Effects of cerebral perfusion pressure and increased fraction of inspired oxygen on brain tissue oxygen, lactate and glucose in patients with severe head injury

OBJECTIVE: The purpose of the study was to measure the effects of increased inspired oxygen on patients suffering severe head injury and consequent influences on the correlations between CPP and brain tissue oxygen (PtiO2) and the effects on brain microdialysate glucose and lactate. METHODS: In a prospective, observational study 20 patients suffering severe head injury (GCS< or =8) were studied between January 2000 and December 2001. Each patient received an intraparenchymal ICP device and an oxygen sensor and, in 17 patients brain microdialysis was performed at the cortical-subcortical junction. A 6 h 100% oxygen challenge (F IO2 1.0) ( Period A) was performed as early as possible in the first 24 hours after injury and compared with a similar 6 hour period following the challenge ( Period B). Statistics were performed using the linear correlation analysis, one sample t-test, as well as the Lorentzian peak correlation analysis. RESULTS: F IO2 was positively correlated with PtiO2 (p < 0.0001) over the whole study period. PtiO2 was significantly higher (p < 0.001) during Period A compared to Period B. CPP was positively correlated with PtiO2 (p < 0.001) during the whole study. PtiO2 peaked at a CPP value of 78 mmHg performing a Lorentzian peak correlation analysis of all patients over the whole study. During Period A the brain microdialysate lactate was significantly lower (p = 0.015) compared with Period B. However the brain microdialysate glucose remained unchanged. CONCLUSION: PtiO2 is significantly positively correlated with F IO2, meaning that PtiO2 can be improved by the simple manipulation of increasing F IO2 and ABGAO2. PtiO2 is positively correlated with CPP, peaking at a CPP value of 78 mmHg. Brain microdialysate lactate can be lowered by increasing PtiO2 values, as observed during the oxygen challenge, whereas microdialysate glucose is unchanged during this procedure. Extension of the oxygen challenge time and measurement of the intermediate energy metabolite pyruvate may clarify the metabolic effects of the intervention. Prospective comparative studies, including analysis of outcome on a larger multicenter basis, are necessary to assess the long term clinical benefits of this procedure.

Cerebral oxygenation in patients after severe head injury: monitoring and effects of arterial hyperoxia on cerebral blood flow, metabolism and intracranial pressure

Early impaired cerebral blood flow (CBF) after severe head injury (SHI) leads to poor brain tissue oxygen delivery and lactate accumulation. The purpose of this investigation was to elucidate the relationship between CBF, local dialysate lactate (lact(md)) and dialysate glucose (gluc(md)), and brain tissue oxygen levels (PtiO2) under arterial normoxia. The effect of increased brain tissue oxygenation due to high fractions of inspired oxygen (FiO2) on lact(md) and CBF was explored. A total of 47 patients with SHI were enrolled in this studies (Glasgow Coma Score [GCS] < 8). CBF was first assessed in 40 patients at one time point in the first 96 hours (27 +/- 28 hours) after SHI using stable xenon computed tomography (Xe-CT) (30% inspired xenon [FiXe] and 35% FiO2). In a second study, sequential double CBF measurements were performed in 7 patients with 35% FiO2 and 60% FiO2, respectively, with an interval of 30 minutes. In a subsequent study, 14 patients underwent normobaric hyperoxia by increasing FiO2 from 35 +/- 5% to 60% and then 100% over a period of 6 hours. This was done to test the effect of normobaric hyperoxia on lact(md) and brain gluc(md), as measured by local microdialysis. Changes in PtiO2 in response to changes in FiO2 were analyzed by calculating the oxygen reactivity. Oxygen reactivity was then related to the 3-month outcome data. The levels of lact(md) and gluc(md) under hyperoxia were compared with the baseline levels, measured at 35% FiO2. Under normoxic conditions, there was a significant correlation between CBF and PtiO2 (R = 0.7; P < .001). In the sequential double CBF study, however, FiO2 was inversely correlated with CBF (P < .05). In the 14 patients undergoing the 6-hour 100% FiO2 challenge, the mean PtiO2 levels increased to 353 (87% compared with baseline), although the mean lact(md) levels decreased by 38 +/- 16% (P < .05). The PtiO2 response to 100% FiO2 (oxygen reactivity) was inversely correlated with outcome (P < .01). Monitoring PtiO2 after SHI provides valuable information about cerebral oxygenation and substrate delivery. Increasing arterial oxygen tension (PaO2) effectively increased PtiO2, and brain lact(md) was reduced by the same maneuver.

Synthesis of computations and experiments for obtaining pulsatile gas flow rates from dynamic pressure difference measurements across an orifice-plate meter

The use of conventional orifice-plate meter is typically restricted to measurements of steady flows. This study proposes a new and effective computational-experimental approach for measuring the time-varying (but steady-in-the-mean) nature of turbulent pulsatile gas flows. Low Mach number (effectively constant density) steady-in-the-mean gas flows with large amplitude fluctuations (whose highest significant frequency is characterized by the value fF) are termed pulsatile if the fluctuations have a direct correlation with the time-varying signature of the imposed dynamic pressure difference and, furthermore, they have fluctuation amplitudes that are significantly larger than those associated with turbulence or random acoustic wave signatures. The experimental aspect of the proposed calibration approach is based on use of Coriolis-meters (whose oscillating arm frequency fcoriolis >> fF) which are capable of effectively measuring the mean flow rate of the pulsatile flows. Together with the experimental measurements of the mean mass flow rate of these pulsatile flows, the computational approach presented here is shown to be effective in converting the dynamic pressure difference signal into the desired dynamic flow rate signal. The proposed approach is reliable because the time-varying flow rate predictions obtained for two different orifice-plate meters exhibit the approximately same qualitative, dominant features of the pulsatile flow.

Effects of fixed night shift work on 24 hour blood pressure regulation, state anxiety levels and total sleep time

Nearly 22 million Americans operate as shift workers, and shift work has been linked to the development of cardiovascular disease (CVD). This study is aimed at identifying pivotal risk factors of CVD by assessing 24 hour ambulatory blood pressure, state anxiety levels and sleep patterns in 12 hour fixed shift workers. We hypothesized that night shift work would negatively affect blood pressure regulation, anxiety levels and sleep patterns. A total of 28 subjects (ages 22-60) were divided into two groups: 12 hour fixed night shift workers (n=15) and 12 hour fixed day shift workers (n=13). 24 hour ambulatory blood pressure measurements (Space Labs 90207) were taken twice: once during a regular work day and once on a non-work day. State anxiety levels were assessed on both test days using the Speilberger’s State Trait Anxiety Inventory. Total sleep time (TST) was determined using self recorded sleep diary. Night shift workers demonstrated increases in 24 hour systolic (122 ± 2 to 126 ± 2 mmHg, P=0.012); diastolic (75 ± 1 to 79 ± 2 mmHg, P=0.001); and mean arterial pressures (90 ± 2 to 94 ± 2mmHg, P<0.001) during work days compared to off days. In contrast, 24 hour blood pressures were similar during work and off days in day shift workers. Night shift workers reported less TST on work days versus off days (345 ± 16 vs. 552 ± 30 min; P<0.001), whereas day shift workers reported similar TST during work and off days (475 ± 16 minutes to 437 ± 20 minutes; P=0.231). State anxiety scores did not differ between the groups or testing days (time*group interaction P=0.248), suggesting increased 24 hour blood pressure during night shift work is related to decreased TST, not short term anxiety. Our findings suggest that fixed night shift work causes disruption of the normal sleep-wake cycle negatively affecting acute blood pressure regulation, which may increase the long-term risk for CVD.

Spray characterization under flash boiling conditions of a DI multi-hole injector at high injection pressures in a combustion vessel

Spray characterization under flash boiling conditions was investigated utilizing a symmetric multi-hole injector applicable to the gasoline direct injection (GDI) engine. Tests were performed in a constant volume combustion vessel using a high-speed schlieren and Mie scattering imaging systems. Four fuels including n-heptane, 100% ethanol, pure ethanol blended with 15% iso-octane by volume, and test grade E85 were considered in the study. Experimental conditions included various ambient pressure, fuel temperature, and fuel injection pressure. Visualization of the vaporizing spray development was acquired by utilizing schlieren and laser-based Mie scattering techniques. Time evolved spray tip penetration, spray angle, and the ratio of the vapor to liquid region were analyzed by utilizing digital image processing techniques in MATLAB. This research outlines spray characteristics at flash boiling and non-flash boiling conditions. At flash boiling conditions it was observed that individual plumes merge together, leading to significant contraction in spray angle as compared to non-flash boiling conditions. The results indicate that at flash boiling conditions, spray formation and expansion of vapor region is dependent on momentum exchange offered by the ambient gas. A relation between momentum exchange and liquid spray angle formed was also observed.

Dynamic properties of wood using the Split-Hopkinson Pressure Bar

Strain rate significantly affects the strength of a material. The Split-Hopkinson Pressure Bar (SHPB) was initially used to study the effects of high strain rate (~103 1/s) testing of metals. Later modifications to the original technique allowed for the study of brittle materials such as ceramics, concrete, and rock. While material properties of wood for static and creep strain rates are readily available, data on the dynamic properties of wood are sparse. Previous work using the SHPB technique with wood has been limited in scope to variability of only a few conditions and tests of the applicability of the SHPB theory on wood have not been performed. Tests were conducted using a large diameter (3.0 inch (75 mm)) SHPB. The strain rate and total strain applied to a specimen are dependent on the striker bar length and velocity at impact. Pulse shapers are used to further modify the strain rate and change the shape of the strain pulse. A series of tests were used to determine test conditions necessary to produce a strain rate, total strain, and pulse shape appropriate for testing wood specimens. Hard maple, consisting of sugar maple (Acer saccharum) and black maple (Acer nigrum), and eastern white pine (Pinus strobus) specimens were used to represent a dense hardwood and a low-density soft wood. Specimens were machined to diameters of 2.5 and 3.0 inches and an assortment of lengths were tested to determine the appropriate specimen dimensions. Longitudinal specimens of 1.5 inch length and radial and tangential specimens of 0.5 inch length were found to be most applicable to SHPB testing. Stress/strain curves were generated from the SHPB data and validated with 6061-T6 aluminum and wood specimens. Stress was indirectly corroborated with gaged aluminum specimens. Specimen strain was assessed with strain gages, digital image analysis, and measurement of residual strain to confirm the strain calculated from SHPB data. The SHPB was found to be a useful tool in accurately assessing the material properties of wood under high strain rates (70 to 340 1/s) and short load durations (70 to 150 μs to compressive failure).

Analysis of in-cylinder pressure transducer data quality utilizing a SIDI turbocharged engine

In-cylinder pressure transducers have been used for decades to record combustion pressure inside a running engine. However, due to the extreme operating environment, transducer design and installation must be considered in order to minimize measurement error. One such error is caused by thermal shock, where the pressure transducer experiences a high heat flux that can distort the pressure transducer diaphragm and also change the crystal sensitivity. This research focused on investigating the effects of thermal shock on in-cylinder pressure transducer data quality using a 2.0L, four-cylinder, spark-ignited, direct-injected, turbo-charged GM engine. Cylinder four was modified with five ports to accommodate pressure transducers of different manufacturers. They included an AVL GH14D, an AVL GH15D, a Kistler 6125C, and a Kistler 6054AR. The GH14D, GH15D, and 6054AR were M5 size transducers. The 6125C was a larger, 6.2mm transducer. Note that both of the AVL pressure transducers utilized a PH03 flame arrestor. Sweeps of ignition timing (spark sweep), engine speed, and engine load were performed to study the effects of thermal shock on each pressure transducer. The project consisted of two distinct phases which included experimental engine testing as well as simulation using a commercially available software package. A comparison was performed to characterize the quality of the data between the actual cylinder pressure and the simulated results. This comparison was valuable because the simulation results did not include thermal shock effects. All three sets of tests showed the peak cylinder pressure was basically unaffected by thermal shock. Comparison of the experimental data with the simulated results showed very good correlation. The spark sweep was performed at 1300 RPM and 3.3 bar NMEP and showed that the differences between the simulated results (no thermal shock) and the experimental data for the indicated mean effective pressure (IMEP) and the pumping mean effective pressure (PMEP) were significantly less than the published accuracies. All transducers had an IMEP percent difference less than 0.038% and less than 0.32% for PMEP. Kistler and AVL publish that the accuracy of their pressure transducers are within plus or minus 1% for the IMEP (AVL 2011; Kistler 2011). In addition, the difference in average exhaust absolute pressure between the simulated results and experimental data was the greatest for the two Kistler pressure transducers. The location and lack of flame arrestor are believed to be the cause of the increased error. For the engine speed sweep, the torque output was held constant at 203 Nm (150 ft-lbf) from 1500 to 4000 RPM. The difference in IMEP was less than 0.01% and the PMEP was less than 1%, except for the AVL GH14D which was 5% and the AVL GH15DK which was 2.25%. A noticeable error in PMEP appeared as the load increased during the engine speed sweeps, as expected. The load sweep was conducted at 2000 RPM over a range of NMEP from 1.1 to 14 bar. The difference in IMEP values were less 0.08% while the PMEP values were below 1% except for the AVL GH14D which was 1.8% and the AVL GH15DK which was at 1.25%. In-cylinder pressure transducer data quality was effectively analyzed using a combination of experimental data and simulation results. Several criteria can be used to investigate the impact of thermal shock on data quality as well as determine the best location and thermal protection for various transducers.

IMPROVING STARTABILITY AND REDUCING EMISSIONS IN FLEXFUEL SPARK IGNITION DIRECT INJECTION VARIABLE CAM TIMING ENGINE

Experimental work and analysis was done to investigate engine startup robustness and emissions of a flex-fuel spark ignition (SI) direct injection (DI) engine. The vaporization and other characteristics of ethanol fuel blends present a challenge at engine startup. Strategies to reduce the enrichment requirements for the first engine startup cycle and emissions for the second and third fired cycle at 25°C ± 1°C engine and intake air temperature were investigated. Research work was conducted on a single cylinder SIDI engine with gasoline and E85 fuels, to study the effect on first fired cycle of engine startup. Piston configurations that included a compression ratio change (11 vs 15.5) and piston geometry change (flattop vs bowl) were tested, along with changes in intake cam timing (95,110,125) and fuel pressure (0.4 MPa vs 3 MPa). The goal was to replicate the engine speed, manifold pressure, fuel pressure and testing temperature from an engine startup trace for investigating the first fired cycle for the engine. Results showed bowl piston was able to enable lower equivalence ratio engine starts with gasoline fuel, while also showing lower IMEP at the same equivalence ratio compared to flat top piston. With E85, bowl piston showed reduced IMEP as compression ratio increased at the same equivalence ratio. A preference for constant intake valve timing across fuels seemed to indicate that flattop piston might be a good flex-fuel piston. Significant improvements were seen with higher CR bowl piston with high fuel pressure starts, but showed no improvement with low fuel pressures. Simulation work was conducted to analyze initial three cycles of engine startup in GT-POWER for the same set of hardware used in the experimentations. A steady state validated model was modified for startup conditions. The results of which allowed an understanding of the relative residual levels and IMEP at the test points in the cam phasing space. This allowed selecting additional test points that enable use of higher residual levels, eliminating those with smaller trapped mass incapable of producing required IMEP for proper engine turnover. The second phase of experimental testing results for 2nd and 3rd startup cycle revealed both E10 and E85 prefer the same SOI of 240°bTDC at second and third startup cycle for the flat top piston and high injection pressures. E85 fuel optimal cam timing for startup showed that it tolerates more residuals compared to E10 fuel. Higher internal residuals drives down the Ø requirement for both fuels up to their combustion stability limit, this is thought to be direct benefit to vaporization due to increased cycle start temperature. Benefits are shown for an advance IMOP and retarded EMOP strategy at engine startup. Overall the amount of residuals preferred by an engine for E10 fuel at startup is thought to be constant across engine speed, thus could enable easier selection of optimized cam positions across the startup speeds.

Comparison of arterial blood pressure measurements and hypertension scores obtained by use of three indirect measurement devices in hospitalized dogs

OBJECTIVE: To evaluate the agreement of blood pressure measurements and hypertension scores obtained by use of 3 indirect arterial blood pressure measurement devices in hospitalized dogs. Design-Diagnostic test evaluation. ANIMALS: 29 client-owned dogs. PROCEDURES: 5 to 7 consecutive blood pressure readings were obtained from each dog on each of 3 occasions with a Doppler ultrasonic flow detector, a standard oscillometric device (STO), and a high-definition oscillometric device (HDO). RESULTS: When the individual sets of 5 to 7 readings were evaluated, the coefficient of variation for systolic arterial blood pressure (SAP) exceeded 20% for 0% (Doppler), 11 % (STO), and 28% (HDO) of the sets of readings. After readings that exceeded a 20% coefficient of variation were discarded, repeatability was within 25 (Doppler), 37 (STO), and 39 (HDO) mm Hg for SAP. Correlation of mean values among the devices was between 0.47 and 0.63. Compared with Doppler readings, STO underestimated and HDO overestimated SAP. Limits of agreement between mean readings of any 2 devices were wide. With the hypertension scale used to score SAP, the intraclass correlation of scores was 0.48. Linear-weighted inter-rater reliability between scores was 0.40 (Doppler vs STO), 0.38 (Doppler vs HDO), and 0.29 (STO vs HDO). CONCLUSIONS AND CLINICAL RELEVANCE: Results of this study suggested that no meaningful clinical comparison can be made between blood pressure readings obtained from the same dog with different indirect blood pressure measurement devices.

Microvascular response to metabolic and pressure challenge in the human coronary circulation

In vivo observations of microcirculatory behavior during autoregulation and adaptation to varying myocardial oxygen demand are scarce in the human coronary system. This study assessed microvascular reactions to controlled metabolic and pressure provocation [bicycle exercise and external counterpulsation (ECP)]. In 20 healthy subjects, quantitative myocardial contrast echocardiography and arterial applanation tonometry were performed during increasing ECP levels, as well as before and during bicycle exercise. Myocardial blood flow (MBF; ml·min(-1)·g(-1)), the relative blood volume (rBV; ml/ml), the coronary vascular resistance index (CVRI; dyn·s·cm(-5)/g), the pressure-work index (PWI), and the pressure-rate product (mmHg/min) were assessed. MBF remained unchanged during ECP (1.08 ± 0.44 at baseline to 0.92 ± 0.38 at high-level ECP). Bicycle exercise led to an increase in MBF from 1.03 ± 0.39 to 3.42 ± 1.11 (P < 0.001). The rBV remained unchanged during ECP, whereas it increased under exercise from 0.13 ± 0.033 to 0.22 ± 0.07 (P < 0.001). The CVRI showed a marked increase under ECP from 7.40 ± 3.38 to 11.05 ± 5.43 and significantly dropped under exercise from 7.40 ± 2.78 to 2.21 ± 0.87 (both P < 0.001). There was a significant correlation between PWI and MBF in the pooled exercise data (slope: +0.162). During ECP, the relationship remained similar (slope: +0.153). Whereas physical exercise decreases coronary vascular resistance and induces considerable functional capillary recruitment, diastolic pressure transients up to 140 mmHg trigger arteriolar vasoconstriction, keeping MBF and functional capillary density constant. Demand-supply matching was maintained over the entire ECP pressure range.

Reciprocal relationship between left ventricular filling pressure and the recruitable human coronary collateral circulation

AIMS The aim of our study in patients with coronary artery disease (CAD) and present, or absent, myocardial ischaemia during coronary occlusion was to test whether (i) left ventricular (LV) filling pressure is influenced by the collateral circulation and, on the other hand, that (ii) its resistance to flow is directly associated with LV filling pressure. METHODS AND RESULTS In 50 patients with CAD, the following parameters were obtained before and during a 60 s balloon occlusion: LV, aortic (Pao) and coronary pressure (Poccl), flow velocity (Voccl), central venous pressure (CVP), and coronary flow velocity after coronary angioplasty (V(Ø-occl)). The following variables were determined and analysed at 10 s intervals during occlusion, and at 60 s of occlusion: LV end-diastolic pressure (LVEDP), velocity-derived (CFIv) and pressure-derived collateral flow index (CFIp), coronary collateral (Rcoll), and peripheral resistance index to flow (Rperiph). Patients with ECG signs of ischaemia during coronary occlusion (insufficient collaterals, n = 33) had higher values of LVEDP over the entire course of occlusion than those without ECG signs of ischaemia during occlusion (sufficient collaterals, n = 17). Despite no ischaemia in the latter, there was an increase in LVEDP from 20 to 60 s of occlusion. In patients with insufficient collaterals, CFIv decreased and CFIp increased during occlusion. Beyond an occlusive LVEDP > 27 mmHg, Rcoll and Rperiph increased as a function of LVEDP. CONCLUSION Recruitable collaterals are reciprocally tied to LV filling pressure during occlusion. If poorly developed, they affect it via myocardial ischaemia; if well grown, LV filling pressure still increases gradually during occlusion despite the absence of ischaemia indicating transmission of collateral perfusion pressure to the LV. With low, but not high, collateral flow, resistance to collateral as well as coronary peripheral flow is related to LV filling pressure in the high range.

Sympathetic stimulation using the cold pressor test increases coronary collateral flow

BACKGROUND Little is known about the vasomotor function of human coronary collateral vessels. The purpose of this study was to examine collateral flow under a strong sympathetic stimulus (cold pressor test, CPT). METHODS In 30 patients (62 +/- 12 years) with coronary artery disease, two subsequent coronary artery occlusions were performed with random CPT during one of them. Two minutes before and during the 1 minute-occlusion, the patient's hand was immerged in ice water. For the calculation of a perfusion pressure-independent collateral flow index (CFI), the aortic (Pao), the central venous (CVP) and the coronary wedge pressure (Poccl) were measured: CFI = (Poccl - CVP)/(Pao - CVP). RESULTS CPT lead to an increase in Pao from 98 +/- 14 to 105 +/- 15 mm Hg (p = 0.002). Without and with CPT, CFI increased during occlusion from 14% +/- 10% to 16% +/- 10% (p = 0.03) and from 17% +/- 9% to 19% +/- 9% (p = 0.006), respectively, relative to normal flow. During CPT, CFI was significantly higher at the beginning as well as at the end of the occlusion compared to identical instants without CPT. CFI at the end of the control occlusion did not differ significantly from the CFI at the beginning of occlusion with CPT. CONCLUSIONS During balloon occlusion, collateral flow increased due to collateral recruitment independent of external sympathetic stimulation. Sympathetic stimulation using CPT additionally augmented collateral flow. The collateral-flow-increasing effect of CPT is comparable to the recruitment effect of the occlusion itself. This may reflect a coronary collateral vasodilation mediated by the sympathetic nervous system.

Influence of left ventricular relaxation on the pressure half time of aortic regurgitation

BACKGROUND The severity of aortic regurgitation can be estimated using pressure half time (PHT) of the aortic regurgitation flow velocity, but the correlation between regurgitant fraction and PHT is weak. AIM To test the hypothesis that the association between PHT and regurgitant fraction is substantially influenced by left ventricular relaxation. METHODS In 63 patients with aortic regurgitation, subdivided into a group without (n = 22) and a group with (n = 41) left ventricular hypertrophy, regurgitant fraction was calculated using the difference between right and left ventricular cardiac outputs. Left ventricular relaxation was assessed using the early to late diastolic Doppler tissue velocity ratio of the mitral annulus (E/ADTI), the E/A ratio of mitral inflow (E/AM), and the E deceleration time (E-DT). Left ventricular hypertrophy was assessed using the M mode derived left ventricular mass index. RESULTS The overall correlation between regurgitant fraction and PHT was weak (r = 0.36, p < 0.005). In patients without left ventricular hypertrophy, there was a significant correlation between regurgitant fraction and PHT (r = 0.62, p < 0.005), but not in patients with left ventricular hypertrophy. In patients with a left ventricular relaxation abnormality (defined as E/ADTI< 1, E/AM< age corrected lower limit, E-DT >/= 220 ms), no associations between regurgitant fraction and PHT were found, whereas in patients without left ventricular relaxation abnormalities, the regurgitant fraction to PHT relations were significant (normal E/AM: r = 0.57, p = 0.02; E-DT< 220 ms: r = 0.50, p < 0.001; E/ADTI < 1: r = 0.57, p = 0.02). CONCLUSIONS Only normal left ventricular relaxation allows a significant decay of PHT with increasing aortic regurgitation severity. In abnormal relaxation, which is usually present in left ventricular hypertrophy, wide variation in prolonged backward left ventricular filling may cause dissociation between the regurgitant fraction and PHT. Thus the PHT method should only be used in the absence of left ventricular relaxation abnormalities.

Delayed diagnosis of cryptococcal meningoencephalitis due to negative cryptococcal antigen test

Cryptococcus spp. commonly causes infection in immunocompromised hosts. Clinical presentation of cryptococcal meningoencephalitis (CM) is variable, but headache, fever and a high intracranial pressure should suggest the diagnosis. The cryptococcal antigen test is a specific and sensitive rapid test that can be performed on blood or cerebrospinal fluid. We report a case of CM in a patient with previously undetected lymphocytopenia. Because cryptococcal antigen test results were negative, diagnosis and treatment were delayed.

Limitations of the use of pressure waves to verify correct epidural needle position in dogs

The use of pressure waves to confirm the correct position of the epidural needle has been described in several domestic species and proposed as a valid alternative to standard methods, namely, control radiographic exam and fluoroscopy. The object of this retrospective clinical study was to evaluate the sensitivity of the epidural pressure waves as a test to verify the correct needle placement in the epidural space in dogs, in order to determine whether this technique could be useful not only in the clinical setting but also when certain knowledge of needle's tip position is required, for instance when performing clinical research focusing on epidural anaesthesia. Of the 54 client-owned dogs undergoing elective surgeries and enrolled in this retrospective study, only 45% showed epidural pressure waves before and after epidural injection. Twenty-six percent of the animals showed epidural pressure waves only after the injection, whereas 29% of the dogs showed epidural pressure waves neither before nor after injection and were defined as false negatives. Our results show that the epidural pressure wave technique to verify epidural needle position lacks sensitivity, resulting in many false negatives. As a consequence, the applicability of this technique is limited to situations in which precise, exact knowledge of the needle's tip position is not mandatory.