Quantitative analysis of macular capillaries in diabetic patients using optical coherence tomography angiography / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To quantify early changes of macular capillary parameters in type 2 diabetic patients using optical coherence tomography angiography(OCTA).METHODS: Retrospective case study. A total of 49 healthy subjects, 52 diabetic patients without retinopathy(noDR)patients, and 43 mild nonproliferative diabetic retinopathy(mNPDR)patients were recruited. Capillary perfusion density, vessel length density(VLD), and average vessel diameter(AVD)were calculated from macular OCTA images(3 mm×3 mm)of the superficial capillary plexus after segmenting large vessels and the deep capillary plexus. Parameters were compared among control subjects, noDR, and mNPDR patients. The area under the receiver operating characteristic curve estimated the abilities of these parameters to detect early changes of retinal microvascular networks.RESULTS: Significant differences were found in the VLD and AVD among the three groups(P<0.001). Compared with the control group, the noDR group had significantly higher AVD(P<0.05). VLD of both layers in patients of mNPDR group was significant decreased compared with that of noDR group(all P<0.01). Deep AVD had a higher area under the curve(AUC)of 0.796 than other parameters to discriminate the noDR group from the healthy group. Deep AVD had the highest AUC of 0.920, followed by that of the deep VLD(AUC=0.899)to discriminate the mNPDR group from the healthy group.CONCLUSIONS: NoDR patients had wider AVD than healthy individuals and longer VLD than mNPDR patients in both layers. When compared with healthy individuals, deep AVD had a stronger ability than other parameters to detect early retinal capillary impairments in noDR patients.

El puntaje de Framingham ayudaría en la estratificación del riesgo de pacientes con ergometría positiva y SPECT normal / The Framingham score could help in risk stratification of patients with positive ergometry and normal SPECT

Antecedentes. El valor pronóstico de una ergometría positiva en el contexto de imágenes tomográficas de perfusión miocárdica de estrés y reposo (SPECT) normales no está bien establecido. Objetivos. Documentar la incidencia de infarto, muerte y revascularización coronaria en pacientes con una ergometría positiva de riesgo intermedio e imágenes de perfusión SPECT normales, y explorar el potencial valor del puntaje de riesgo de Framingham en la estratificación pronóstica de estos pacientes. Métodos. Cohorte retrospectiva integrada por pacientes que habían presentado síntomas o hallazgos electrocardiográficos compatibles con enfermedad arterial coronaria durante la prueba de esfuerzo, con criterios de riesgo intermedio en la puntuación de Duke y perfusión miocárdica SPECT normal. Fueron identificados a partir de la base de datos del laboratorio de cardiología nuclear del Instituto de Cardiología y Cirugía Cardiovascular de la ciudad de Posadas, Argentina. Resultados. Fueron elegibles 217 pacientes. El seguimiento fue de 3 1,5 años. La sobrevida libre de eventos (muerte,infarto de miocardio no fatal, angioplastia coronaria o cirugía de bypass de arteria coronaria) a uno, tres y cinco años fue significativamente menor (Log-rank test, p= 0,001) en el grupo con puntaje de Framingham alto o muy alto (77, 71y 59 %, respectivamente) que en el grupo de puntaje bajo o intermedio (89, 87 y 83 %). Tomando como referencia a los pacientes con riesgo bajo en el puntaje de Framingham, luego de ajustar por edad, sexo y puntaje de Duke, los pacientes categorizados en los estratos alto y muy alto riesgo del puntaje de Framingham presentaron una incidencia del evento combinado cercana al triple (hazard ratio [HR] 2,81; intervalo de confianza [IC] del 95 % 0,91 a 8,72; p= 0,07 y HR 3,61;IC 95 % 1,23 a 10,56; p= 0,019 respectivamente). Conclusiones. La estimación de riesgo con el puntaje de Framingham sería de ayuda en la estratificación pronóstica de los pacientes con ergometría positiva y SPECT normal. (AU)

Background. The prognostic value of positive exercise testing with normal SPECT myocardial perfusion imaging is not well established. Objectives. To document the incidence of infarction, death, and coronary revascularization in patients with a positive intermediate-risk exercise test and normal SPECT perfusion images and to explore the potential value of the Framingham Risk Score in the prognostic stratification of these patients. Methods. A retrospective cohort comprised patients who presented symptoms or electrocardiographic findings compatible with coronary artery disease during the stress test, with intermediate risk criteria in the Duke score and normal SPECT myocardial perfusion. They were identified from the database of the nuclear cardiology laboratory of the Instituto de Cardiología y Cirugía Cardiovascular of Posadas, Argentina. Results. 217 patients were eligible. Follow-up was 3 1.5 years. Event-free survival (death, non-fatal myocardial infarction, coronary angioplasty, or coronary artery bypass surgery) at one, three, and five years was significantly lower (Log-ranktest, p: 0.001) in the group with a score of Framingham high or very high (77, 71 and 59 %, respectively) than in the lowor intermediate score group (89, 87 and 83 %). Taking as reference the low-risk patients in the Framingham score, after adjusting for age, sex, and Duke score, the patients categorized in the high-risk and very high-risk strata showed about three times higher incidence of the combined event (hazard ratio [HR] 2.81; 95 % confidence interval [CI] 0.91 to 8.72;p=0.07 and HR 3.61; 95 % CI 1.23 to 10.56; p=0.019 respectively). Conclusions. Risk estimation with the Framingham score would be helpful in the prognostic stratification of patients with positive exercise testing and normal SPECT. (AU)

El dilema clínico frente a los pacientes con ergometría positiva y prueba de perfusión miocárdica con SPECT normal / The clinical dilemma facing patients with positive stress test and normal SPECT myocardial perfusion imaging

La evaluación de la perfusión miocárdica con SPECT combina una prueba de esfuerzo (ergometría o estrés farmacológico) junto a imágenes de perfusión con radioisótopos. Este estudio es útil para establecer el diagnóstico de enfermedad arterial coronaria, estratificar el riesgo de infarto y tomar decisiones terapéuticas. Un resultado normal aporta un alto valor predictivo negativo, es decir, una muy baja probabilidad de que el paciente presente eventos cardiovasculares. El hallazgo de signos de isquemia en la ergometría podría poner en jaque el valor predictivo negativo de una perfusión normal. En presencia de este resultado, el paso siguiente es evaluar los predictores de riesgo en la ergometría, el riesgo propio del paciente en función de los antecedentes clínicos y el puntaje cálcico coronario, cuando este se encuentra disponible. Ante la presencia concomitante de otros marcadores de riesgo se sugiere completar la evaluación con un estudio anatómico.El uso de nuevas tecnologías podría mejorar la precisión en la predicción de eventos. (AU)

Assessment of myocardial perfusion with SPECT combines a stress test (ergometry or pharmacological stress) with radioisotope perfusion imaging. This test is helpful to diagnose coronary artery disease, stratify the risk of heart attack, and make therapeutic decisions. A normal result provides a high negative predictive value; therefore, the probability of cardiovascular events is very low. Signs of ischemia on an ergometry could jeopardize the negative predictive value of normal perfusion. In this clinical setting, the next step is to evaluate the risk predictors in the stress test, the individual risk based on the clinical history, and the coronary calcium score when available. Given the simultaneous presence of other risk markers,completing the evaluation with an anatomical study is suggested. The use of new technologies could improve the accuracy of event prediction. (AU)

Lactate and Lactate Clearance Are Predictive Factors for Mortality in Patients with Extracorporeal Membrane Oxygenation

ABSTRACT Introduction: Findings of inadequate tissue perfusion might be used to predict the risk of mortality. In this study, we evaluated the effects of lactate and lactate clearance on mortality of patients who had undergone extracorporeal membrane oxygenation (ECMO). Methods: Patients younger than 18 years old and who needed venoarterial ECMO support after surgery for congenital heart defects, from July 2010 to January 2019, were retrospectively analyzed. Patients successfully weaned from ECMO constituted Group 1, and patients who could not be weaned from ECMO were in Group 2. Postoperative clinics and follow-ups of the groups including mortality and discharge rates were evaluated. Results: There were 1,844 congenital heart surgeries during the study period, and 55 patients that required ECMO support were included in the study. There was no statistically significant difference between the groups regarding demographics and operative variables. The sixth-, 12th-, and 24th-hour lactate levels in Group 1 were statistically significantly lower than those in Group 2 (P=0.046, P=0.024, and P<0.001, respectively). There were statistically significant differences regarding lactate clearance between the groups at the 24th hour (P=0.009). The cutoff point for lactate level was found as ≥ 2.9, with 74.07% sensitivity and 78.57% specificity (P<0.001). The cutoff point for lactate clearance was determined as 69.44%, with 59.26% sensitivity and 78.57% specificity (P=0.003). Conclusion: Prognostic predictive factors are important to initiate advanced treatment modalities in patients with ECMO support. In this condition, lactate and lactate clearance might be used as a predictive marker.

Uso de Índices Aterogênicos como Métodos de Avaliação das Doenças Ateroscleróticas Clínicas / Use of Atherogenic Indices as Assessment Methods of Clinical Atherosclerotic Diseases

Resumo Fundamento A busca por métodos clinicamente úteis de avaliação de doenças ateroscleróticas, com boa acurácia, de baixo custo, sem invasividade e de fácil manejo, há anos vem sendo estimulada. Dessa forma, os índices aterogênicos avaliados deste estudo podem se encaixar nesta demanda crescente. Objetivos Avaliar o potencial dos índices aterogênicos como métodos de avaliação de pacientes portadores de aterosclerose clínica. Métodos Estudo transversal de centro único, por meio do qual foram avaliados os índices de Castelli I e II, índice aterogênico plasmático (IAP), índice de combinação de lipoproteínas e a variação do índice de perfusão periférica entre 90 e 120 segundos após um estímulo vasodilatador endotélio-dependente (ΔIPP90-120) na predição de aterosclerose. A significância estatística foi estabelecida em p < 0,05. Resultados A amostra foi composta por 298 indivíduos com idade média de 63,0 ± 16,1 anos, dos quais 57,4% eram mulheres. Comparações pareadas da análise curva ROC dos índices que alcançaram área sob a curva (ASC) > 0,6 mostram que ΔIPP90-120 e IAP foram superiores aos demais índices, sem diferenças observadas entre si (diferença entre ASC = 0,056; IC95% -0,003-0,115). Ademais, tanto a ΔIPP90-120 [odds ratio (OR) 9,58; IC95% 4,71-19,46] quanto o IAP (OR 5,35; IC95% 2,30-12,45) foram preditores independentes de aterosclerose clínica. Conclusões O IAP e ΔIPP90-120 apresentaram melhor acurácia para discriminar aterosclerose clínica. Além disso, foram preditores independentes de aterosclerose clínica, evidenciando uma possibilidade promissora para o desenvolvimento de estratégias preventivas e de controle para doenças cardiovasculares. Tratam-se, portanto, de marcadores adequados para estudos multicêntricos do ponto de vista de praticidade, custo e validade externa.

Abstract Background The search for clinically useful methods to assess atherosclerotic diseases (ASCVD) with good accuracy, low cost, non-invasiveness, and easy handling has been stimulated for years. Thus, the atherogenic indices evaluated in this study may fit this growing demand. Objectives To assess the potential of atherogenic indices to evaluate patients with clinical atherosclerosis. Methods Single-center cross-sectional study, through which the Castelli I and II indices, the atherogenic index of plasma (AIP), the lipoprotein combine index, and the variation in the peripheral perfusion index between 90 and 120 seconds after an endothelium-dependent (ΔPI90-120) vasodilator stimulus were evaluated in the prediction of atherosclerosis. Statistical significance was set at p < 0.05. Results The sample consisted of 298 individuals with an average age of 63.0±16.1 years, of which 57.4% were women. Paired comparisons of the ROC curve analysis of the indices that reached the area under the curve (AUC) > 0.6 show that ΔPI90-120 and AIP were superior to other indices, and no differences were observed between them (difference between AUC = 0.056; 95%CI -0.003-0.115). Furthermore, both the ΔPI90-120 [odds ratio (OR) 9.58; 95%CI 4.71-19.46)] and AIP (OR 5.35; 95%CI 2.30-12.45) were independent predictors of clinical atherosclerosis. Conclusions The AIP and ΔPI90-120 represented better accuracy in discriminating clinical ASCVD. Moreover, they were independent predictors of clinical ASCVD, evidencing a promising possibility for developing preventive and control strategies for cardiovascular diseases. Therefore, they are markers for multicenter studies from the point of view of practicality, low cost, and external validity.

Análisis multivariado de factores pronósticos en niños con traumatismo craneoencefálico grave que requirieron craneotomía descompresiva / Multivariate Analysis of Prognostic Factors in Children with Severe Cranioencephalic Trauma Requiring Decompressive Craniotomy

Introducción: El traumatismo craneoencefálico en edades pediátricas constituye un problema de salud relevante a nivel mundial y en Cuba. Objetivo: Determinar los factores pronósticos del trauma craneoencefálico grave en niños que requirieron craneotomía descompresiva. Métodos: Se realizó un estudio transversal correlacional, de tipo serie de casos, en el Servicio de Neurocirugía del Hospital Pediátrico de Camagüey durante el período comprendido desde enero de 2019 a diciembre de 2021. Fueron estudiados un total de 27 niños con traumatismo craneoencefálico grave, que cumplieron con los criterios de selección de la investigación. Las variables analizadas incluyeron: grupo etario, sexo, intensidad de la lesión, técnica quirúrgica, perfusión cerebral y resultados quirúrgicos obtenidos. Resultados: Predominó el grupo etario de 11-18 años (45,5 porciento) y el sexo masculino (72,7 porciento). El mayor puntaje en la variable intensidad de la lesión correspondió con la realización de craneotomías bilaterales (media = 78,63). Se halló disminución significativa (p = 0,024) de la perfusión cerebral en los pacientes con edad menor o igual a 8 años (media = 61,6387) y se encontró más disminuida en los pacientes que requirieron craneotomía bilateral (p = 0,001). Los peores resultados obtenidos correspondieron a los pacientes con edad biológica igual o menor a 8 años, que requirieron craneotomía bilateral. Conclusiones: La edad menor a 8 años se relacionó con mayor deterioro de la perfusión cerebral y peores resultados. La necesidad de craneotomías bilaterales se asoció con mayor intensidad de la lesión encefálica, presión intracraneal preoperatoria más elevada y deterioro de la perfusión cerebral(AU)

Introduction: Cranioencephalic trauma in pediatric ages is a relevant health problem worldwide and in Cuba. Objective: To determine the prognostic factors of severe cranioencephalic trauma in children who required decompressive craniotomy. Methods: A cross-sectional and correlational study of case series type was carried out at the neurosurgery service of Hospital Pediátrico de Camagüey during the period from January 2019 to December 2021. A total of 27 children with severe cranioencephalic trauma who met the research selection criteria were studied. The analyzed variables included age group, sex, injury intensity, surgical technique, cerebral perfusion and obtained surgical outcomes. Results: The age group 11-18 years (45.5 percent) and male sex (72.7 percent) predominated. The highest score in the variable injury intensity corresponded to the realization of bilateral craniotomies (mean = 78.63). A significant decrease (p = 0.024) in cerebral perfusion was found in patients aged 8 years or under (mean = 61.6387) and it was found to be more diminished in patients who required bilateral craniotomy (p = 0.001). The worst obtained outcomes corresponded to patients with a biological age of 8 years or under, who required bilateral craniotomy. Conclusions: Age under 8 years was associated with greater cerebral perfusion impairment and worse outcomes. The need for bilateral craniotomies was associated with greater intensity of the encephalic injury, higher preoperative intracranial pressure and cerebral perfusion impairment(AU)

ADDED UTILITY OF COMPUTED TOMOGRAPHY PERFUSION STUDY IN THE ASSESSMENT OF EARLY ISCHEMIC STROKE IN COMPARISON WITH NON- CONTRAST COMPUTED TOMOGRAPHY - A PROSPECTIVE OBSERVATIONAL STUDY

Objective: 1. T o study the added utility of computed tomography perfusion study in the assessment of early ischemic stroke in comparison with non-contrast computed tomography. 2. To study the role of computed tomography perfusion study in deciding thrombolytic treatment/ therapeutic protocols aimed at reversing the cerebral ischemic insult. Conclusions and Results: It was observed that 15 (46.68%) patients were in the 61-70 years of age group followed by 8 (25%) in the age group of 51-60 years. The mean age of the patients was 58.87 ±12.14 years. Ÿ Females were affected more i.e. 18 (56.25%) compared to the male patients 14 (43.75%). Ÿ Most observed co-morbid condition was hypertension in 9 (28.13%) patients followed by hypertension and diabetes in 7 (21.87%) patients and diabetes in 6 (18.75%) patients. Ÿ Among the study participants 4 (12.50%) were smokers followed by 6 (18.75%) were alcoholic and smokers & alcoholic (15.62%) respectively. Ÿ It was observed that the symptoms of palsy were present among 23 (71.88%) patients Ÿ The most commonly observed time of onset of symptoms was 3-5 hours in 23 (71.88%) patients followed by 1-3 hours (21.87%) and >5 hours in 2 (6.25%) patients. Ÿ NCCT ?ndings observed was de?nite signs of stroke in 12 (37.5%) patients followed by suspected signs of stroke on NCCT (25%) Ÿ It was observed that no sign of stroke was observed in 12 (37.5%) patients. Ÿ CT perfusion ?ndings observed was increased mean transient time (MTT) in all (100%) patients followed by decreased blood ?ow in all (100%) patients. It was observed that cerebral blood volume decreased in 12 (37.5%) patients, increased in 8 (25%) and normal in 12 (37.5%) patients. Ÿ The correlation of NCCT and CT perfusion ?ndings observed that out of total 32 patients NCCT study identi?es 20 patients while all 32 patients were identi?ed by CT perfusion study with sensitivity of 100%. Ÿ CT perfusion provides early diagnosis of ischemic stroke thus helps in management of stroke patients. Inference : The present study concludes that CT-perfusion had more sensitivity compared to NCCT in identifying early ischemic stroke. CT perfusion has additional utility in management of early ischemic stroke. CT Perfusion study provides important information to the neurologist and neuro-interventionalist when evaluating patients for endovascular reperfusion therapy by identifying the size of core infarction and penumbra

Retinal perfusion density can predict cardiovascular disease risk in patients with retinal vein occlusion

Purpose: To correlate microvascular changes and assess the relationship between microvascular changes and cardiovascular disease (CVD) risk in patients with retinal vein occlusion (RVO). Methods: Patients over 40 years of age with unilateral RVO were included in this prospective study. Those known to have cardiovascular disease were excluded. A detailed medical history was taken and physical exam was done to measure the height, weight, body mass index (BMI), and systolic blood pressure (SBP). A comprehensive eye check?up was followed by optical coherence tomography angiography (OCTA). Microvascular indices such as vessel density (VD) and perfusion density (PD) were noted. A statistical model was developed for prediction of CVD risk and was integrated with the World Health Organization (WHO)’s risk prediction charts. Results: This study included 42 patients with RVO and 22 controls with an age range of 42–82 years. There were 40 males (62.5%) and 24 females (37.5%). Along with age, SBP, and gender, perfusion density was found to have significant impact on CVD risk (P = 0.030). Reduction in PD was associated with increase in CVD risk. PD had a greater influence on CVD in <50 years age than in >70 years group. Using linear regression, a model with accuracy of 72.1% was developed for CVD risk prediction and was converted into color coded charts similar to WHO risk prediction charts. Conclusion: These findings suggest a significant correlation between microvascular parameters and CVD risk in RVO patients. Based on these parameters, an easy?to?use and color?coded risk prediction chart was developed

Perfusão arterial reversa gemelar: revisão da literatura / Twin reverse arterial perfusion: literature review

A perfusão arterial reversa gemelar é uma anormalidade rara que pode ocorrer em gestações gemelares monocoriônicas. Consiste em uma alteração na circulação fetoplacentária, com desvio de sangue de um dos gemelares para o outro, por meio de anastomoses arterioarteriais e venovenosas na superfície placentária e anastomoses arteriovenosas em áreas de circulação placentária compartilhada. O feto bombeador pode desenvolver insuficiência cardíaca devido ao aumento do débito cardíaco, e o feto receptor, perfundido por sangue pobre em oxigênio por meio do fluxo reverso, é severamente malformado, incompatível com a vida extrauterina. Este artigo apresenta o caso de uma gestação gemelar monocoriônica diamniótica, com manejo clínico conservador. O objetivo é relatar um caso de complicação rara de gestações monozigóticas e revisar condutas para diagnóstico e manejo adequado.(AU)

Twin reverse arterial perfusion is a rare abnormality that can occur in monochorionic twin pregnancies. It consists of an alteration in the fetal-placental circulation, with blood diversion from one of the twins to the other, through arterio-arterial and veno- venous anastomosis on the placental surface and arterio-venous anastomosis in areas of shared placental circulation. The pumping fetus may develop heart failure due to increased cardiac output, and the recipient fetus, perfused by oxygen-poor blood through reverse flow, is severely malformed, incompatible with extrauterine life. This article presents the case of a monochorionic diamniotic twin pregnancy, with conservative clinical management. The objective is to report a case of rare complication of monozygotic pregnancies and review procedures for diagnosis and adequate management.(AU)

Neurocritical care management supported by multimodal brain monitoring after acute brain injury / Abordagem de cuidados neurocríticos apoiada por monitorização cerebral multimodal após lesão cerebral aguda

ABSTRACT Objective: To evaluate the association between different intensive care units and levels of brain monitoring with outcomes in acute brain injury. Methods: Patients with traumatic brain injury and subarachnoid hemorrhage admitted to intensive care units were included. Neurocritical care unit management was compared to general intensive care unit management. Patients managed with multimodal brain monitoring and optimal cerebral perfusion pressure were compared with general management patients. A good outcome was defined as a Glasgow outcome scale score of 4 or 5. Results: Among 389 patients, 237 were admitted to the neurocritical care unit, and 152 were admitted to the general intensive care unit. Neurocritical care unit management patients had a lower risk of poor outcome (OR = 0.228). A subgroup of 69 patients with multimodal brain monitoring (G1) was compared with the remaining patients (G2). In the G1 and G2 groups, 59% versus 23% of patients, respectively, had a good outcome at intensive care unit discharge; 64% versus 31% had a good outcome at 28 days; 76% versus 50% had a good outcome at 3 months (p < 0.001); and 77% versus 58% had a good outcome at 6 months (p = 0.005). When outcomes were adjusted by SAPS II severity score, using good outcome as the dependent variable, the results were as follows: for G1 compared to G2, the OR was 4.607 at intensive care unit discharge (p < 0.001), 4.22 at 28 days (p = 0.001), 3.250 at 3 months (p = 0.001) and 2.529 at 6 months (p = 0.006). Patients with optimal cerebral perfusion pressure management (n = 127) had a better outcome at all points of evaluation. Mortality for those patients was significantly lower at 28 days (p = 0.001), 3 months (p < 0.001) and 6 months (p = 0.001). Conclusion: Multimodal brain monitoring with autoregulation and neurocritical care unit management were associated with better outcomes and should be considered after severe acute brain injury.

RESUMO Objetivo: Avaliar a associação entre diferentes tipos de unidades de cuidados intensivos e os níveis de monitorização cerebral com desfechos na lesão cerebral aguda. Métodos: Foram incluídos doentes com traumatismo craniencefálico e hemorragia subaracnoide internados em unidades de cuidados intensivos. A abordagem na unidade de cuidados neurocríticos foi comparada à abordagem na unidade de cuidados intensivos polivalente geral. Os doentes com monitorização cerebral multimodal e pressão de perfusão cerebral ótima foram comparados aos que passaram por tratamento geral. Um bom desfecho foi definido como pontuação de 4 ou 5 na Glasgow outcome scale. Resultados: Dos 389 doentes, 237 foram admitidos na unidade de cuidados neurocríticos e 152 na unidade de cuidados intensivos geral. Doentes com abordagem em unidades de cuidados neurocríticos apresentaram menor risco de um mau desfecho (Odds ratio = 0,228). Um subgrupo de 69 doentes com monitorização cerebral multimodal (G1) foi comparado aos demais doentes (G2). Em G1 e G2, respectivamente, 59% e 23% dos doentes apresentaram bom desfecho na alta da unidade de cuidados intensivos; 64% e 31% apresentaram bom desfecho aos 28 dias; 76% e 50% apresentaram bom desfecho aos 3 meses (p < 0,001); e 77% e 58% apresentaram bom desfecho aos 6 meses (p = 0,005). Quando os desfechos foram ajustados para o escore de gravidade do SAPS II, usando o bom desfecho como variável dependente, os resultados foram os seguintes: para o G1, em comparação ao G2, a odds ratio foi de 4,607 na alta da unidade de cuidados intensivos (p < 0,001), 4,22 aos 28 dias (p = 0,001), 3,250 aos 3 meses (p = 0,001) e 2,529 aos 6 meses (p = 0,006). Os doentes com abordagem da pressão de perfusão cerebral ótima (n = 127) apresentaram melhor desfecho em todos os momentos de avaliação. A mortalidade desses doentes foi significativamente menor aos 28 dias (p = 0,001), aos 3 meses (p < 0,001) e aos 6 meses (p = 0,001). Conclusão: A monitorização cerebral multimodal com autorregulação e abordagem na unidade de cuidados neurocríticos foi associado a melhores desfechos e deve ser levado em consideração após lesão cerebral aguda grave.

Relationship between peripheral ischemic microvascular reserve, persistent hyperlactatemia, and its temporal dynamics in sepsis: a post hoc study / Relação entre reserva microvascular isquêmica periférica, hiperlactatemia persistente e sua dinâmica temporal na sepse: um estudo post hoc

ABSTRACT Objective: To measure the prognostic value of peripheral ischemic microvascular reserve in the context of persistent sepsis-induced hyperlactatemia and measure its influence on the temporal dynamics of lactate and the strength of association between these variables. Methods: This post hoc analysis of the peripheral perfusion index/postocclusive reactive hyperemia trial, an observational cohort study that enrolled patients with sepsis who persisted with lactate levels ≥ 2mmol/L after fluid resuscitation (with or without shock). Peripheral ischemic microvascular reserve was evaluated using the association of the peripheral perfusion index and postocclusive reactive hyperemia techniques. The cutoff point of ∆ peripheral perfusion index peak values (%) defined the groups with low (≤ 62%) and high peripheral ischemic microvascular reserve (> 62%). Results: A total of 108 consecutive patients with persistent sepsis-induced hyperlactatemia were studied. The high peripheral ischemic microvascular reserve group showed higher 28-day mortality than the low peripheral ischemic microvascular reserve group (p < 0.01). The temporal dynamics of lactate within the first 48 hours showed a rapid decrease in lactate levels in the low peripheral ischemic microvascular reserve group (p < 0.01). However, this result was not reproduced in the linear mixed effects model. A weak correlation between peripheral ischemic microvascular reserve (%) and lactate level (mmol/L) was observed within the first 24 hours (r = 0.23; p < 0.05). Conclusion: The prognostic value of high peripheral ischemic microvascular reserve was confirmed in the context of persistent sepsis-induced hyperlactatemia. Although there was a weak positive correlation between peripheral ischemic microvascular reserve value and lactate level within the first 24 hours of sepsis diagnosis, the low peripheral ischemic microvascular reserve group appeared to have a faster decrease in lactate over the 48 hours of follow-up.

RESUMO Objetivo: Avaliar o valor prognóstico da reserva microvascular isquêmica periférica no contexto da hiperlactatemia persistente induzida pela sepse, determinar sua influência na dinâmica temporal de lactato e analisar a força da associação entre essas variáveis. Métodos: Análise post hoc do estudo de índice de perfusão periférica/hiperemia reativa pós-oclusiva caracterizada por uma coorte observacional que incluiu pacientes com sepse que persistiram com níveis de lactato ≥ 2mmol/L após a ressuscitação volêmica (com ou sem choque). A reserva microvascular isquêmica periférica foi mensurada utilizando-se a associação dos métodos do índice de perfusão periférica e hiperemia reativa pós-oclusiva. O ponto de corte dos valores da ∆ índice de perfusão periférica de pico (%) definiu os grupos com baixa (≤ 62%) e alta (> 62%) reserva microvascular isquêmica periférica. Resultados: Estudaram-se 108 pacientes consecutivos com hiperlactatemia persistente induzida pela sepse. O grupo com alta reserva microvascular isquêmica periférica apresentou maior mortalidade aos 28 dias em relação ao grupo com baixa reserva microvascular isquêmica periférica (p < 0,01). A dinâmica temporal de lactato nas primeiras 48 horas mostrou redução rápida dos níveis de lactato no grupo com baixa reserva microvascular isquêmica periférica (p < 0,01). No entanto, esse resultado não foi reproduzido no modelo de efeitos mistos lineares. Observou-se fraca correlação (%) entre os valores da reserva microvascular isquêmica periférica e níveis de lactato (mmol/L) nas primeiras 24 horas (r = 0,23; p < 0,05). Conclusão: O valor prognóstico da alta reserva microvascular isquêmica periférica foi confirmado no contexto da hiperlactatemia persistente induzida por sepse. Embora tenha sido observada uma baixa correlação positiva entre os valores da reserva microvascular isquêmica periférica e os níveis de lactato nas primeiras 24 horas do diagnóstico de sepse, o grupo com baixa reserva microvascular isquêmica periférica pareceu apresentar redução mais rápida do lactato nas 48 horas de seguimento.

Acute Paraplegia Result from Spinal Ischemia Nine Years After Hybrid Total Arch Repair with Frozen Elephant Trunk: A Case Report

ABSTRACT Spinal cord ischemia due to decreased cord perfusion is a devastating complication in patients with thoracoabdominal dissection following frozen elephant trunk (FET) repair surgery. However, rare occurrence of spinal cord ischemia leading to paraplegia after long-term follow-up of FET repair has been reported. Here, we describe a case of spinal cord ischemia resulting in paraplegia nine years after hybrid total arch repair with FET. Cerebrospinal fluid drainage and serial treatment were utilized to decrease intraspinal pressure and increase blood flow to the spinal cord. Three months after the onset of paraplegia and with treatment and rehabilitation, the patient recovered to walk.

Long-term assessment of systemic microcirculatory function and plasma cytokines after coronavirus disease 2019 (COVID-19)

Abstract Systemic microvascular dysfunction has been shown to be present in COVID-19, and serum cytokines are known to be involved in the regulation of vascular function. We sought to evaluate systemic microvascular endothelial function, with laser doppler perfusion monitoring (LDPM), and plasma levels of cytokines after acute COVID-19. Individuals admitted to a Cardiology hospital with acute COVID-19 and followed for 12-15 months after recovery underwent noninvasive evaluation of systemic endothelium-dependent microvascular reactivity by cutaneous LDPM with local thermal hyperemia (LTH). A multiplex biometric immunoassay panel was used to assess 48 serum cytokines and chemokines. Twenty patients and 14 control volunteers were enrolled. The areas under the curves of vasodilation induced by LTH were significantly increased after recovery (P=0.009) and were not different from values obtained in healthy volunteers (P= 0.85). The peak microvascular flow during LTH did also significantly increase (P= 0.02), and was not different form values obtained in healthy volunteers (P= 0.55). Several cytokines displayed significantly reduced serum concentrations after recovery from COVID-19. In conclusion, endothelium-dependent systemic microvascular reactivity improved after recovery from COVID-19 in patients with cardiovascular diseases, in parallel with a reduction in the levels of several serum cytokines and chemokines involved in the regulation of vascular function and inflammation.

The comparison of anatomical and functional features between patients with ischemic with non-obstructive coronary artery disease and obstructive coronary artery disease by CT / 中华放射学杂志

Objective:To explore the difference of the vessel and plaque characteristics, myocardial perfusion and cardiac function between patients with ischemia with non-obstructive coronary artery disease (INOCA) and obstructive coronary artery disease (CAD).Methods:From July 2021 to June 2022, 101 patients with angina were referred to dynamic computed tomography myocardial perfusion (CTP) and coronary computed tomography angiography (CCTA) and retrospectively included in our hospital. Based on the results of CTP and CCTA, patients were divided into INOCA (27 cases), moderate obstructive CAD (26 cases) and severe obstructive CAD (48 cases). The anatomical coronary artery stenosis, plaque characteristics and myocardial perfusion features of all patients were analyzed. Furthermore, left ventricular global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) were obtained on full-phase reconstruction CCTA image by using Medis Suite 3.2 postprocessing software. Multigroup analysis used one way ANOVA or Kruskal Wallis H test. Results:Patients with INOCA were younger than patients with moderate and severe obstructive CAD ( P<0.001). INOCA patients (7.4%, 2/27) had lower rate of positive remodeling than both moderate (57.7%, 15/26, P<0.001) and severe obstructive CAD patients (33.3%, 16/48, P=0.017). The percentage of ischemic myocardium volume in patients with INOCA were similar with those in patients with severe CAD (all P>0.05), but significantly higher than those in patients with moderate CAD (all P<0.05). No significant difference in terms of GLS was detected between patients with INOCA [-17.4% (-21.6%, -11.6%)] and severe CAD [-17.6% (-21.9%, -14.8%), P=0.536], however, patients both with INOCA and severe CAD also had higher GLS than patients with moderate obstructive CAD [-22.3% (-29.8%, -19.0%), all P<0.05]. Conclusions:Based on"one-stop-shop"CTP combined with CCTA imaging, early cardiac functional changes including abnormal myocardial perfusion and myocardial strain in INOCA patients were similar to those in patients with severe obstructive CAD and more severe than those in patients with moderate obstructive CAD.

Construction of a porcine model of ischemia with non-obstructive coronary artery and assessment by CT myocardial perfusion imaging combined with coronary CT angiography / 中华放射学杂志

Objective:To construct a porcine model of ischemia with non-obstructive coronary artery (INOCA) and explore the diagnostic value of a one-stop noninvasive method including CT myocardial perfusion imaging (CT-MPI) and coronary CT angiography (CCTA).Methods:Twelve swines were divided into the experimental group (9) and the normal group (3). Coronary microvascular dysfunction (CMD) porcine model was constructed in the experimental group by inducing diabetes mellitus, chronic kidney disease, and hypercholesterolemia. Invasive coronary angiography (ICA) and functional examination were performed on all 7+3 trial swines to clarify the INOCA diagnosis after completion of the modeling. Then, CT-MPI and CCTA were performed on all individuals to explore the CT-MPI and CCTA characteristics of INOCA porcine models. CT-MPI parameters, including myocardial blood flow (MBF), and myocardial blood volume (MBV) in rest and stress conditions, and CCTA parameters, including severity of stenosis and CAD-RADS, were analyzed.Results:ICA and functional tests showed that all swines in the experimental group met the diagnostic criteria for INOCA, which meant that INOCA porcine model was constructed successfully. CCTA results confirmed that there was no obstructive coronary stenosis in all 10 swines which were examined, which was consistent with ICA findings. CT-MPI results demonstrated that the mean MBF values, as well as the mean MBV values, in the rest and stress condition of each swines in the experimental group were lower than those of the control group. In contrast to the control group, the mean MBF and MBV values of swines in the experimental group in stress condition were generally lower than those in resting condition.Conclusions:In this study, a porcine model of CMD is successfully constructed by inducing hypercholesterolemia+diabetes mellitus+chronic kidney disease. ICA and invasive functional tests show that this CMD model meet the diagnostic criteria for INOCA. It has been confirmed that one-stop CT multimodality examination including CT-MPI and CCTA can be used for the diagnosis of INOCA as a noninvasive diagnostic method.

Tumor perfusion enhancement effect combined with programmed cell death-Ligand 1 antibody improves the immune microenvironment of solid tumors / 中华超声影像学杂志

Objective:To investigate the tumor perfusion enhancement induced by low intensity ultrasound stimulated microbubble cavitation (USMC) combined with programmed cell death-Ligand 1(PD-L1) antibody on improving the immune microenvironment of solid tumors.Methods:Tumor-bearing mice were divided into 4 groups: Control ( n=26) group, USMC ( n=27) group, anti-PD-L1 ( n=27) group and USMC+ anti-PD-L1 ( n=27) group. USMC treatment was performed with a VINNO 70 ultrasound theranostics system. Tumor perfusion was evaluated by contrast-enhanced ultrasound (CEUS). The anti-tumor efficacy was assessed by the tumor growth curve and the survival time of mice. The number and function of CD8 + T cells, the differentiation of CD4 + T cells, the proportion of MDSC and the phenotype distribution of TAM in tumors were analyzed by flow cytometry. The content of CXCL9, CXCL10 and HIF-1α in tumor were detected by ELISA. The expression of VEGF in tumor tissues was analyzed by immunofluorescence. Results:CEUS showed that the values of PI and AUC of tumors were significantly increased after USMC compared with before USMC (all P<0.05). USMC combined with anti-PD-L1 therapy did suppress the tumor progression. FCM showed the number, the expression of proliferation antigen Ki67, the secretion of IFN-γ and Granzyme B of CD8 + T cells in tumors were higher in combined group than those in other three groups after therapy (all P<0.05). Meantime, the proportion of Th1 was rose while Tregs and MDSC were declined and the polarization of TAM was toward M1 type by combined therapy. ELISA analysis showed that the combined therapy also increased the concentration of CXCL9, CXCL10 and decreased the content of HIF-1α in tumors (all P<0.05). Meanwhile, the immunofluorescence expression of VEGF was significantly lower in combined group than that in the control group after treatment ( P<0.05). Conclusions:Tumor perfusion enhancement by USMC combined with PD-L1 antibody therapy could improve tumor immune microenvironment and USMC might be a novel effective method for potentiating PD-L1 antibody immunotherapy.

Adenosine stress myocardial contrast echocardiography evaluates myocardial perfusion abnormalities in patients with hypertrophic cardiomyopathy / 中华超声影像学杂志

Objective:To detect the abnormal changes of myocardial blood perfusion in patients with hypertrophic cardiomyopathy(HCM) by myocardial contrast echocardiography (MCE) combined with adenosine stress test.Methods:Fifteen adult patients with HCM who were treated in Fuwai Central China Cardiovascular Hospital from May 2021 to March 2022 were prospectively selected as the HCM group, and eighteen healthy volunteers matched by gender, age and body surface area during the same period were chosen as the control group. All subjects underwent routine echocardiography, rest and adenosine stress MCE. The MCE images were analyzed by QLab software to obtain the myocardial perfusion parameters: peak signal intensity (A value), rising slope of the curve (β value) and A×β value, and the differences of above parameters between the two groups were compared.According to whether the end-diastolic wall thickness ≥12 mm, the myocardial segments in the HCM group were divided into hypertrophic segments and non-hypertrophic segments. The differences in myocardial perfusion parameters were compared among control group segments, hypertrophic segments and non-hypertrophic segments of the HCM group. The correlations of stress myocardial blood flow with maximal left ventricular wall thickness (MLVWT), left ventricular mass index (LVMI) and left atrial volume index (LAVI) in the HCM group were analyzed.Results:Compared with the control group, the A value, β value and A×β value of whole myocardium, hypertrophic segments and non-hypertrophic segments in the HCM group were significantly decreased in the rest and adenosine stress state, and the differences were statistically significant (all P<0.05). In the stress state, the A value, β value and A×β value of the hypertrophic segments were significantly lower than those in the non-hypertrophic segments in the HCM group, and the detection rate of abnormal perfusion segments in the HCM group was significantly higher than that in the rest state(all P<0.05). Compared with the control group, the myocardial blood flow reserve of whole myocardium, hypertrophic segments and non-hypertrophic segments in the HCM group were significantly decreased, and the differences were statistically significant(all P<0.05). The stress myocardial blood flow in the HCM group was negatively correlated with MLVWT, LVMI and LAVI ( r=-0.815, -0.805, -0.742; all P<0.05). Conclusions:Myocardial blood perfusion abnormalities can occur in both hypertrophic and non-hypertrophic myocardial segments in patients with HCM, and adenosine stress MCE can significantly improve the sensitivity of detecting myocardial perfusion abnormalities. The stress myocardial blood flow in patients with HCM is negatively correlated with MLVWT, LVMI and LAVI.

Effect of levofloxacin combined with metronidazole intrauterine infusion on infertility patients with chronic endometritis / 中国综合临床

Objective:To investigate the clinical outcomes of using the levofloxacin combined with intrauterine infusion of metronidazole for the treatment of the infertility patients with chronic endometritis (CE).Methods:Using a case-control study method. 82 infertility patients with CE admitted to Xuzhou Central Hospital from March 2018 to March 2021 were selected and randomly divided into an observation group and a control group using a random number table method, with 41 cases in each group. The control group was treated with oral levofloxacin hydrochloride, while the observation group was treated with metronidazole sodium chloride injection intrauterine infusion on the basis of the control group. Both groups were treated for 14 days. Compare the serum C-reactive protein (CRP) and tumor necrosis factor between two groups before and after treatment α(tumor necrosis factor-α, TNF-α) The levels of monocyte chemotactic protein 1 (MCP-1), natural pregnancy rate within six months, total effective rate, and incidence of adverse reactions during treatment were measured. The measurement data with normal distribution is expressed as: independent sample t-test is used for comparison between the two groups, and paired t-test is used for comparison before and after treatment within the group; The measurement data of non normal distribution is represented by M( Q1, Q3), and the comparison between groups is made by Wilcoxon Rank sum test. The counting data is represented by examples (%), and the comparison between groups is conducted using the χ 2 test. Results:Before treatment, two groups of serum CRP and TNF-α There was no statistically significant difference compared to the levels of MCP-1 (all P>0.05); After 14 days of treatment, both groups had serum CRP and TNF-α、MCP-1 were all lower than before treatment, and the observation group was lower than the control group [(4.12±1.9) ng/L vs (6.36±1.63) ng/L, (47.28±9.10) ng/L vs (62.79±9.34) ng/L, (212.04±24.82) ng/L vs (326.15±27.38) ng/L], with statistically significant differences ( t-values of 5.61, 7.62, and 19.77, all P<0.001). After 14 days of treatment, the total effective rate of the observation group was higher than that of the control group [95.12% (39/41) vs 78.05% (32/41)], with a statistically significant difference (χ 2=5.14, P=0.023). After 6 months of treatment, the natural pregnancy rate in the observation group was higher than that in the control group [53.66% (22/41) vs 31.71% (13/41)], with a statistically significant difference (χ 2=5.96, P=0.044). There was no statistically significant difference in the incidence of adverse reactions between the two groups during the treatment period (χ 2=0.55, P=0.457). Conclusions:The combination of levofloxacin and intrauterine infusion of metronidazole has a good clinical effect in treating infertility patients with CE. It can significantly improve the inflammatory state of the body, reduce serum inflammatory factor levels, increase the natural pregnancy rate within 6 months, and do not increase the incidence of adverse reactions.

Diagnostic value of cardiac magnetic resonance contrast medium perfusion and delayed contrast enhancement for early myocardial ischemia / 中国基层医药

Objective:To investigate the diagnostic value of cardiac magnetic resonance (CMR) contrast medium perfusion and delayed contrast enhancement for early myocardial ischemia.Methods:Ninety-one patients with coronary artery stenosis diagnosed by coronary angiography (CAG) between March 2020 and March 2022 in Yiwu Central Hospital were included in this study. These patients underwent first-pass perfusion cardiac magnetic resonance imaging and delayed enhancement examination. Arrival time ( t0), accumulative signal intensity (ASI), relative peak enhancement rate (SI%), maximum intensity of signal enhancement (SIp), and maximum curve slope (α) were statistically analyzed in the CMR contrast agent normal-dose perfusion and low-dose perfusion segments. The diagnostic value of CMR contrast agent perfusion versus CAG for early myocardial ischemia was determined. The signal intensity was compared between enhanced and non-enhanced areas of CMR contrast agent perfusion. Results:There were significant differences in ASI, SI%, SIp, and Slope (α) between normal perfusion and low perfusion segments ( t = 9.62, 10.65, 8.67, 6.93, all P < 0.05). There was no significant difference in the detection rate of lesioned vessels in early myocardial ischemia between CMR contrast agent perfusion and CAG [50.42% (120/238) vs. 51.68% (123/238), χ2 = 1.32, P = 0.163). There was a significant difference in the detection rate of lesioned vessels in myocardial ischemia between CMR contrast agent perfusion and CAG ( χ2 = 15.31, P < 0.001, r = 0.71). The signal intensity value in the delayed enhancement segment was significantly higher than that in the non-delayed enhancement segment [(598.43 ± 40.19) vs. (298.64 ± 70.58), t =19.85, P = 0.001). Conclusion:CMR contrast agent perfusion can effectively evaluate the severity of early myocardial ischemia and locate the diseased blood vessels. Delayed enhancement can determine the location and area of early myocardial ischemia, and can objectively reflect the severity of myocardial ischemia.