Ori Galante

Admission Cell Free DNA Levels Predict 28-Day Mortality in Patients with Severe Sepsis in Intensive Care

Aim The aim of the current study is to assess the mortality prediction accuracy of circulating cell-free DNA (CFD) level at admission measured by a new simplified method. Materials and Methods CFD levels were measured by a direct fluorescence assay in severe sepsis patients on intensive care unit (ICU) admission. In-hospital and/or twenty eight day all-cause mortality was the primary outcome. Results Out of 108 patients with median APACHE II of 20, 32.4% have died in hospital/or at 28-day. CFD levels were higher in decedents: median 3469.0 vs. 1659 ng/ml, p<0.001. In multivariable model APACHE II score and CFD (quartiles) were significantly associated with the mortality: odds ratio of 1.05, p = 0.049 and 2.57, p<0.001 per quartile respectively. C-statistics for the models was 0.79 for CFD and 0.68 for APACHE II. Integrated discrimination improvement (IDI) analyses showed that CFD and CFD+APACHE II score models had better discriminatory ability than APACHE II score alone. Conclusions CFD level assessed by a new, simple fluorometric-assay is an accurate predictor of acute mortality among ICU patients with severe sepsis. Comparison of CFD to APACHE II score and Procalcitonin (PCT), suggests that CFD has the potential to improve clinical decision making.

B-type natruiretic peptide levels stratify the risk for arrhythmia among implantable cardioverter defibrillator patients.

We sought to study the association between brain natriuretic peptide (BNP) levels and the occurrence of ventricular arrhythmias in patients with left ventricular dysfunction (LVD) and an implantable cardioverter defibrillator (ICD).

Positive fluid balance as a major predictor of clinical outcome of patients with sepsis/septic shock after ICU discharge

INTRODUCTION Sepsis and septic shock continue to be syndromes that carry a high mortality rate worldwide. Early aggressive fluid and vasopressor support have resulted in significant improvement in patient outcomes. The prognostic clinical significance of a positive fluid balance in septic intensive care unit (ICU) patients remains undetermined. METHODS We collected data from 297 septic patients hospitalized in our general and medical ICUs at Soroka Medical Center between January 2005 and June 2011 and divided the 4 study groups into the following 4 fluid balances: group 1, patients with fluid balance at discharge from ICU (FBD) less than 10 L; group 2, patients with an FBD of 10 to 20 L; group 3, patients with an FBD of 20 to 30 L; and group 4, patients with FBD in excess of 30 L. RESULTS The ICU and in-hospital mortality rate was also significantly higher in groups 2 to 4 as compared with group 1 (P < .001 for both ICU and in-hospital mortality). The positive cumulative FBD was found to be an independent predictor of ICU mortality (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06; P < .001; Table 3) and in-hospital mortality (OR, 1.06; 95% CI, 1.03-1.08; P < .001; Table 5) and also to constitute a risk factor for new organ system dysfunction at hospital discharge (OR, 1.01; 95% CI, 1.01-1.013; P < .001; Table 6) in critically ill patients with severe sepsis/septic shock. CONCLUSIONS Although it is a monocentric retrospective study, we suggest that positive cumulative fluid balance is one of the major factors that can predict the clinical outcome of critically ill patients during their ICU stay and after their discharge from the ICU.

The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum

BackgroundTeaching cardiac ultrasound to medical students in a brief course is a challenge. We aimed to evaluate the feasibility of teaching large groups of medical students the acquisition and interpretation of cardiac ultrasound images using a pocket ultrasound device (PUD) in a short, specially designed course.MethodsThirty-one medical students in their first clinical year participated in the study. All were novices in the use of cardiac ultrasound. The training consisted of 4 hours of frontal lectures and 4 hours of hands-on training. Students were encouraged to use PUD for individual practice. Finally, the students’ proficiency in the acquisition of ultrasound images and their ability to recognize normal and pathological states were evaluated.ResultsSixteen of 27 (59%) students were able to demonstrate all main ultrasound views (parasternal, apical, and subcostal views) in a six-minute test. The most obtainable view was the parasternal long-axis view (89%) and the least obtainable was the subcostal view (58%). Ninety-seven percent of students correctly differentiated normal from severely reduced left ventricular function, 100% correctly differentiated a normal right ventricle from a severely hypokinetic one, 100% correctly differentiated a normal mitral valve from a rheumatic one, and 88% correctly differentiated a normal aortic valve from a calcified one, while 95% of them correctly identified the presence of pericardial effusion.ConclusionsTraining of medical students in cardiac ultrasound during the first clinical year using a short, focused course is feasible and enables students with modest ability to acquire the main transthoracic ultrasound views and gain proficiency in the diagnosis of a limited number of cardiac pathologies.

Self-learning of point-of-care cardiac ultrasound – Can medical students teach themselves?

Background Point-of-care ultrasonography (PoCUS) is a rapidly evolving discipline that aims to train non-cardiologists, non-radiologists clinicians in performing bedside ultrasound to guide clinical decision. Training of PoCUS is challenging, time-consuming and requires large amount of resources. The objective of our study was to evaluate if this training process can be simplified by allowing medical students self-train themselves with a web-based cardiac ultrasound software. Methods A prospective, single blinded, cohort study, comparing performance of 29 medical students in performing a six-minutes cardiac ultrasound exam. Students were divided into two groups: self-learning group, using a combination of E-learning software and self-practice using pocket ultrasound device compared to formal, frontal cardiac ultrasound course. Results All 29 students completed their designated courses and performed the six-minutes exam: 20 students participated in the frontal cardiac ultrasound course and 9 completed the self-learning course. The median (Q1,Q3) test score for the self-learning group was higher than the frontal course group score, 18 (15,19) versus 15 (12,19.5), respectively. Nevertheless, no statistically significant difference was found between the two study groups (p = 0.478). All students in the self-learning course group (9/9, 100%) and 16 (16/20, 80%) of students in the frontal ultrasound course group obtained correct alignment of the parasternal long axis view (p = 0.280). Conclusions Self-learning students combining E-learning software with self-practice cardiac ultrasound were as good as students who received a validated, bedside, frontal cardiac ultrasound course. Our findings suggest that independent cardiac ultrasound learning, combining utilization of E–learning software and self-practice, is feasible. Self-E- learning of cardiac ultrasound may serve as an important, cost-effective adjunct to heavily resource consuming traditional teaching.

Cerebral air emboli complicating trans-bronchial needle aspiration using endo-bronchial ultrasound

A 71-year-old patient underwent trans-bronchial needle aspiration (TBNA) from mediastinal lymph nodes using endo-bronchial ultrasound (EBUS). The procedure was performed under conscious intravenous sedation through a peripheral vein, using a 21-gauge needle and was associated with only minimal bleeding. After the procedure, he remained comatose. CT angiography revealed diffuse cerebral air emboli (Fig. 1) and ruled out pneumothorax and pneumomediastinum. Echocardiography using color Doppler and bubbles ruled out PFO. Air emboli following bronchoscopy are exceedingly rare. Few cases have been described, mostly after Argon plasma coagulation or Nd-YAG laser. Lung biopsy may cause traumatic break of the blood–air interface potentially leading to gas embolism. Spontaneous breathing and coughing may further augment the pressure gradient forcing air into the vasculature. Systemic embolization may occur through a cardiac right to left shunt or arterio-venous anastomoses in the lungs, resulting in arterial gas emboli (AGE). AGE may have serious CNS and cardiovascular manifestations. Air in the unsealed needle and the high lymph node vascularity may serve as risk factors for AGE caused by transient broncho-vascular fistula while performing EBUS-guided TBNA. The patient was treated in a hyperbaric chamber within 8 h of the procedure. He eventually regained normal neurologic function.

High-frequency QRS analysis in the evaluation of chest pain in the emergency department

OBJECTIVES High frequency QRS (HFQRS) analysis has been shown to be an accurate marker for myocardial ischemia. Our objective was to test the use of HFQRS in diagnosing ACS in the emergency department. METHODS 324 patients presenting to the ED with chest pain were enrolled. Resting ECG was recorded and later analyzed by an HFQRS algorithm. Results were compared to the conventional ECG diagnosis by 3 independent interpretations: treating physician, expert cardiologist and an automated computer program. RESULTS The HFQRS analysis demonstrated improved sensitivity (67.5%) for the NSTE-ACS group compared to the human interpreters (59.7% and 53.2% for the treating physician and cardiologist respectively) with similar specificity. The automatic program had significantly lower sensitivity (31%) with a higher specificity (77%). CONCLUSIONS HFQRS which has shown great promise in diagnosing stable CAD may also be helpful in the ED for diagnosing ACS.

Non Traumatic Brachiocephalic Pseudo Aneurysm

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Bilateral pulmonary emboli.

A 79-year-old woman presented with an aggravating effort dyspnoea during the preceding week. On examination, her oxygen saturation was 87% while breathing ambient air; her blood pressure was 120/75; she had distended neck veins; normal breath sounds and regular heart sounds. Her liver was mildly enlarged. She had no leg oedema, swelling or tenderness. Her laboratory results were within normal limits, including troponin level. One month before admission, …

Severe unrecognised hypoglycaemia presenting as pseudonormoglycaemia and unexplained coma in two patients with renal failure

We describe the occurrence of pseudonormoglycaemia and the consequences of severe prolonged hypoglycaemia observed in two patients with renal failure requiring renal replacement therapy. There was a persistent discrepancy, in both cases, between glucose levels measured by the hospital laboratory and those measured by the bedside glucometer, resulting in a significantly false high glucose measurement (pseudonormoglycaemia). This inaccurate glucose determination led to a delayed diagnosis of their truly severe and prolonged hypoglycaemia ultimately leading to prolonged coma and death. Icodextrin, a polysaccharide commonly used in continuous ambulatory peritoneal dialysis solutes, and maltose-containing solutions such as immunoglobulins for intravenous administration, can cause a dangerous overestimation of glucose levels determined by capillary blood glucose analysers utilising glucose dehydrogenase. A high level of awareness is required in order to avoid incidents related to misinterpretation of glucose levels.