Temporal artery compression sign--a novel ultrasound finding for the diagnosis of giant cell arteritis.

PURPOSE: In patients with suspected giant cell arteritis (GCA), a search for the perivascular halo sign, a sophisticated color duplex ultrasound (CDU) finding, at experienced centers reliably identifies inflamed temporal arteries (TA). We tested whether TA compression in patients with GCA, a simple, largely operator-independent maneuver, elicits contrasting echogenicity between the diseased artery wall and the surrounding tissue (compression sign). MATERIALS AND METHODS: 80 individuals with suspected GCA were prospectively enrolled in this single-center study. In all study participants, bilateral ultrasound examination of the TA established the presence/absence of the halo and compression sign. A positive compression sign was defined as visibility of the TA upon transducer-imposed compression of the artery. Based on ACR criteria, a team of specialized physicians independently grouped patients as GCA versus non-GCA. RESULTS: 43/80 study participants were grouped as GCA. Both the halo sign and the compression sign were positive in 34/43 patients in the GCA group, and negative in all 37/37 of the non-GCA group, resulting in a sensitivity of 79 % and a specificity of 100 % for both the halo and the compression sign. CONCLUSION: In this cohort of individuals with suspected GCA, the halo sign and the compression sign were equal in their diagnostic performance. The simplicity of the compression sign suggests a level of reliability warranting further evaluation.

Prospective comparison of noninvasive, bedside ultrasound methods for assessing central venous pressure.

PURPOSE: To prospectively evaluate the accuracy of noninvasive central venous pressure (CVP) assessment by compression ultrasound of a forearm vein (CUS), inferior vena cava (IVC-C) and internal jugular vein collapsibility (IJV-C) compared to invasive CVP measurement (invCVP) as the gold standard. MATERIALS AND METHODS: CUS, IVC-C and IJV-C were performed in a random sequence in 81 consecutive intensive care patients with simultaneous invCVP monitoring. Examiners were blinded to invCVP and previous examinations. RESULTS: Median invCVP was 12.0 mmHg (range 1 - 23). CUS, IVC-C and IJV-C could be obtained in 89 %, 95 % and 100 % of cases, respectively, within a median time of 188 sec [IQR 125; 270], 133 sec [IQR 100; 211] and 60 sec [IQR 50; 109], respectively. The Spearman correlation coefficient between invCVP and CUS, IVC-C, and IJV-C was 0.485 95 %-CI [0.25; 0.65], -0.186 [-0.42; 0.07], and -0.408 [-0.59; -0.18], respectively. The median absolute difference between CUS and invCVP was 3 mmHg [IQR 2; 6.75]. CVP was categorized as low (< 7 mmHg; collapsibility > 0.6), normal (7 - 12 mmHg; collapsibility 0.6 - 0.2) and high (> 12 mmHg; collapsibility < 0.2) as prespecified. The proportions of identical CVP classifications compared to invCVP were 61.4% 95%-CI [49.3%; 72.4%] with CUS, 48.7% [37.4%; 60%] with IVC-C and 51.3% [40.3%; 62.3%] with IJV-C (p > 0.10 for all pair-wise comparisons). CONCLUSION: The overall ability of CUS, IVC-C and IJV-C to assess invCVP was only moderate. CUS seems to be the preferable method if absolute CVP values are needed. IJV-C seems to be the fastest and most easily acquirable method, and thus may be especially valuable in emergency rooms.

Nonirritant intradermal skin test concentrations of ciprofloxacin, clarithromycin, and rifampicin.

BACKGROUND: Intradermal skin testing of the clinically important antibiotics ciprofloxacin, clarithromycin, and rifampicin in the case of suspected allergies to antibiotics is poorly standardized. For clinical practice, standardized procedures and protocols are desired. METHODS: Fifteen healthy volunteers were tested with different concentrations of the antibiotics as well as with appropriate controls. Test readings included wheal area measured by digital image analysis and blood flow increase measured by laser Doppler flowmetry (LDF). To reduce interpersonal variability, test results were normalized with the individual controls using a novel protocol. RESULTS: Nonirritating concentrations of the three antibiotics (ciprofloxacin ~0.0067 mg/ml, clarithromycin ~0.05 mg/ml, rifampicin ~0.002 mg/ml) could be defined for healthy volunteers. Laser Doppler flowmetry generates comparable results to wheal area measurement. Normalization of the test results is necessary and can be applied in a practical algorithm. CONCLUSIONS: Standardized skin testing to detect sensitization to broadly used nonbetalactam antibiotics was presented and should be applied in truly sensitized patients. This approach should help to minimize the inter- and intraindividual differences in reactivity.

Calcium dobesilate in patients suffering from chronic venous insufficiency: a double-blind, placebo-controlled, clinical trial.

OBJECTIVE: To test the efficacy of calcium dobesilate (CaD) in chronic venous insufficiency (CVI). METHOD: Double-blind, parallel groups, placebo-controlled, multicentre trial in adult patients with symptomatic CVI and pitting oedema. Wearing of compression stockings Class II was admitted. During treatment period of eight weeks, the patients received CaD 3 × 500 mg/day or placebo. The leg volume calculation was based on a truncated cone model. RESULTS: A total of 256 patients was randomized to treatment (dobesilate: n = 132, placebo: n = 124); the demographic and anamnestic data at admission were comparable in the two therapeutic groups. The volume of the lower calf diminished in the dobesilate group at the end of the active treatment period by -64.72 ± 111.93 cm³ (mean ± SD), independent of the concomitant usage of compression stockings versus placebo +0.8 ± 152.98 cm³ (P = 0.0002). The symptoms of pain, discomfort, heavy legs, tired legs, tingling, itching and cramps, as well as the global assessments by investigators and patients, also improved significantly (P < 0.05) better in the dobesilate group at the end of the treatment. The observed adverse events correspond to the known profile. CONCLUSION: Dobesilate reduces leg oedema and improves the symptoms of objectively diagnosed CVI, independent of the concomitant usage of compression stockings.

Use of B-type natriuretic peptide to predict blood pressure improvement after percutaneous revascularisation for renal artery stenosis.

OBJECTIVES: The purpose of this study was to evaluate the utility of B-type natriuretic peptide (BNP) to predict blood pressure (BP) response in patients with renal artery stenosis (RAS) after renal angioplasty and stenting (PTRA). METHODS: In 120 patients with RAS and hypertension referred for PTRA, 24-h ambulatory BP recordings were obtained before and 6 months after intervention. BNP was measured before, 1 day and 6 months after PTRA. RESULTS: BP improved in 54% of patients. Median BNP levels pre-intervention were 97 pg ml(-1) (interquartile range (IQR) 35-250) and decreased significantly within 1 day of PTRA to 62 pg ml(-1) (IQR 24-182) (p < 0.001), remaining at 75 pg ml(-1) (IQR 31-190) at 6 months. The area under the receiver operating curve for pre-intervention BNP to predict BP improvement was 0.57 (95% confidence interval (CI) 0.46-0.67). Pre-intervention BNP >50 pg ml(-1) was seen in 79% of patients with BP improvement compared with 56% in patients without improvement (p = 0.01). In a multivariate logistic regression analysis, BNP >50 pg ml(-1) was significantly associated with BP improvement (odds ratio (OR) 4.0, 95% CI 1.2-13.2). CONCLUSIONS: BNP levels are elevated in patients with RAS and decrease after revascularisation. Although BNP does not seem useful as a continuous variable, pre-interventional BNP >50 pg ml(-1) may be helpful to identify patients in whom PTRA will improve BP.

Giant arteriovenous fistula after implantation of a percutaneous left ventricular assist device.

INTRODUCTION: Percutaneous left ventricular assist devices are an important tool in the management of patients with severe cardiogenic shock. Limited experiences concerning vascular complications after long term implantation of these devices exist. We report on a large arteriovenous fistula after placement of a left ventricular assist device, which has not been described in the literature. The arteriovenous fistula was of clinical relevance because it represented a supplementary cardiac burden in a patient with impaired left ventricular function after a severe myocardial infarction.

Intraoperative color duplex ultrasound during renal transplantation.

The purpose of this pictorial essay is to describe the role of intraoperative color duplex ultrasound in detecting vascular complications during renal transplantation. Intraoperative color duplex scanning during renal transplantation detects vascular complications noninvasively. Reasons for disturbed perfusion can be malposition or external compression, intravascular thrombi, vessel wall dissection and vasospasm. Color duplex ultrasound is a useful procedure in selected conditions with an intraoperatively suspected perfusion problem during renal transplantation.

Do we need new guidelines?

Early on in our medical training, we were told that experience is more important than knowledge in the medical field and that medicine is therefore not an exact science but an art. We were encouraged to become medical artists. Although this statement has proven to be largely correct, we perceived it as a provocation. The scientific nature of our profession of choice was being called into question. We had spent day and night cramming our heads full of knowledge and even after more than 30 years in the field were still trying to increase our knowledge on a daily basis, but this was apparently not highly valued. Based on the demands, the statement was justified and we are in fact shaped by medicine and the daily routine. In many critical situations intuition and experience, not learned data, determine what is right for a patient. It's not surprising that the terms "guidelines" and "quality control" set off mental warning bells in many colleagues who view medicine as an art. The reactions to new guidelines can be expected to range from an inexpressible feeling of discomfort to clear verbal rejection. The tem "total quality management" as specially developed and practiced in the Japanese auto industry will unavoidably be met with simple refusal. It is important for us to occasionally address quality assurance issues, and we must not avoid the necessary socio-economic discussion by hiding behind humanitarian and ethical arguments. One of the goals of the European Federation for Ultrasound in Medicine and Biology (EFSUMB) is quality assurance for ultrasound diagnostics [1]. As a result, the first guidelines for using ultrasound contrast agents were published in 2004 in Ultraschall in der Medizin/European Journal of Ultrasound, the official publication of EFSUMB [2]. An updated and enhanced version of these guidelines will be published in this issue [3]. These two publications are compatible with earlier publications regarding standardization [4-10], training [11-22]and continuing education [23-28].

Effect of bolus length of intraarterial injections on contrast-enhanced MR-angiography in patients.

PURPOSE: To perform MR-guided interventions, repetitive injections of contrast agent in the arterial system are necessary. By reducing the intraarterial bolus length during image acquisition and consecutively reducing the gadolinium-chelate-based contrast agent dose, we focus on a comparable vascular depiction. The tradeoff in reducing bolus length is vascular depiction. MATERIALS AND METHODS: Intraarterial gadolinium-chelate injection was performed to depict the femoropopliteal artery and infrapopliteal arteries in six patients. Six measurements with a bolus length of 20% to 100% of the total acquisition time were performed (three-dimensional [3D] Turbo-fast low-angle shot (FLASH) sequence, 1.5 T). Contrast-to-noise ratio (CNR) was determined and a consensus reading of vascular depiction was performed. RESULTS: CNR values comparable 100% of bolus length were obtained for the femoropopliteal artery at >or=40% and for the infrapopliteal arteries at >or=60%. Qualitative analysis demonstrated that a bolus length of >or=60% is necessary to reveal a good diagnostic vascular depiction. CONCLUSION: Quantitatively, a reduction of intraarterial gadolinium-chelate dosage in patients is possible down to 40% in the femoropopliteal artery and to 60% in the infrapopliteal arteries to acquire a CNR comparable to 100% of bolus length. Qualitatively, however, the bolus length can only be reduced down to 60% for both level to produce a good diagnostic vascular depiction and is, for diagnostic purposes, the limiting factor.