Longitudinal Analysis of Quality of Life, Clinical, Radiographic, Echocardiographic, and Laboratory Variables in Dogs with Preclinical Myxomatous Mitral Valve Disease Receiving Pimobendan or Placebo: The EPIC Study.

BACKGROUND: Changes in clinical variables associated with the administration of pimobendan to dogs with preclinical myxomatous mitral valve disease (MMVD) and cardiomegaly have not been described. OBJECTIVES: To investigate the effect of pimobendan on clinical variables and the relationship between a change in heart size and the time to congestive heart failure (CHF) or cardiac-related death (CRD) in dogs with MMVD and cardiomegaly. To determine whether pimobendan-treated dogs differ from dogs receiving placebo at onset of CHF. ANIMALS: Three hundred and fifty-four dogs with MMVD and cardiomegaly. MATERIALS AND METHODS: Prospective, blinded study with dogs randomized (ratio 1:1) to pimobendan (0.4-0.6 mg/kg/d) or placebo. Clinical, laboratory, and heart-size variables in both groups were measured and compared at different time points (day 35 and onset of CHF) and over the study duration. Relationships between short-term changes in echocardiographic variables and time to CHF or CRD were explored. RESULTS: At day 35, heart size had reduced in the pimobendan group: median change in (Δ) LVIDDN -0.06 (IQR: -0.15 to +0.02), P < 0.0001, and LA:Ao -0.08 (IQR: -0.23 to +0.03), P < 0.0001. Reduction in heart size was associated with increased time to CHF or CRD. Hazard ratio for a 0.1 increase in ΔLVIDDN was 1.26, P = 0.0003. Hazard ratio for a 0.1 increase in ΔLA:Ao was 1.14, P = 0.0002. At onset of CHF, groups were similar. CONCLUSIONS AND CLINICAL IMPORTANCE: Pimobendan treatment reduces heart size. Reduced heart size is associated with improved outcome. At the onset of CHF, dogs treated with pimobendan were indistinguishable from those receiving placebo.

Promotion of physical activity in patients with non-communicable diseases in Luxembourg: a follow-up of the Sport-Sante inventory from 2014.

Regular practice of physical activity (PA) has many health benefits in both healthy individuals and in people with non-communicable diseases (NCDs). In order to disseminate this evidence and to strengthen the promotion of PA in people with NCDs, the Sport-Santé project was created in Luxembourg and officially launched in April 2015. In 2014, a stocktaking of the different organizations offering PA for people with NCDs was realized in order to develop the Sport-Santé project. Different communication tools were used to promote Sport-Santé as well as the aforementioned organizations. The present study aimed to re-evaluate the offers of PA for people with NCDs in Luxembourg one year after the launch of the project. The organizations offering PA for people with NCDs (orthopaedics, obesity and overweight, neurology and rare diseases, oncology and cardiology) were screened in 2014 and in 2016. The number of weekly offered hours of PA for people with NCDs were collected and the participation rate was observed. Participants (192 in 2014 and 196 in 2016) volunteered to answer a survey, which contained questions regarding their age, sex, time since enrolment, travel distance, former and current PA participation, and type of recruitment. Additional items regarding prescription and refund were explored only in 2016. In 2016, more than 55 hours per week of PA were offered for people with NCDs in Luxembourg (≈44 hours per week were identified in 2014). However, this increase was not statistically significant. No difference was observed between 2014 and 2016 regarding the participation rate (2014: 8.9 ± 5.1 participants per hour; 2016: 8.4 ± 5.7 participants per hour). Participants were younger in 2016 than in 2014. The time since enrolment was shorter in 2016 than in 2014. No difference between 2014 and 2016 was observed for travel distance, sex distribution, former and current PA participation, and type of recruitment. Participants were mainly recruited by the healthcare professionals. More than 69 % of the participants would like to receive a medical prescription for the PA. Fifty-two percent of the participants would appreciate a refund of the participation fees by their health insurance. The increasing efforts of Sport-Santé and the organizations offering PA for people with NCDs lead to increase the offer. However, the participation rate remains unchanged. The decrease in age and in time since enrolment observed in 2016 could be explained by the creation of new activities, a larger participant's turnover or high number of withdrawals among long-term participants. Even if participants are mainly recruited by healthcare professionals, this type of recruitment can be attributed to very few idealists. All healthcare professionals should be aware of the offers of Sport-Santé and advise their patients to participate in a PA program. It is now time to advance the idea of prescription of PA as a privileged treatment option and to convince the policymakers to take action against sedentary behaviours in Luxembourg. Nevertheless, this type of promotion is not enough to increase the number of participants and additional strategies must be explored and developed. The best sustainable strategies are always those that approach the problem from different viewpoints.

[Cutaneous manifestation of late-type syphilis]. / Hautmanifestation bei Spätsyphilis.

HISTORY AND CLINICAL FINDINGS: A 49-year-old, otherwise healthy man presented at his dermatologist with tuberous skin changes that had be present for several weeks on head, arm and leg. These were asymptomatic, but disturbed him cosmetically. A skin biopsy was performed. INVESTIGATIONS: The skin biopsy showed a granulomatous inflammation with prominent plasma cells, consistent with granulomatous infiltrate. Serologic tests confirmed a Treponema pallidum-infection. In addition, the patient was tested positive for hepatitis C and HIV (CDC stage A1). The clinical neurological examination did not show any pathological findings, however, analysis of the cerebrospinal fluid revealed a mild pleocytosis, elevation of protein and the glucose quotient and a normal Treponema pallidum TPPA-antibody index. A mesaortitis was excluded. THERAPY AND COURSE: We diagnosed a tertiary syphilis (stage III). The patient refused prolonged inpatient treatment with penicillin G i.v., as recommended as first-line therapy in the national guidelines for asymptomatic neurosyphilis. Therefore, after a single oral administration of 100 mg prednisolone he received ceftriaxone intravenously for 14 days. The skin changes resolved. With regard to the HIV infection anti-retro-viral therapy was not yet indicated. CONCLUSIONS: In view of the increasing incidence of syphilis in Germany clinicians should consider this diagnosis when confronted with oligosymptomatic skin lesions.

[Flagellate dermatitis after bleomycin chemotherapy in a patient with malignant germ cell tumor]. / Flagellanten-Dermatitis nach Bleomycingabe bei einem Patienten mit malignem Keimzelltumor.

HISTORY AND CLINICAL FINDINGS: A 49-year-old patient with malignant germ cell tumor within the first cycle PEB (platinum [P], etoposid [E] and bleomycin [B]) presented with an itchy linear papular erythema with discrete vesicles. The rash had appeared three days ago i. e. four days after the second application of bleomycin. INVESTIGATIONS: Visual diagnosis of a flagellate dermatitis. TREATMENT AND CLINICAL COURSE: Primary treatment consisted of systemic antihistamines, local and systemic application of steroids. Bleomycin treatment was stopped and substituted by ifosfamide. CONCLUSION: Flagellate dermatitis occurs with an incidence up to 66 % after bleomycin treatment. There is no association between bleomycin dose and incidence or severity of the lesions. Flagellate dermatitis is a self-limiting condition but hyperpigmentation may persist. Similar lesions may occur with bendamustine and docetaxel, the intake of insufficiently cooked shiitake mushrooms as well as in dermatomyositis and Still's syndrome.

[Extravasal position of central venous catheters despite unsuspicious ECG-guidance]. / Extravasale Lage von zentralen Venenkathetern bei korrekter EKG-Ableitung.

OBJECTIVE: Does the electrocardiographic method for central venous catheter positioning distinguish between a correct intravasal and a malpositioned extravasal position? METHODS: 24 cardiac surgical patients were enrolled in this prospective observational study. In 18 patients the left, in another 6 patients the right internal jugular vein was cannulated. Using a J-wire within a triple-lumen catheter the amplitude of the P-wave was measured at 3 different intravasal sites: Intra-1: (intravasal baseline electrocardiogram), i. e. 10 cm marking of the catheter on skin level; Intra-2: clear rise of the P-wave amplitude upon further insertion of the catheter; Intra-3: maximum P-wave amplitude. At this position the control of the catheter tip was achieved by means of transoesophageal echocardiography (TOE). Intraoperatively, another J-wire within a triple-lumen catheter was placed by the heart surgeon on 3 extravasal sites and the ECG was recorded: Extra-1: extravasal at the left innominate vein above the pericardial reflection; Extra-2: extravasal on the superior vena cava below the pericardial reflection; Extra-A: extravasal on ascending aorta below the pericardial reflection. The catheter was suture fixed with its tip in position Intra-3. Post surgery a chest radiograph was taken. RESULTS: All catheter tips were visualised at the basis of the Crista terminals (border between right atrium and superior vena cava) by TOE control. The rise of the P wave amplitude at Intra-2, Extra-2 and Extra-A was highly significant compared to the base line at Intra-1 (Intra-1/Intra-2, Intra-1/Extra-2, Intra-1/Extra-A: p in each case < 0.001). The P wave amplitudes of the corresponding intra- and extravasal positions of the left innominate vein (Intra-1/Extra-1, n = 18, p = 0.096)) as well as those of the superior vena cava (Intra-2/Extra-2, n = 24, p = 0.859) did not differ. CONCLUSION: The electrocardiographic method can not differentiate between intra- and extravasal position of a central venous catheter, and thus, presumably fails to identify malpositioning as a result of vascular perforation.

ECG recording of central venous catheter misplaced in inferior thyroid artery.

A 71-year-old male patient with liver metastases secondary to rectal carcinoma was scheduled for hemi-hepatectomy. Two months earlier he had undergone subtotal resection of the thyroid gland. Prior to surgery, a triple-lumen catheter and an introducer sheath were introduced into the right internal jugular vein using a landmark technique. No problems occurred during insertion of the triple-lumen catheter, but resistance was noticed during insertion of the 8.5 FG introducer sheath. After placement of the introducer sheath, intra-arterial misplacement was confirmed using a pressure transducer. The opportunity was taken to record and compare intravascular ECG by the arterial and venous catheters before removal. No difference was noticed in the P-wave patterns; both showed a marked increase. Surgical exploration of the neck, recommended by the vascular surgeon consulted, showed that the carotid artery was not injured. The introducer sheath had completely punctured the right internal jugular vein and entered the inferior thyroid artery. A thrill was felt. The management of this case is discussed, with suggestions for best practice. Intravascular ECG was unhelpful in differentiating between venous and arterial placement of the catheter.

ECG-guided central venous catheter positioning: does it detect the pericardial reflection rather than the right atrium?

BACKGROUND AND OBJECTIVE: Although electrocardiography (ECG) guidance of central venous catheters (CVCs) is traditionally thought to detect the entrance into the right atrium (RA), there is little evidence in the literature to confirm this. We previously observed a high incidence of left-sided CVCs abutting the wall of the superior vena cava (SVC), even when the catheters were advanced past the point of increased P-wave amplitude. Our hypothesis was that this ECG amplitude signal is actually detecting the pericardial reflection rather than the RA. The goal of the study was to position catheter tips under ECG guidance outside the RA. METHODS: One-hundred central venous triple-lumen catheters inserted either via the right or the left internal jugular veins, respectively, were analysed in cardiac surgical patients. The position of the catheter tip was ascertained by ECG. METHOD A: A Seldinger guide-wire in the distal lumen served as exploring electrode, the respective insertion depth was recorded. METHOD B: The middle lumen (port opening 2.5 cm from the catheter tip, thus the catheter was advanced more towards the atrium) filled with a saline 10% fluid column served as the exploring electrode, and the insertion depth was recorded again. Descriptive data are given as mean+/-standard deviation. RESULTS: On average, the catheters were advanced by the expected 2+/-0.3 cm using Method B beyond the initial insertion by Method A. All 100 CVCs were finally correctly positioned in the SVC and confirmed by transoesophageal echocardiography. When chest radiography was performed after surgery not a single catheter abutted the lateral wall of the SVC. CONCLUSION: Since both methods detected the same structure, and catheters placed by Method B did not result in intra-atrial CVC tip position, the first increase in P-wave amplitude does correspond to a structure in the SVC, most likely the pericardial reflection.

Central venous catheters--the inability of 'intra-atrial ECG' to prove adequate positioning.

BACKGROUND: The classic increase in P wave size, known as 'P-atriale', is a widely accepted criterion for determination of proper positioning of central venous catheter tips. Recent transoesophageal echocardiography (TOE) studies did not confirm intra-atrial position despite advancing the central venous catheter further than indicated by ECG guidance. We postulate that the pericardial reflection rather than the entry into the right atrium corresponds to the ECG changes. In order to test our hypothesis we sought to determine the anatomical substrate for the electrical changes in an animal study. Subsequently, a modified version of the study was undertaken in man and is also reported. METHODS: In six juvenile pigs the left external jugular vein and right carotid artery were cannulated. A triple-lumen central venous catheter was positioned by ECG guidance using a Seldinger wire as an exploring electrode. The venous and arterial catheters were suture fixed 2 cm beyond the onset of an increase in P wave size. The corresponding anatomical catheter tip position was determined by open exploration of the vessels and the heart. Subsequently the catheter tip position (during advancement) of a pulmonary artery catheter and the corresponding electrical ECG changes were examined in 10 patients during open chest cardiac surgery. RESULTS: All catheters-arterial and venous, in animals and humans-revealed an increase in size of the P wave as well as the QRS complex. All venous catheters were positioned in the superior vena cava, beyond the pericardial reflection but outside the right atrium. All arterial catheters were positioned in the ascending aorta thus also beyond the pericardial reflection. CONCLUSIONS: The start of an increase in P wave size does not correspond with the entrance of the right atrium. The anatomic equivalent for the electrophysiological changes of the ECG is the pericardial reflection. ECG guidance is unable to distinguish between venous and arterial catheter position.

[Delayed onset of malignant hyperthermia crisis during a living donor liver transplantation caused by sevoflurane]. / Verzögertes Einsetzen einer Malignen Hyperthermie während einer Leberlebendspende unter Sevoflurananästhesie.

We report on a 25-year old ASA physical status I patient, who developed within 20 minutes a full-blown malignant hyperthermia (MH) in the context of a living donor liver transplantation after 180 minutes of uneventful anaesthesia. The only trigger substance applied was Sevoflurane. The patient had already received a short, uneventful anaesthesia with Isoflurane a couple of years ago. In the context of the special constellation an initial dose of Dantrolene of 10 mg/kg body weight was administered. The patient was stabilised within 30 minutes, and the enzyme levels remained low compared with other case reports. The post-operative in vitro caffeine halothane contracture testing confirmed that son and mother were susceptible to MH, contracture testing in the father was negative. All known triggers may cause life-threatening MH crisis - even after hours and after inconspicuous multiple exposures to known trigger substances. Therefore all trigger substances must be avoided in all patients susceptible to MH.

[On the use of ultrasound to assist central vein cannulation in Germany: a surgery of 817 departments of anesthesia]. / Zur Anwendung von Ultraschall bei der Anlage zentraler Venenkatheter in Deutschland: Eine Umfrage unter 817 Anästhesieabteilungen.

OBJECTIVE AND METHODS: A survey on the current practice in using portable ultrasound machines to assist central vein cannulation was performed by sending a questionnaire to 817 departments of anaesthesiology and intensive care medicine in Germany. Also, incomplete questionnaires were included in the analysis. RESULTS: There was a 54 % response rate. Ultrasound guidance is used by 83 (18.7 %) departments for central vein cannulation. Of these, only 7 (8.4 %) use it routinely and 43 (51.8 %) use it when faced with a difficult vein cannulation. Only one third of the departments with ultrasound facilities are using it optimally, e. g. cannulation under ultrasound guidance. Of those units not using ultrasound for central vein cannulation, 136 (37.7 %) said it was because of lack of equipment and 199 (55.1 %) did not think that it was necessary. CONCLUSION: In Germany, placement of central venous catheters is usually based on anatomical landmarks. Every anaesthetist and intensive care physician should be able to place central venous catheters without an ultrasound device. Still there is not a doubt that ultrasound assistance is useful for beginners, in children, and when blind cannulation fails. Also in patients in whom catheterisation is likely to be difficult (e. g. patients, with previous central venous catheters, with abnormal anatomy etc.) Due to our data a promotion of ultrasound assistance seems urgently required.

[Extravasation: a rare complication of central venous cannulation? Case report of an imminent erosion of the common carotid artery]. / Extravasation-eine seltene Komplikation zentralvenöser Katheter? Fallbericht einer drohenden Arrosion der A. carotis.

Extravasation is the non-intentional leakage of substances/solutions into the perivascular or subcutaneous space that can result in significant tissue damage. The extent of destruction depends on the properties of the substance, its concentration, and the amount applied. Substances known to cause severe tissue damage include certain chemotherapeutic agents, vasoactive substances, concentrated electrolytes, and other hyperosmolar solutions. Extravasation can be avoided by meticulous monitoring of venous access. When extravasation occurs, the infusion should be stopped immediately. Substances known to cause tissue damage should be removed from perivascular or subcutaneous space within 24 hours by local incision and irrigation. A delay in early treatment may necessitate more extensive surgical debridement and skin coverage operations. Since the extent of deep soft tissue damage is difficult to predict and is often underestimated, a magnetic resonance imaging should be performed before surgery. We report here on a 73-year-old patient, in whom extravasation of potassium-chloride from a dislocated multi-lumen central venous catheter led to a life-threatening skin and soft-tissue necrosis of the neck. This article provides an overview of common vesicants, theories of tissue destruction, potential risk factors, guidelines for prevention, and current treatment strategies.