Comparison between transcranial color Doppler ultrasonography and angiography in the confirmation of brain death.

OBJECTIVE: Cerebral blood flow tests have increasingly been advocated for the confirmation of brain death (BD). Angiography has been considered the gold standard in the diagnosis of BD but is invasive. We validated transcranial color Doppler ultrasonography (TCD) to confirm BD by comparing it to angiography. PATIENTS AND METHODS: Forty patients experienced the clinical diagnosis of brain death due to head injury in 19 cases (47.5%), cerebral hemorrhage in 11 (27.5%), subarachnoid hemorrhage in 7 (17.5%), and cerebral infarction in 3 (7.5%). Blood pressure, heart rate, SPO2, and PCO2 were monitored throughout the study. Patients were excluded if episodes of hypoxia, arrhythmia, and hypotension occurred during examinations, or if the TCD was not technically feasible. RESULTS: Both angiography and TCD confirmed BD in all patients. The agreement between the above methods to confirm BD was 100%. Angiography showed the absence of filling of intracranial arteries, while TCD revealed: (1) brief systolic forward flow or systolic spikes and diastolic reversed flow (50%); (2) brief systolic forward flow or systolic spikes and no diastolic flow (25%); (3) no demonstrable flow in a patient in whom flow had been clearly documented on a previous TCD examination (12.5%). Five patients required repeated TCD examinations, because of initial detection of a diastolic to-and-fro flow pattern. BD was confirmed by TCD in the above patients after 30 hours of clinical BD. CONCLUSION: TCD was a sensitive tool to diagnose BD, affording a reliable alternative examination to standard angiography.

Severe accidents due to windsurfing in the Aegean Sea.

Windsurfing is a popular sport and has recently become an Olympic event. As an open-air water activity that requires the participant to be in perfect physical condition, windsurfers may be prone to accidents when certain basic rules or procedures are violated. The current study monitored severe injuries due to windsurfing over a period of 12 months in the Aegean Sea in Greece. Our study revealed 22 cases of severe accidents due to windsurfing, with a wide range of injuries including head injuries, spinal cord injuries, and severe fractures of the extremities. Prolonged hospitalization, severe disability and two deaths occurred as consequences of these accidents. The study examined the characteristics of these patients and the possible risk factors and conditions associated with the accidents. We also focused on the most common types of injuries and reviewed the mechanisms that may provoke them. Water sports and particularly windsurfing represent a major challenge for the emergency medical system, especially in the Aegean Sea. Hundreds of islands, kilometres of isolated coasts, millions of tourists, an extended summer period and rapidly changing weather create conditions that constantly test the efficacy of the emergency services. The development of an appropriate infrastructure and maximum control of the risk factors causing these accidents could reduce the morbidity and mortality that, unfortunately but rather predictably, accompany this popular summer activity.

Immunohistochemical localization of extracellular matrix proteins in luteal phase endometrium of fertile and infertile patients.

The lack of expression of certain components involved in cell adhesion and migration is believed to contribute to endometrial dysfunction and implantation failure. The purpose of this study was to investigate whether luteal phase endometrium in women with unexplained infertility differs, with respect to specific extracellular matrix (ECM) proteins, from endometrium of normal fertile women. A panel of monoclonal antibodies to collagen type IV, fibronectin and laminin was used to characterize the localization of ECM components in the different endometrial compartments. Precisely timed endometrial biopsies obtained at 4, 7, 10 and 13 days following the luteinizing hormone surge were obtained from 22 normal fertile women (group 1) and 24 women suffering from unexplained infertility (group 2). Paraffin-embedded sections were labelled using the streptavidin-biotin alkaline phosphatase technique. In group 1, collagen type IV, fibronectin and laminin were absent from the luminal epithelium but present in stromal cells and the basement membrane of glands and blood vessels. In group 2, these components were absent from all endometrial regions using equivalent titres of antibody to those used in group 1. This suggests that the endometrium of women with unexplained infertility demonstrates defects in the distribution of certain ECM glycoproteins. A possible consequence of this defect may be implantation failure.

Transmyometrial embryo transfer after difficult immediate mock transcervical transfer.

OBJECTIVE: To evaluate the place of ultrasound-directed transvaginal transmyometrial ET in a protocol using both the transcervical and transmyometrial routes in a step-wise fashion. DESIGN: A prospective descriptive clinical study. SETTING: A university-based assisted conception unit. PATIENTS: Thirteen patients who had difficult or impossible mock transcervical ET immediately before the real transfer. INTERVENTION: Ultrasound-directed transvaginal transmyometrial ET. MAIN OUTCOME MEASURES: Pregnancy and clinical pregnancy. RESULTS: Four patients became pregnant, including three with clinical pregnancies. CONCLUSIONS: In cases in which transcervical ET isd difficult or impossible, transvaginal transmyometrial ET is a viable option. The use of mock transcervical ET immediately before the real transfer would identify patients needing transmyometrial ET.

Do patients need to remain in bed following embryo transfer? The Birmingham experience of 103 in-vitro fertilization cycles with no bed rest following embryo transfer.

Since the early days of human in-vitro fertilization and embryo transfer, rest in bed for hours immediately following the transfer has been advocated and widely practised. However, there is no scientific validation for this practice which is both time-consuming for the patient and increases space occupancy in the hospital or clinic. We report here on a study of 103 in-vitro fertilization cycles with no bed rest in hospital following the embryo transfer. The mean number of embryos transferred was 2.7 (range 1-3) and the clinical pregnancy rate per embryo transfer procedure was 40%. These results suggest that bed rest is not necessary following embryo transfer.

Early plasmapheresis in patients with thrombotic thrombocytopenic purpura.

OBJECTIVES: To investigate the relationship of thrombotic thrombocytopenic purpura to adult respiratory distress syndrome (ARDS) and study the responses of thrombotic thrombocytopenic purpura patients to early plasmapheresis. DESIGN: Case series. SETTING: ICU of a university hospital. PATIENTS: Twenty-four consecutive patients with thrombotic thrombocytopenic purpura, with various periods of time (1 to 18 days) having elapsed since the onset of this condition. Patients ranged in age from 17 to 66 yrs. INTERVENTIONS: Plasmapheresis, using intermittent flow separators, was instituted soon after the patients' ICU admission. The retinoscopic findings on admission and the relationship of Pao2 to platelet counts before and after plasmapheresis therapy were recorded. Antiplatelet agents were given to the survivors to prevent relapses. MEASUREMENTS AND MAIN RESULTS: Eighteen patients survived and six died. Plasmapheresis was administered for a range of 1 to 5 days (mean 3) and 3 to 18 days (mean 9.8) in survivors and nonsurvivors, respectively (p less than .001). Four patients with confluent fundus hemorrhages died and seven without these fundoscopic findings had easily controlled disease. Increases in Pao2 paralleled increases in platelet counts after plasmapheresis (p less than .001) in this small series of patients. Three of 18 discharged survivors relapsed over a period of 3 to 56 months of follow-up. CONCLUSIONS: Early introduction of plasmapheresis in thrombotic thrombocytopenic purpura seems to increase the survival rate and to halt the development of ARDS. Fundus findings may be a prognostic factor in thrombotic thrombocytopenic purpura. The antiplatelet agents seem to be efficacious in the prevention of relapses.

Pefloxacin versus imipenem in the therapy of nosocomial lung infections of intensive care unit patients.

In a prospective open randomized trial pefloxacin (400 mg, iv, 8-hourly) and imipenem (1 g, iv, 8-hourly) were given for 5-30 days to 35 and 36 ICU patients, respectively, suffering from bronchopneumonia (54) or purulent bronchitis (17). All were spiking high fevers (greater than or equal to 39 degrees C) while 25 and 26 patients in the two groups were under mechanical ventilation. Underlying predisposing disorders, mainly chronic obstructive pulmonary disease, ischaemic heart disease, neurological diseases and traumatic lung injuries, were encountered in almost all. In appropriate bronchial secretion cultures, multiresistant Acinetobacter anitratus (40), Pseudomonas aeruginosa (25), various Enterobacteriaceae (17) and Staphylococcus aureus (6) were isolated. A successful clinical response, as proved by elimination of abnormal lung x-ray findings, temperature normalization and decreases in oxygen requirements, permitting weaning from mechanical ventilation and/or removal of nasotracheal intubation, was observed in 23 patients given pefloxacin (65.7%) and 19 patients given imipenem (52.8%). The differences in clinical outcome did not reach statistical significance. During therapy pathogens persisted in 9 (25.7%) patients given pefloxacin versus 18 (50%) given imipenem (P less than 0.05), while persisters developed resistance to pefloxacin and imipenem in seven and 12 patients, respectively (P less than 0.05). Tolerance was excellent for both antimicrobials. In the therapy of lung infections in ICU patients, pefloxacin when compared to imipenem was associated with more promising results, lower numbers of persisting pathogens and a lower incidence of resistance development.