Quantitative assessment of carotid ultrasound diameter measurements in the operating room:a comparable analysis of long-axis versus rotated and tilted orientation

OBJECTIVE: Carotid ultrasound (US) has been studied as a non-invasive alternative for hemodynamic monitoring. A long-axis (LA) view is traditionally employed but is difficult to maintain and operator experience may impact the diameter estimates, making it unsuitable for monitoring. Preliminary results show that a new, i.e., rotated and tilted (RT) view is more robust to motion and less operator-dependent. This study aimed to quantitatively assess common carotid diameter estimates obtained in a clinical setting from an RT view and compare those to corresponding estimates obtained using other views.APPROACH: Carotid US measurements were performed in 30 adult cardiac-surgery patients (26 males, 4 females) with short-axis (SA), LA, and RT probe orientations, the first being used as a reference for measuring the true vessel diameter. Per 30-s acquisition, the median and spread in diameter values were computed, the latter representing a measure of robustness, and were statistically compared between views.MAIN RESULTS: The median (IQR) over all the patients of the median diameter per 30-s acquisition was 7.15 (1.15) mm for the SA view, 7.03 (1.51) mm for the LA view, and 6.99 (1.72) mm for the RT view. The median spread in diameter values was 0.18 mm for the SA view, 0.16 mm for the LA view, and 0.18 mm for the RT view. There were no statistically significant differences between views in the median diameter values (p=0.088) or spread (p=0.122).SIGNIFICANCE: The RT view results in comparable and equally robust median carotid diameter values compared to the reference. These findings open the path for future studies investigating the use of the RT view in new applications, such as in wearable ultrasound devices.</p

Уровень провоспалительных цитокинов внутриматочных смывов при гиперплазиях эндометрия

Проведено вивчення змін рівня прозапальних цитокінів ІЛ -1ß, ІЛ -6 та ФНП-α в маткових змивах у жінок з різними видами гіперплазій ендометрію. Встановлено, що формування гіперплазії ендометрію супроводжується активацією прозапальних цитокінів. Найбільш виражені зміни виявлені при комплексній гіперплазії ендометрію. Запальний процес в урогенітальної системі сприяє більш вираженому зростанню рівня цитокінів в маткових змивах. Оцінка вираженості змін в рівні цитокінів маткових змивів може використовуватися в якості додаткового критерію, що характеризує гіперплазії ендометрію, для оцінки формування запальних змін в ендометрії при його гіперплазії і для оцінки прогнозу перебігу гіперплазій.Levels of proinflammatory cytokines IL-1ß, IL-6 and TNF-α in uterine lavage fluid of women with different types of endometrial hyperplasia were studied. It is established that the formation of endometrial hyperplasia is associated with activation of proinflammatory cytokines. The most intensive changes were found in complex endometrial hyperplasia. Inflammation in the urogenital system leads to more intensive increase of cytokines level in the uterine washout. Investigation of changes in cytokines levels in uterine lavage fluid can be used as an additional criterion for characteristics of endometrial hyperplasia, to assess the formation of inflammatory changes in the endometrium and for prognosis of hyperplasia

Biplanar versus conventional two-dimensional ultrasound guidance for radial artery catheterisation

Background: Ultrasound guidance increases first-pass success rates and decreases the number of cannulation attempts and complications during radial artery catheterisation but it is debatable whether short-, long-, or oblique-axis imaging is superior for obtaining access. Three-dimensional (3D) biplanar ultrasound combines both short- and long-axis views with their respective benefits. This study aimed to determine whether biplanar imaging would improve the accuracy of radial artery catheterisation compared with conventional 2D imaging. Methods: This before-and-after trial included adult patients who required radial artery catheterisation for elective cardiothoracic surgery. The participating anaesthesiologists were experienced in 2D and biplanar ultrasound-guided vascular access. The primary endpoint was successful catheterisation in one skin break without withdrawals. Secondary endpoints were the numbers of punctures and withdrawals, scanning and procedure times, needle visibility, perceived mental effort of the operator, and posterior wall puncture or other mechanical complications. Results: From November 2021 until April 2022, 158 patients were included and analysed (2D=75, biplanar=83), with two failures to catheterise in each group. First-pass success without needle redirections was 58.7% in the 2D group and 60.2% in the biplanar group (difference=1.6%; 95% confidence interval [CI], –14.0%–17.1%; P=0.84), and first-pass success within one skin break was 77.3% in the 2D group vs 81.9% in the biplanar group (difference=4.6%; 95% CI, 8.1%–17.3%; P=0.473). None of the secondary endpoints differed significantly. Conclusions: Biplanar ultrasound guidance did not improve success rates nor other performance measures of radial artery catheterisation. The additional visual information acquired with biplanar imaging did not offer any benefit. Clinical trial registration: N9687 (Dutch Trial Register).</p

Proinflammatory T cells and IL-17 stimulate osteoblast differentiation

The local immune response is important to consider when the aim is to improve bone regeneration. Recently T lymphocytes and their associated cytokines have been identified as regulators in fracture callus formation, but it is not known whether T cells affect bone progenitor cells directly. The goal of this in vitro study was to investigate the role of different T cell subsets and their secreted factors on the osteogenic differentiation of human mesenchymal stem cells (MSCs). Significant increases in the alkaline phosphatase activity and the subsequent matrix mineralization by MSCs were found after their exposure to activated T cells or activated T cell-derived conditioned medium. Blocking IFN-γ in the conditioned medium abolished its pro-osteogenic effect, while blocking TGF-β further enhanced osteogenesis. The relative contribution of an anti- or proinflammatory T cell phenotype in MSC osteogenic differentiation was studied next. Enrichment of the fraction of anti-inflammatory regulatory T cells had no beneficial osteogenic effect. In contrast, soluble factors derived from enriched T helper 17 cells upregulated the expression of osteogenic markers by MSCs. IL-17A, and IL-17F, their main proinflammatory cytokines, similarly exhibited strong osteogenic effects when exposed directly to MSCs. IL-17A in particular showed a synergistic action together with bone morphogenetic protein 2. These results indicate that individual T cell subsets, following their activation, affect osteoblast maturation in a different manner through the production of soluble factors. From all T cells, the proinflammatory T cells, including the T helper 17 cells, are most stimulatory for osteogenesis

Quantitative assessment of carotid diameter measurements in parallel versus rotated and tilted orientation using ultrasound in the operating room:a comparative analysis

Introduction. Hemodynamic monitoring is of utmost importance when treating critically ill patients, but the currently used techniques are invasive and related with catheter-related complications. Over the last two decades, carotid artery ultrasound (US) was investigated as a non-invasive alternative for hemodynamic monitoring, including cardiac output estimation. Both vessel diameter and blood velocity are needed to compute blood flow in a vessel. Traditionally, carotid flow measurements are performed with the US probe oriented in the long-axis (LA) view [1]. Assuming a circular cross-section of the vessel and a parabolic flow profile, the probe should be properly positioned along the mid-axis to obtain an accurate blood flow estimation. However, obtaining and maintaining this mid-axis parallel view is difficult and literature describes that operator experience may impact the reliability of carotid flow measurements [2]. While the short-axis (SA) view allows for measurement of the true diameter, it does not allow for velocity estimation as the Doppler frequency shift approaches 0 degrees. Another way of assessing the cross-section of the carotid artery is by rotating and tilting (RT) the probe, a view that is easier to visualize and assess for sonographers. Regarding velocity measurements, preliminary research showed that the RT view was more robust to motion and less operator-dependent than the LA view [3]. To our knowledge, there is no literature regarding clinical diameter estimates with the RT view.Objectives. To evaluate the use of the RT view in a clinical setting, and to compare it with the LA and SA views using systolic diameter and spread of systolic diameter estimates per acquisition. The spread of systolic diameter values serves as a measure of robustness.Methods. We performed 30 s US acquisitions of the carotid artery in adult cardiac surgery patients, with a LA, SA, and RT probe orientation. The 30 s US recordings were analyzed to derive a diameter waveform. From this, we computed the systolic diameter values and a measurement of spread (calculated as the IQR of the systolic diameter estimates per acquisition) and investigated for potentially significant differences between views. Results. US acquisitions were performed in 29 patients. The median systolic diameter (IQR) per 30 s acquisition was 7.08 (1.59) mm, 7.22 (1.20) mm, and 6.95 (1.77) mm for the LA, SA, and RT views, respectively (Fig. 1). The median spread (IQR) per 30 s acquisition was 0.12 (0.13) mm, 0.10 (0.10) mm, and 0.09 (0.10) mm for the LA, SA, and RT views, respectively. Normality was checked using the Shapiro–Wilk test and Friedman tests showed no statistically significant difference between the views for either the median (p=0.142) or spread (p=0.786) of systolic diameter per 30 s acquisition. Conclusions. It was feasible to acquire data and derive diameter estimates using the three probe orientations. The median and spread in systolic diameter values per 30 s acquisition were comparable for the LA, SA, and RT views, suggesting that the different views result in evenly robust measurements and can be used interchangeably to obtain diameter estimates. This study opens the path for further investigation of the newly introduced RT view for new applications and possibilities, such as hands-free measurements

Quantitative Assessment Of Carotid Diameter Measurements In Parallel Versus Rotated And Tilted Orientation Using Ultrasound In The Operating Room - A Comparative Analysis

Hemodynamic monitoring is of utmost importance when treating critically ill patients, but currently used techniques are invasive and associated with catheter-related complications. Carotid artery ultrasound (US) has been investigated as a non-invasive alternative, including for cardiac output estimation, in which vessel diameter and blood flow velocity are needed to compute flow. Traditionally, carotid flow measurements are performed in the long-axis (LA) view, in which the probe should be properly positioned along the mid-axis to obtain an accurate blood flow calculation. However, obtaining and maintaining this mid-axis LA view is difficult, and operator experience may impact the reliability of the measurements. Therefore, a view that is robust to motion while providing accurate diameter and velocity estimates is clinically desirable. An alternative view is obtained by rotating and tilting the probe, which is easier to visualize and assess for sonographers, and preliminary evidence suggests it might be more robust to motion and less operator-dependent than the LA view. To evaluate these findings in a clinical setting, we performed carotid Doppler measurements in 25 adult cardiac surgery patients with a LA and RT probe orientation intending to compare diameter estimates. Short-axis (SA) measurements were used as a reference, as these represent the most truthful depiction of the vessel's cross-sectional area. Per 30s US recording, the median and spread in diameter values were computed and differences between views were statistically compared. Preliminary results of the first 18 patients show that the median RT diameter values were comparable to those of the SA (p=0.349), whereas the median LA values were smaller (p&lt;0.001). With respect to the SA view, the spread in diameter values during the 30s measurements was lower for the RT view (p=0.014) and comparable for the LA view (p=0.306). These preliminary findings seem promising for the usage of the RT view to enable free-hand US measurements and usage of the view in wearable US devices. Future analysis comprises expansion of the current results and investigating inter- and intra-operator reliability of the different views

Biplanar versus conventional two-dimensional ultrasound guidance for radial artery catheterisation

Background: Ultrasound guidance increases first-pass success rates and decreases the number of cannulation attempts and complications during radial artery catheterisation but it is debatable whether short-, long-, or oblique-axis imaging is superior for obtaining access. Three-dimensional (3D) biplanar ultrasound combines both short- and long-axis views with their respective benefits. This study aimed to determine whether biplanar imaging would improve the accuracy of radial artery catheterisation compared with conventional 2D imaging. Methods: This before-and-after trial included adult patients who required radial artery catheterisation for elective cardiothoracic surgery. The participating anaesthesiologists were experienced in 2D and biplanar ultrasound-guided vascular access. The primary endpoint was successful catheterisation in one skin break without withdrawals. Secondary endpoints were the numbers of punctures and withdrawals, scanning and procedure times, needle visibility, perceived mental effort of the operator, and posterior wall puncture or other mechanical complications. Results: From November 2021 until April 2022, 158 patients were included and analysed (2D=75, biplanar=83), with two failures to catheterise in each group. First-pass success without needle redirections was 58.7% in the 2D group and 60.2% in the biplanar group (difference=1.6%; 95% confidence interval [CI], –14.0%–17.1%; P=0.84), and first-pass success within one skin break was 77.3% in the 2D group vs 81.9% in the biplanar group (difference=4.6%; 95% CI, 8.1%–17.3%; P=0.473). None of the secondary endpoints differed significantly. Conclusions: Biplanar ultrasound guidance did not improve success rates nor other performance measures of radial artery catheterisation. The additional visual information acquired with biplanar imaging did not offer any benefit. Clinical trial registration: N9687 (Dutch Trial Register)

Applications of rotational thromboelastometry in heparin monitoring in critical COVID-19 disease: Observations in the Maastricht Intensive Care COVID cohort

Background: Critically ill COVID-19 patients are at risk for venous thromboembolism (VTE). Therefore, they receive thromboprophylaxis and, when appropriate, therapeutic unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH). To monitor heparins in COVID-19 disease, whole-blood rotational thromboelastometry (ROTEM) may be a promising alternative to the aPTT and anti-Xa assays. Objective: To evaluate the ROTEM INTEM/HEPTEM ratios in mechanically ventilated COVID-19 patients treated with UFH and therapeutic LMWH. Material and methods: A subcohort of mechanically ventilated COVID-19 patients of the prospective Maastricht Intensive Care Covid (MaastrICCht) cohort was studied. Anti-Xa, aPTT, and ROTEM measurements following treatment with UFH or therapeutic dose of LMWH (nadroparin) were evaluated using uni- and multivariable linear regression analysis and receiver operating characteristics. Results: A total of 98 patients were included, of which 82 were treated with UFH and 16 with therapeutic LMWH. ROTEM-measured INTEM/HEPTEM CT ratio was higher in patients using UFH (1.4 [1.3–1.4]) compared to patients treated with LMWH (1.0 [1.0–1.1], p < 0.001). Both the aPTT and anti-Xa were associated with the CT ratio. However, the β-regression coefficient (95%CI) was significantly higher in patients on UFH (0.31 (0.001–0.62)) compared to therapeutic LMWH (0.09 (0.05–0.13)) for comparison with the anti-Xa assay. Furthermore, ROC analysis demonstrated an area under the curve for detecting UFH of 0.936(0.849–1.00), 0.851(0.702–1.000), and 0.645(0.465–0.826) for the CT ratio, aPTT, and anti-Xa, respectively. Conclusion: The ROTEM INTEM/HEPTEM CT ratio appears a promising tool to guide anticoagulant therapy in ICU patients with COVID-19 disease, but associations with clinical endpoints are currently lacking