Correlation between dialysis solution type and cardiovascular morbidity rate in patients undergoing continuous ambulatory peritoneal dialysis

Background/Aim. Peritoneal dialysis (PD) patients have an increased risk for cardiovascular diseases. The aim of the study was to evaluate the cardiovascular changes in patients undergoing chronic PD and the eventual existing differences depending on biocompatibility of dialysis solutions. Methods. After 3±2 years of starting PD, 21 PD patients on the treatment with bioincompatible dialysis solutions (conventional glucose- based solutions: PDP-1), average age 47.43±12.87 years, and 21 PD patients on the treatment with biocompatible dialysis solutions (neutral solutions with lower level of glucose degradation products, lower concentration of Ca2+ and neutral pH: PDP-2), average age 68.62±13.98 years, participated in the longitudinal study. The average number of episodes of peritonitis was similare in both groups: 1 episode per 36 months of the treatment. The control group included 21 patients with preterminal phase of chronic renal failure (Glomerular Filtration Rate: 22.19±10.73 ml/min), average age 65.29± 13.74 years. All the patients underwent transthoracal echocardiography (in order to detect: eject fraction (EF), left ventricular hypertrophy (LVH), and valvular calcification (VC) and B-mode ultrasonography of common carotid artery (CCA): IMT, lumen narrowing, and plaque detection. Results. The values of EF were: in PDP-1 group 62.05±5.65%, in PDP-2 group 53.43±7.47%, and in the control group 56.71±8.12% (Bonferroni test, p = 0.001). The recorded LVH was: in PDP-1 group in 47.6% of the patients; in PDP-2 group in 61.9% of the patients; and in control the group in 52.4% (χ2 test; p = 0.639). The detected VC was: in PDP-1 in 52.4% of the patients, in PDP-2 group in 42.9% of the patients, and in the control group in 23.8% of the patients (χ2 test; p = 0.776). The IMT was: in PDP-1 group 1.26±0.54 mm, in PDP-2 group 1.23±0.32, and in the control group 1.25±0.27 mm (Bonferroni test; p = 0.981). An average lumen narrowing was: in PDP-1 group 13.78±18.26%, in PDP-2 group 18.57±22.98%, and in the control group 25.00±28.02% (Kruskal Wallis test; p = 0.413). Calcified plaques of CCA were detected in PDP-1 group in 61.9% of the patients, in PDP-2 group in 85.7%, of the patients and in the control group in 81% of the patients (χ2 test; p = 0.159). Conclusion. Generally, PD had a significant influence on cardiovascular morbidity in the treated patients, especially on the left ventricular function and peripherial atherosclerosis. The age of the patients had more influence on acceleration of atherosclerosis than the length of dialysis or biocompatibility of dialysis solutions

Ultrasonographic assessment of the maxillary artery and middle meningeal artery in the infratemporal fossa

Purpose: To investigate with Doppler ultrasonography the maxillary and middle meningeal arteries in the infratemporal fossa, and describe their hemodynamic characteristics. Methods: We included 24 female and 11 male volunteers without vascular diseases, with a median age of 43 years. We used the acoustic window, enlarged by subjects half-opening their mouth, located below the zygomatic arch, in front of temporo-mandibular joint, to reach the maxillary and middle meningeal arteries. Results: In the 35 subjects, 112 arteries were visualized successfully: 60 maxillary (85.7%), and 52 middle meningeal arteries (74.3%), at a depth of 2.40 and 2.50 cm, respectively. Their blood flow was directed anteriorly and away from the probe. While all the measured hemodynamic characteristics differed significantly between the maxillary and the middle meningeal artery (P < 0.001), there was no significant difference between male and female subjects, nor between the left or the right side. Conclusions: The maxillary and middle meningeal arteries can be insonated in the infratemporal fossa through the easily accessible acoustic window below the zygomatic arch, when the patient holds his mouth half open. They can be differentiated by their ultrasonographic characteristics and blood flow features

Importance of angle corection in transcranial color-coded duplex insonation of arteries at the base of the brain

Background/Aim. Transcranial color-coded duplex (TCCD) sonography allows visualization of the vessels being examined and measurement of the angle of insonation. The published literature suggests that blood vessels are insonated at the angle lower than 30 degrees, hence no correction for the angle is necessary. The aim of this study was to determine the availability of intracranial blood vessels for insonation, and the percentage of arteries and their segments which can be insonated at the angles lower than 30 degrees. Methods. The study included 120 patients (mean age 51). For each of the segments the angle of insonation was registered based on TCCD vizualization, and hemodynamic parameters were measured. The angle of insonation was measured using combined B-mode and color Doppler vizualization, as the angle between the direction of the ultrasound beam and the axis of the shown arterial segment. Results. The total success rate of insonation was 86.33% (1,554 out of 1,800). The mean angle of insonation value in all the examined arterial segments was 42 degrees. The insonation angle was higher than 30 degrees in about three quarters of the examined segments, especially in the A2 segment of the anterior cerebral artery (98%), the P1 segmet of the posterior cerebral artery (87%) and in the terminal internal carotid artery (83%). The A1 segment of the anterior cerebral artery showed the best insonation conditions with the angle of insonation lower than 30 degrees in 53% of the cases. Conclusion. The presented results of angles of insonation measurements for the anterior, middle and posterior cerebral arteries and their segments, as well as the terminal portion of the internal carotid artery clearly indicate that their average values in tested segments were very often higher than 30 degrees, which can cause an error in blood flow velocity measurement that cannot be ignored. The results confirm the necessity of correcting flow velocity values on the basis of the angle of insonation in TCCD sonography

Comparative analgesic efficacy of ultrasound-guided nerve blocks induced by three anesthetics with different duration of action in the treatment of resistant neuropathic pain in the lower extremities

Background/Aim. The neuropathic pain (NP) treatment is a big medical and socioeconomical problem. The new sorts of the NP treatment was developed and are applied in case of a medical treatment failure. The aim of this work was to investigate the efficacy of the ultrasound-assisted treatment of the resistant and chronic peripheral neuropathic pain with the local anesthetic nerve blocks. Due to the inefficacy of conventional treatment, three local anesthetics (shortacting, medium-term and long-acting) were administered in a series of the same minimal dose on a daily basis. Complications, side effects, the execution time of procedure and the onset time of local anesthetic were also investigated. Methods. In this prospective, randomized and doubleblinded study, 108 patients (of which 53 were diagnosed with diabetes and 55 with radiculopathy) with the resistant and chronic peripheral neuropathic pain in the lower extremities were treated with a series of ultra-sound assisted peripheral nerve blocks. The conventional treatment was exhausted. The presence of this neuropathic pain was confirmed by, at least, one of the three scales – the Leeds Assesment of Neuropathic Simptoms and Signs (LANSS) scale, the Dolour Neuropathic 4 questions (DN4) scale and the pain DETECT(PD-Q) scale. Other therapies were not applied. The nerve blocks were administered on a daily basis until the relief of pain (visual analogue scale – VAS 50% – excellent results; 31–49% – good results; < 30% the therapy did not work. The side effects, complications, the execution duration of procedure, the onset time of numbness, the number of corrections of the needle direction were recorded as well. Results. For all three groups: nerve blocks took 5.4 ± 1.48 minutes to do (withouth difference among the groups), the onset of numbness occured, on average, within 3.75 ± 2.62 minutes (withouth differences among the groups), and the need for corrections of needle direction was minimal (1.03 ± 0.17 corrections). All the patients experienced a loss of pain sensation (VAS < 30); when a long-acting anesthetic was used, the number of required nerve blocks was significant (p < 0.001) smallest (4.33 ± 0.63 blocks), than in other two groups, and the percentage pain reduction was highest (73.13%) (p < 0.001). The pain relief lasted one month after the therapy without the application of any other therapy. Neither complications nor side effects were observed. Conclusion. The procedure dercibed is a safe, efficient and easy-to-perform and does not lead to any complications and side effects. The pain relief is achieved most effectively and rapidly with the longacting local anesthetics, and maintained even for one month without the introduction of any additional therapy

Does the blood glucose control have an effect on the success of the painful diabetic neuropathy treatment?

Background/Aim. Diabetic neuropathy (DN) is the basic complication of diabetes, associated with impared glucoregulation, metabolic distrurbances, microvascular vessel damage and increased cardiovascular risk. We monitored the impact of glucoregulation on the efficacy of painful diabetic neuropathy (PDN) treatment, when all pharmaceutical treatment options were exhausted. Methods. Patients (n = 53, both gender, average age 68.3 ± 12.6) with PDN resistant to the pharmacotherapy were treated with the ultrasound- guided local anesthetic (0.5% procaine hydrochloride, 1% lidocaine, 0.25% levobupivacaine) blocks. Neuropathy was confirmed in accordance with the applicable European Federation of Neurological Societies (EFNS) criteria. Glycosylated hemoglobin (HbA1C) and blood glucose levels were monitored before and after therapy and one month after the treatment. Neuropathic pain was confirmed by Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) or Douleur neuropathique (DN4) or pain DETECT scales. The pain intensity was assessed by Visual analog scale, Neuropathic pain symptom and Neuropathic pain symptom inventory (VAS, NPS and NPSI, respectively) scales before and after therapy and one month after the treatment. The efficacy of the therapy was assessed as: excellent result (> 50% of pain loss), good result (30%–49% of pain loss and the therapy does not work (< 30% of pain loss). The correlation between glucoregulation and the outcome was examined. Results. Because the values of glycenia and HbA1c were not different among patients treated with different local anesthetics, they were presented together. All patients had elevated blood glucose and HbA1C levels before (8.23 ± 2.77 mmol/L and 8.53% ± 2.48% respectively), after (8.43 ± 2.461 mmol/L and 8.85% ± 2.87%, respectively) and one month after the treatment (8.49 ± 2.22 mmol/L and 8.51% ± 2.09%, respectively). The loss of the pain was not result of the decrease in blood glucose and HbA1C blood levels. VAS, NPS, NPSI values were the following before the therapy: 81.53 ± 11.62 mm; 62.00 ± 13.04; 53.40 ± 17.63, respectively; after the therapy: 29.00 ± 9.23 mm; 13.79 ± 6.65; 11.83 ± 7.93, respectively; and one month later: 26.15 ± 8.41 mm; 12.68 ± 6.03; 9.81 ± 7.64, respectively]. There was no correlation between glucoregulation and excellent outcome. Conclusion. Even though the disturbance of glucose control is the key factor for the progression of PDN, it is not significant for the outcome of the pain treatment. New investigations are required

The Protective and Dose-Dependent Effects of L-Name in Aluminium-Induced Neurotoxicity

Numerous research studies have undoubtedly shown that aluminium is a very harmful substance which enters the human body externally from the environment. The aluminum intake usually happens unintentionally, due to the fact that people know little about its prevalence in water, factory-processed foods, medicines, cosmetics, etc. When accumulated in human organs, it can cause severe damage, and even lead to chronic neurodegenerative diseases, including Alzheimer‘s disease. The extent to which nitric oxide (NO) is involved in the basic mechanisms of aluminum neurotoxicity, like oxidative stress and the antioxidant defense, is intriguing scientific community. In this chapter are presented results of the intrahippocampal application of aluminum chloride and a pretreatment with Nω-nitro-L-arginine methyl ester (L-NAME), the non-selective inhibitor of nitric oxide synthase activities. It turned out that, in order to avoid erroneous conclusions about NO not being involved in aluminium-induced neurotoxicity, it was necessary to titrate the dose of L-NAME (1, 10 and 100 micrograms). Among the three doses applied prior to the application of aluminum, only the highest dose acted as an antioxidant in the four examined brain structures.Jelenković A, editor. Aluminum Neurotoxicity: From Subtle Molecular Lesions to Neurological Diseases. Nova Science Publishers; 2016. p. 69–90

A Spontaneous Cervical Epidural Hematoma Mimicking a Stroke: A Challenging Case

Background: A spontaneous cervical epidural hematoma (SCEH) is a rare occurrence, with < 500 cases reported to date. Clinically, it usually presents with quadriparesis, but in extremely rare cases it can present with hemiparesis or hemiplegia, and can easily be misdiagnosed as stroke. The cervical epidural hematoma by itself is an urgent condition that requires a quick and accurate diagnosis and a prompt surgical treatment. Case Report: We present a case where an SCEH mimicked the much more frequent condition of a stroke, and discuss the importance of diagnostics procedures that help differentiate SCEH from acute cerebral infarction. The patient's history of neck pain and spondylosis render this case more challenging. Why Should an Emergency Physician Be Aware of This?: Considering that the emergency tissue plasminogen activator treatment for acute cerebral infarction can worsen the state of an SCEH patient, or even lead to permanent damage or death, it is of great importance to rapidly and accurately differentiate these two conditions

Intimomedial thickness of the vertebral arteries complex: A new useful parameter for the assessment of atheroclerotic process?

Bacground/Aim. An integral part of Doppler ultrasound examination of cervical blood vessels is determination of intimomedial thicknes (IMT) of the common carotid. The aim of the study was to estimate the relations between IMT of the common carotid and vertebral arteries in order to determine if the value of IMT obtained on the vertebral artery could be applied in clinical practice. Methods. We measured IMT in a randomized, prospective and crosssectional study, performed on 50 persons both sexes (29 men and 21 women), at the age from 18 to 79 years (mean age 52.4 ± 17.63 years). All the persons were healthy, what was confirmed with clinical examination and laboratory analyses. Measurements were perfomed from January 2006 until September 2008. Intimomedial thickness was recorded by twodimensional ultrasonography in B-mode on both common carotid arteries: one value was obtained as average of three successeful measurements (measurements were perform on different places). We measured IMT on the first segment of both vertebral arteries, 1.5 cm proximal from the connection of the first and second segments (we got results of the measurement of IMT on the vertebral arteries in the same way: mean value from the three records). Results. (IMT = 0.782 ± 0.248 mm), obtained from 50 healthy persons, was higher than that measured on the vertabral artery on the first segment (IMT = 0.585 ± 0.134 mm). The values of IMT after measurement on two different places were statistically highly different (t = 7.03, SD = 0.028, p &lt; 0.01). Coefficient of variability of IMT values in carotid circulation (CV = 34.4%) was higher than that in vertebral circulation (22.9%). Values of IMT on vertebral arteries were in statistically significant correlation with those in carotid circulation (r = 0.24 and t- = 2.48; p &lt; 0.02). There were no statistically significant difference between IMT measurement on the right and the left side so they were analysed as the same set Conclusion. Values of IMT on the vertebral arteries are one more undependent parameter of doplersonographic examination of cervical vessels, which significantly correlates with IMT values on common carotid artery. Variability of this parameter is lower, and absolute values lower than the same in the common carotid artery. Therefore, this parameter is probably not so sensitive. On the other hand, lower variability of IMT values on the vertebral artery might be of higher specificity for prediction of atherosclerotic progress by the increased values of this parameter than based on IMT values obtained on the common carotid arteries

Relapse of Takayasu arteritis as a cause of suicidal poisoning and subsequent major ischemic stroke successfully treated with thrombolytic therapy

Introduction. Takayasu arteritis (TA) is a rare large vessel arteritis, affecting primarily aorta and its major branches. Its clinical manifestations can vary significantly - from asymptomatic to serious vascular events. Acute neurological complications are frequent at the onset of the disease and in relapses. Anxiety and depression are more frequent in TA patients than in general population as well as during relapses. Prevalence of transient ischemic attack or ischemic stroke in TA patients is approximately 10-20%. Case report. We presented a patient with TA that began with a depressive episode resulting in attempted suicide by bromazepame poisoning. This was subsequently followed by major ischemic stroke caused by thrombosis of the left middle cerebral artery (probably due to aortic arch embolism) successfully treated with intravenous thrombolysis. Conclusion. Intravenous thrombolysis appears to be safe and effective in patients with TA and stroke

Urgent carotid stenting before cardiac surgery in a young male patient with acute ischemic stroke caused by aortic and carotid dissection

Introduction. Acute aortic dissection (AD) is the most common life-threatening disorder affecting the aorta. Neurological symptoms are present in 17-40% of cases. The management of these patients is controversial. Case report. We presented a 37-year-old man admitted for complaining of left-sided weak-ness. Symptoms appeared two hours before admission. The patient had no headache, neither thoracic pain. Neurological examination showed mild confusion, left-sided hemiplegia, National Institutes of Health Stroke Scale (NIHSS) score was 10. Ischemic stroke was suspected, brain multislice computed tomography (MSCT) and angiography were performed and right intrapetrous internal carotid artery dissection noted. Subsequent color Doppler ultrasound of the carotid arteries showed dissection of the right common carotid artery (CCA). The patient underwent thoracic and abdominal MSCT aortography which showed ascending aortic dissection from the aortic root, propagating in the brachiocephalic artery and the right CCA. Digital subtraction angiography was performed subsequently and two stents were successfully implanted in the brachiocephalic artery and the right CCA prior to cardiac surgery, only 6 hours after admission. The ascending aorta was reconstructed with graft interposition and the aortic valve re-suspended. The patient was hemodynamically stable and with no neurologic deficit after surgery. Unfortinately, at the operative day 6, mediastinitis developed and after intensive treatment the patients died 35 days after admission. Conclusion. In young patients with suspected stroke and oscillatory neurological impairment urgent MSCT angiography of the brain and neck and/or Doppler sonography of the carotid and vertebral artery are mandatory to exclude carotid and aortic dissection. The prompt diagnosis permits urgent carotid stenting and cardiosurgery. To the best of our knowledge, this is the first published case of immediate carotid stenting in acute ischemic stroke after the diagnosis of carotid and aortic dissection and prior to cardiac surgery