamics is not as well developed but is a promising candidate for future more complex simulations. Finally, we discuss some of the other situations where these simulation methods could be usefully applied, and look to the future of numerical tools for non-equilibrium flows.