Berta M. Montalvo

Lower extremity blood flow and responses to occlusion ischemia differ in exercise-trained and sedentary tetraplegic persons

OBJECTIVE To test whether lower extremity blood flow and hyperemic responses to vascular occlusion differ among electrically stimulated exercise trained and sedentary tetraplegic persons and subjects without tetraplegia (control). DESIGN Blinded cross-sectional comparison, control group. SETTING Academic medical center. PARTICIPANTS Ten sedentary tetraplegic men, 10 tetraplegic persons previously habituated to electrically stimulated cycling exercise for 0.4 to 7 years, and 10 nondisabled controls. OUTCOME MEASURES Subjects underwent quantitative Doppler ultrasound examination of the common femoral artery (CFA). End-diastolic arterial images and arterial flow-velocity profiles obtained at rest and following five minutes of suprasystolic thigh occlusion were computer digitized for analysis of heart rate (HR), CFA peak systolic velocity (PSV), CFA cross-sectional area (CSA), flow velocity integral (FVI), and computed CFA inflow volume (IV). RESULTS No group main effects were observed for resting HR or FVI. At rest, trained tetraplegic men had 14.9% greater PSV, 29.8% larger CSA, and 51.3% greater IV (p values < .05) than sedentary tetraplegic subjects. Resting PSV and IV of the trained subjects did not differ from controls, although CSA was smaller than controls (p < .05). Following occlusion, PSV, CSA, and IV averaged 16.5%, 33.4%, and 65.1% greater for trained tetraplegics persons, respectively, than sedentary tetraplegic subjects (p values < .05). Only CSA differed between the control and the trained groups (p < .05). CONCLUSION Tetraplegic persons conditioned by electrically stimulated cycling have greater lower extremity blood flow and hyperemic responses to occlusion than do their sedentary counterparts.

Evaluation of a training program for persons with SCI paraplegia using the Parastep®1 ambulation system: Part 5. Lower extremity blood flow and hyperemic responses to occlusion are augmented by ambulation training

OBJECTIVE To test whether 12 weeks of exercise conditioning using functional neuromuscular stimulation (FNS) ambulation alters the resting lower extremity blood flow and hyperemic responses to vascular occlusion in subjects with paraplegia, and to determine whether an association exists between limb flow and lower extremity fat-free mass. DESIGN Pretest, posttest. SETTING Academic medical center. PARTICIPANTS Subjects with chronic neurologically complete paraplegia. INTERVENTION Thirty-two sessions of microprocessor-controlled ambulation using electrically stimulated contractions of lower extremity muscles and a rolling walker. OUTCOME MEASURES Subjects underwent quantitative Doppler ultrasound examination of the common femoral artery (CFA) before and after training. End-diastolic arterial images and arterial flow-velocity profiles obtained at rest and after 5 minutes of suprasystolic thigh occlusion were computer-digitized for analysis of heart rate (HR), CFA peak systolic velocity (PSV), CFA cross-sectional area (CSA), flow velocity integral (FVI), pulse volume (PV), and CFA (arterial) inflow volume (AIV). RESULTS Significant effects of training on CSA (p < .0001), FVI (p < .05), computed PV (p < .001), and computed AIV (p < .01) were observed. Resting HR was lower following training (p < .05). The change for resting PSV approached but did not reach significance (p = .083). Analysis of postocclusion PV and AIV showed significant effects for conditioning status (p values < .01), postcompression time (p values < .0001), and their interaction (p values < .01). At 1 minute after occlusion, the posttraining AIV response was 78.2% greater in absolute magnitude and 17.4% more robust when expressed as a percentage change from its resting value than before training. Significant correlations were found between thigh fat free mass and both AIV and PV (p values < .05). CONCLUSION Exercise training using FNS ambulation increases the resting lower extremity AIV in individuals with paraplegia and augments the hyperemic response to vascular occlusion. Improved posttraining blood flow is attributable both to vascular structural changes and upregulation of vascular flow control mechanisms. Limb mass is associated with the volume of arterial blood flow.

Percutaneous Sclerotherapy of Lymphoceles Related to Renal Transplantation

PURPOSE To determine the advantages of using transcatheter sclerotherapy to treat renal allograft-related lymphoceles. MATERIALS AND METHODS Eighteen patients first seen with symptomatic lymphoceles secondary to renal transplantation were treated with povidone-iodine percutaneous sclerotherapy. Percutaneous catheters were place by means of sonographic, computed tomographic, or combined fluoroscopic and sonographic guidance. Sclerotherapy was initiated while patients were in the hospital, and the patients then instilled povidone-iodine twice a day at home. RESULTS One patient had an inadequate trial period of therapy and was not included in the analysis. Seventeen lymphoceles were adequately sclerosed. Average length of treatment was 35 days. Three lymphoceles recurred and were effectively treated percutaneously. Follow-up studies showed no recurrence 1 month to 2 years after completion of therapy. No patient needed surgery for lymphocele repair. CONCLUSION Because of its safety and efficacy, percutaneous transcatheter sclerotherapy with povidone-iodine should be the treatment of choice in patients with lymphoceles that develop after renal transplantation.

Intraoperative cranial sonography

SummaryThe use of real time ultrasound in the neurosurgical operating room can enhance the ability to localize intracerebral masses, allow accurate needle biopsies, diminish the amount of potential damage to normal brain tissue, show the results of tumor resection, and help in the placement of ventricular and cyst shunts. The end result makes the surgical procedure faster, safer, and more accurate.

Histopathological changes after microwave coagulation therapy for patients with hepatocellular carcinoma: review of 15 explanted livers

OBJECTIVES:Microwave coagulation therapy (MCT) is a well established local ablation technique for hepatocellular carcinoma (HCC). However, pathological changes in liver tissue after this therapy have not been well described. We examined the histological changes of HCC after MCT observed in explanted livers in relation to CT findings.METHODS:A total of 15 patients with 18 lesions of HCC underwent MCT and subsequent liver transplantation. Explanted livers were examined macro- and microscopically, and an evaluation of mitochondrial activity of ablated tissue was accomplished by using succinic dehydrogenase (SDH) stain in frozen sections.RESULTS:Of the 18 lesions, 16 were ablated completely and another two had residual tumor. The size of the ablated areas on CT scan corresponded to the macroscopic findings. Histologically the area of ablation was rimmed by a palisading, histiocytic, giant cell, inflammatory reaction associated with fibrotic bands. Coagulative necrosis with faded nuclei and eosinophilic cytoplasm were the predominant findings in the ablated areas. There were also areas in which the tumor cells had cytoplasmic eosinophilia, but nuclei were present and the cells seemed to be viable. On the SDH stain of frozen tissue taken from the edge of the ablated area, SDH activity was negative in both necrotic and nonnecrotic ablated areas.CONCLUSION:Most of the treated areas after microwave ablation develop coagulative necrosis accompanied by a foreign body–like inflammatory reaction and fibrosis. Pathologists need to be aware that after this form of therapy, portions of the tumor maintain their native morphological features as if the area is fixed, but their cellular activity is destroyed.

Acute lipodermatosclerosis is associated with venous insufficiency

BACKGROUND Acute lipodermatosclerosis is characterized by pain and tenderness in the medial aspect of the leg. It is thought to be the result of venous insufficiency and to be the acute counterpart of chronic lipodermatosclerosis, a hallmark of venous disease. However, there is no direct evidence linking acute lipodermatosclerosis to venous disease. OBJECTIVE Our purpose was to determine whether acute lipodermatosclerosis is associated with venous insufficiency. METHODS With air plethysmography, we determined the venous filling index, the ejection fraction, and the residual volume fraction in 15 sequential patients with acute lipodermatosclerosis. RESULTS Ten of the 15 patients (67%) had at least one abnormal result, eight (53%) had two, and two (13%) had three. In four patients (27%), abnormalities of both reflux and ejection were noted. Duplex venous ultrasonography, in two of the patients with normal results from air plethysmography, showed incompetent perforators at sites of lipodermatosclerosis. CONCLUSION Acute lipodermatosclerosis is associated with objective findings of venous insufficiency in a high percentage of patients. It is likely that this condition is the result of venous disease.

The role of intraoperative ultrasonography in the treatment of thoracic and lumbar spine fractures.

The technique of intraoperative ultrasonography is outlined in detail and examples of normal spinal canal anatomy are shown. Twenty-three patients with unstable thoracic and lumbar spine fractures were prospectively treated with Harrington rod reduction and fusion using intraoperative ultrasonography. The pathology at all levels studied corresponded exactly to that seen on preoperative myelograms and computed tomography scans. Intradural pathology also was seen clearly in four patients. This technique makes the use of Harrington rod reduction and posterolateral decompression a possibly safer and more effective method of treating these fractures.

Sonographic diagnosis of aneurysm of the right portal vein.

The rarity of portal vein aneurysms (PV As) has been emphasized in the world literature with most reported cases occurring in the extrahepatic portal circulation. ]n 1950, Barzilai and Kleckner first reported this entity in a patient with postnecrotic cirhosis.l Reports of similar lesions followed.27 Intrahepatic PYAs are exceedingly rare. Ohnishi et al described two patients with right PYAs confinned by angiography.8 We report a case of intrahepatic PV A initially detected by CT and con~ finned by pulsed Doppler ultrasound.

A randomized blinded comparison of two methods used for venous antistasis in tetraplegia

Abstract Objective:The hemodynamic effects of slow sequential compression (SCD) were compared with rapid intermittent pulsatile compression (IPC) in subjects with complete tetraplegia. Methods: Twenty subjects underwent Doppler examination of the bilateral popliteal and femoral veins. Resting volume flow per minute (VFM), average venous velocity (AVV), and maximal venous velocity (MVV) were measured in both veins. SCD and IPC were then randomly applied to one limb each, followed by repeat Doppler measurements under compression conditions. Doppler spectral recordings were stored for future analysis, and then measured by an investigator blinded to testing conditions (rest versus compression) and device (SCD versus IPC). Results:Sequential compression and IPC compression both increased popliteal and femoral vein VFM, AVV, and MVV above resting levels (all p’s < 0.001 ). In the femoral vein VFM(p < 0.05) and MVV (p < 0.05) were augmented during IPC compared to SCD compression. Conclusion: As MVV best reflects performance effectiveness of compression devices, these data find IPC more effective than SCD for stimulating venous blood flow in subjects with tetraplegia.

Allograft Pancreatic Duct Dilatation Following Bladder Drained Simultaneous Pancreas-Kidney Transplantation: Clinical Significance

OBJECTIVE Radiologic imaging of the allograft pancreatic duct dilatation is an uncommon multifactorial finding that is not well described. The purpose of this investigation is to determine the clinical correlation of this finding. DESIGN Retrospective study. SETTING University Hospital, USA. SUBJECTS One hundred forty five simultaneous pancreas-kidney transplants have been performed for treatment of type I diabetes mellitus and end-stage renal disease between February 1993 and December 1999 at the University of Miami. MAIN OUTCOME MEASURES In 5 recipients, the pancreatic duct was noted to be dilated by ultrasound 1-18 months post-transplant. RESULTS In all 5 recipients a Foley catheter was placed as the first line of treatment. This reduced the size of the pancreatic duct in one patient, who presented with normal serum amylase and lipase and hyperglycemia. A pancreas biopsy done with Foley catheter in place showed fibrosis with no evidence of rejection. Four patients with dilated pancreatic duct presented with increased serum amylase and lipase; however improvement of the pancreatic duct dilatation was seen only after anti-rejection therapy. One of the patients developed recurrence of pancreatic duct dilatation and a video-urodynamic study subsequently demonstrated voiding with abdominal straining and no detrusor activity. He ultimately underwent enteric conversion with resolution of pancreatic duct dilatation. CONCLUSIONS This infrequent complication of dilated transplant pancreatic duct could be multifactorial. It could suggest the diagnosis of reflux pancreatitis, which should resolve with bladder decompression. In fact, 1 patient presented with reflux pancreatitis caused by external sphincter detrusor pseudodyssynergia. However, this ultrasound finding may also be associated with pancreas rejection (4/5 patients).