Imágenes Doppler de arterias intrapulmonares dentro de la atelectasia y su impacto en la poscarga del ventrículo derecho con ecocardiografía transesofágica / Doppler images of intrapulmonary arteries within atelectasis and its impact on right ventricular afterload with transesophageal echocardiography

La cirugía cardíaca por toracoscopia videoasistida (VATS) requiere ventilación unipulmonar (VUP) y monitorización con ecografía transesofágica (ETE). Utilizando Doppler color y espectral es posible estudiar el patrón de flujo sanguíneo en los vasos pulmonares dentro del pulmón atelectasiado. El objetivo de este reporte de casos es evidenciar la habilidad de la ETE para detectar el flujo sanguíneo dentro del pulmón atelectásico, así como también valorar la resistencia vascular pulmonar (RVP) y poscarga del ventrículo derecho, utilizando esta misma herramienta. Hallazgos: Tres adultos anestesiados y ventilados mecánicamente programados para cirugía cardíaca por VATS fueron escaneados con ETE cardiopulmonar. Una vez que se realizó la VUP quedando el pulmón derecho sin ventilar, la sonda se giró desde el corazón para lograr un escaneo pulmonar 2D y con Doppler color para detectar el flujo de sangre dentro del parénquima pulmonar consolidado. Se pudo identificar el patrón de flujo correspondiente a las ramas de la arteria intrapulmonar. La RVP fue registrada aplicando Doppler pulsado cardíaco, basal luego de la inducción de anestesia general, a los 20min de la VUP y al finalizar la VUP, luego de realizar una maniobra de reclutamiento alveolar (MRA) que condujo a la resolución completa de la consolidación mencionada. Conclusiones: La ETE cardiopulmonar es una herramienta de imagen semiinvasiva que permite no solo el diagnóstico y estudio de atelectasias inducidas por VUP, sino también el análisis del shunt dentro de esta consolidación y sus posibles consecuencias en la RVP.(AU)

Video-assisted thoracoscopy (VATS) cardiac surgery requires one-lung ventilation (OLV) and transoesophageal ultrasound (TOE) monitoring. Colour and spectral Doppler make it possible to study the pattern of blood flow in the pulmonary vessels within the atelectatic lung. In this case report we describe how TOE can be used to detect blood flow within the atelectatic lung and to assess pulmonary vascular resistance (PVR) and right ventricular afterload. Findings: Three anaesthetised, mechanically ventilated adults scheduled for VATS cardiac surgery were monitored using TOE. After left OLV, the transducer was rotated away from the heart to obtain 2D colour Doppler images of blood flow within the consolidated lung parenchyma. We were able to identify the flow pattern of the intrapulmonary branches of the pulmonary artery. PVR was recorded using pulsed cardiac Doppler at baseline, after induction of general anaesthesia, 20min after OLV and at the end of OLV, and after performing an alveolar recruitment manoeuvre (ARM) that led to complete resolution of the aforementioned consolidation. Conclusions: TOE is a semi-invasive imaging tool that can be used to diagnose and study PVR-induced atelectasis and to analyse the resulting pulmonary shunt and its possible effect on PVR.(AU)

Doppler images of intrapulmonary arteries within atelectasis and its impact on right ventricular afterload with transesophageal echocardiography.

Video-assisted thoracoscopy (VATS) cardiac surgery requires one-lung ventilation (OLV) and transoesophageal ultrasound (TOE) monitoring. Colour and spectral Doppler make it possible to study the pattern of blood flow in the pulmonary vessels within the atelectatic lung. In this case report we describe how TOE can be used to detect blood flow within the atelectatic lung and to assess pulmonary vascular resistance (PVR) and right ventricular (RV) afterload. FINDINGS: Three anaesthetised, mechanically ventilated adults scheduled for cardiac surgery by VATS were scanned with TOE. After left OLV, the transducer was rotated away from the heart to obtain 2D colour Doppler images of blood flow within the consolidated lung parenchyma. We were able to identify the flow pattern of the intrapulmonary branches of the pulmonary artery. PVR was recorded using pulsed cardiac Doppler at baseline, after induction of general anaesthesia, 20 min after OLV and at the end of OLV, and after performing an alveolar recruitment manoeuvre (ARM) that led to complete resolution of the aforementioned consolidation. CONCLUSIONS: TOE is a semi-invasive imaging tool that can be used to diagnose and study PVR-induced atelectasis and to analyse the resulting pulmonary shunt and its possible effect on PVR.

Whole-body magnetic resonance imaging in the evaluation of children with fever without a focus.

BACKGROUND: Fever without a focus is defined as a temperature of 38° C or higher as the single presenting symptom. After extensive investigation, a large percentage (12-67%) of cases remain undiagnosed. OBJECTIVE: To assess the diagnostic value of whole-body magnetic resonance imaging (WB-MRI) in children with fever without a focus. MATERIALS AND METHODS: A retrospective study was performed to identify children who underwent WB-MRI for fever without a focus. Ninety-two children, 50 boys, with a mean age of 6.1 years were included. A multidisciplinary team of physicians completed in consensus a medical record review that included: 1) immune status, 2) underlying chronic conditions, 3) hospitalization status at onset of fever, and 4) results of tissue, body fluid cultures and biopsies. Original MRI reports were evaluated. WB-MRI studies were categorized into helpful WB-MRI and not helpful WB-MRI. RESULTS: A final diagnosis for the cause of the fever was available for 68/92 cases (73.9%), which were determined to be infectious in 33/68 (48.5%), oncological in 3/68 (4.4%), rheumatological etiologies in 23/68 (33.8%) and miscellaneous in 9/68 (13.2%) cases. WB-MRI was found to be helpful in 62/92 cases (67.4%) and not helpful in 30/92 cases (32.6%). WB-MRI was 10.2 times less likely to be helpful in immunosuppressed children and almost 5.7 times less likely to be helpful in cases of prolonged fever (>3 weeks) at the time of MRI (P≤0.01). CONCLUSION: WB-MRI provides helpful information in approximately 2/3 of children with fever without a focus. In most cases, it was helpful to exclude the need of further investigation.

Tromboembolismo intracardíaco durante trasplante hepático / Intracardiac tromboembolism during liver transplantation

Describimos un caso de trombosis cardíaca intraoperatoria durante una cirugía de trasplante ortotópico hepático que derivó en muerte intraoperatoria. Mediante ecocardiografía transesofágica, colocada durante la descompensación del paciente, se pudo determinar la causa del problema y observar con precisión el mecanismo de migración de trombos desde la circulación venosa hacia el corazón izquierdo

We describe a case of intraoperative cardiac trombosis during orthotopic liver transplant surgery that resulted in intraoperative death. By using transesophageal echocardiography, the cause of the descompensation of the patient could be determined and the mechanism of trombus migration from thrombi from the venous circulation to the left heart was accurately observed

Intracardiac tromboembolism during liver transplantation. / Tromboembolismo intracardíaco durante trasplante hepático.

We describe a case of intraoperative cardiac trombosis during orthotopic liver transplant surgery that resulted in intraoperative death. By using transesophageal echocardiography, the cause of the descompensation of the patient could be determined and the mechanism of trombus migration from thrombi from the venous circulation to the left heart was accurately observed.

Improving health in cities through systems approaches for urban water management.

BACKGROUND: As human populations become more and more urban, decision-makers at all levels face new challenges related to both the scale of service provision and the increasing complexity of cities and the networks that connect them. These challenges may take on unique aspects in cities with different cultures, political and institutional frameworks, and at different levels of development, but they frequently have in common an origin in the interaction of human and environmental systems and the feedback relationships that govern their dynamic evolution. Accordingly, systems approaches are becoming recognized as critical to understanding and addressing such complex problems, including those related to human health and wellbeing. Management of water resources in and for cities is one area where such approaches hold real promise. RESULTS: This paper seeks to summarize links between water and health in cities and outline four main elements of systems approaches: analytic methods to deal with complexity, interdisciplinarity, transdisciplinarity, and multi-scale thinking. Using case studies from a range of urban socioeconomic and regional contexts (Maputo, Mozambique; Surat and Kolkata, India; and Vienna, Austria). CONCLUSION: We show how the inclusion of these elements can lead to better research design, more effective policy and better outcomes.

Diagnostic Performance of Whole-Body MRI as a Tool for Cancer Screening in Children With Genetic Cancer-Predisposing Conditions.

OBJECTIVE: Children with cancer-predisposing conditions are at increased risk to develop and die of cancer. Limited data exist on the utility of whole-body MRI as a cancer screening tool in children. In this study, we examined the diagnostic performance of whole-body MRI as a mechanism of tumor surveillance for children at increased genetic risk for cancer. MATERIALS AND METHODS: Twenty-four children (six boys and 18 girls) with a mean age of 11.2 years (range, 2.1-18.2 years) underwent 50 unenhanced whole-body MRI examinations over a 5-year period. Scans were retrospectively reviewed and assessed for image quality; sequences performed; and the presence of osseous, soft-tissue, or solid organ abnormalities. Findings suggestive of a malignancy were stratified by risk as low (< 20% chance for cancer), moderate (20-80%), or high (> 80%). MRI findings were correlated with medical records, biopsy results, or additional follow-up imaging; biopsy and follow-up were considered as the reference standards. RESULTS: Forty-eight of 50 (96%) examinations were of very good quality. Nine findings suspicious for malignancy were identified, including two high-risk, two moderate-risk, and five low-risk lesions. One high-risk lesion was proven by biopsy to be a papillary thyroid carcinoma, with the remaining lesions deemed nonmalignant. The sensitivity of whole-body MRI was 100%; specificity, 94%; positive predictive value, 25%; and negative predictive value (NPV), 100%. CONCLUSION: Unenhanced whole-body MRI is safe and produces excellent images. The high sensitivity, specificity, and NPV make whole-body MRI a valuable cancer screening tool in children with a genetic predisposition for cancer.

Reference values of MRI measurements of the common bile duct and pancreatic duct in children.

BACKGROUND: Magnetic resonance imaging/cholangiopancreatography (MRI/MRCP) is now an essential imaging modality for the evaluation of biliary and pancreatic pathology in children, but there are no data depicting the normal diameters of the common bile duct (CBD) and pancreatic duct. Recognition of abnormal duct size is important and the increasing use of MRCP necessitates normal MRI measurements. OBJECTIVE: To present normal MRI measurements for the common bile duct and pancreatic duct in children. MATERIALS AND METHODS: In this retrospective study we searched all children ages birth to 10 years in our MR urography (MRU) database from 2006 until 2013. We excluded children with a history of hepatobiliary or pancreatic surgery. We stratified 204 children into five age groups and retrospectively measured the CBD and the pancreatic duct on 2-D axial and 3-D coronal T2-weighted sequences. We performed statistical analysis, using logistic and linear regressions to detect the age association of the visibility and size of the duct measurements. We used non-parametric tests to detect gender and imaging plane differences. RESULTS: Our study included 204 children, 106 (52%) boys and 98 (48%) girls, with a median age of 33 months (range 0-119 months). The children were distributed into five age groups. The common bile duct was visible in all children in all age groups. The pancreatic duct was significantly less visible in the youngest children, group 1 (54/67, 80.5%; P = 0.003) than in the oldest children, group 5 (22/22, 100%). In group 2 the pancreatic duct was seen in 19/21 (90.4%), in group 3 52/55 (94.5%), and in group 4 39/39 (100%). All duct measurements increased with age (P < 0.001; r-value > 0.423), and the incremental differences between ages were significant. The measurement variations between the axial and coronal planes were statistically significant (P < 0.001); however these differences were fractions of millimeters. For example, in group 1 the mean coronal measurement of the CBD was 2.1 mm and the axial measurement was 2.0 mm; the mean coronal measurement of the pancreatic duct was 0.9 mm and the axial measurement was 0.8 mm. CONCLUSION: Our study provides normative measurements for the common bile duct and pancreatic duct for children up to age 10 years. The upper limits of the CBD and pancreatic duct increase with age, and the values range 1.1-4.0 mm for the CBD and 0.6-1.9 mm for the pancreatic duct.