Risk factors related to coronary artery occlusion in female patients with ischemic angina pectoris / 中华心血管病杂志

Objective: To analyze the risk factors of coronary artery occlusion in female patients with ischemic angina pectoris. Methods: Clinical data of 1 600 patients (666 females and 934 males) who underwent coronary angiography from January 2013 to December 2015 due to angina pectoris in 6 major coronary intervention centers in China were retrospectively analyzed. The clinical characteristics were compared between the female and male groups, and between the non-obstructive coronary artery disease (INOCA) and ischemic obstructive coronary artery disease (IOCA) subgroups of female subjects with angina pectoris. The risk factors related to the degree of coronary artery occlusion in female patients were analyzed. Results: In the enrolled patients who underwent coronary angiography for angina pectoris, female group was older than the male group, and the proportion of patients with hypertension, diabetes and ischemia accompanied by IOCA was significantly higher than that of the male group (P<0.05). Univariate analysis showed that age≥65 years, hypertension, diabetes, and typical angina symptoms were associated with an increased risk of IOCA in female patients with angina pectoris. Multivariate regression analysis showed that age≥65 years old (OR=1.784, 95%CI: 1.146-2.776, P=0.010), hypertension (OR=1.782, 95%CI: 1.201-2.644, P=0.004) and typical angina symptoms (OR=1.642, 95%CI: 1.127-2.393, P=0.010) were independent risk factors for female patients with angina pectoris diagnosed as IOCA. The correlation analysis between the number of risk factors and the type of coronary artery disease obstruction showed that the incidence of INOCA decreased significantly with the increase of the number of risk factors, from 45.5% to 14.2%. The incidence of IOCA increased significantly with the number of risk factors, from 54.5% to 85.8% (P for trend<0.001). Conclusion: The incidence of INOCA in female patients with angina pectoris suspected of coronary heart disease is higher than that of male. The incidence of IOCA increased significantly, and the incidence of INOCA decreased significantly in proportion to the increase of the number of combined risk factors.

Spinal cord ischemia as intraoperatory complication in shoulder surgery positioned in beach chair: case report

Abstract Spinal cord infarction is an uncommon phenomenon, which can be caused by different etiologies, constituting a real diagnostic challenge which can lead to devastating consequences. General anesthesia in beach chair positioning with intraoperative hypotension in order to avoid surgical bleeding are associated with hypoperfusion and potential neurological ischemia-related complications. We present a case of spinal cord ischemia in the context of shoulder surgery in a beach chair position.

Embarazo con miomatosis uterina complicado con isquemia intestinal: reporte de un caso / Pregnancy with uterine myomatosis complicated by intestinal ischemia: case report

Resumen Los miomas uterinos, también conocidos como fibromas o leiomiomas, son los tumores uterinos benignos más prevalentes. Afectan a las mujeres principalmente durante sus años reproductivos y se diagnostican hasta en un 70% de las mujeres blancas y en más del 80% de las mujeres de ascendencia africana durante su vida, con una prevalencia durante el embarazo del 2% al 10%. Pueden ser asintomáticos hasta en un 70% de las pacientes, y se estima que pueden ocurrir complicaciones en aproximadamente una de cada 10 mujeres embarazadas. Se han asociado a complicaciones y resultados adversos del embarazo, según su tamaño y ubicación en el útero, y pueden manifestarse de diferentes formas. Presentamos el caso de una mujer de 30 años, con embarazo en el tercer trimestre, quien consultó por dolor abdominal, con ecografías obstétricas durante su control prenatal que reportaban miomatosis uterina, quien presentó isquemia intestinal por un vólvulo de intestino delgado versus compresión extrínseca.

Abstract Uterine fibroids, also known as fibroids or leiomyomas, are the most prevalent benign uterine tumors, affecting women mainly during their reproductive years and are diagnosed in up to 70% of white women and more than 80% of women of African descent during their lifetime, with a prevalence during pregnancy of 2% to 10%; they may be asymptomatic in up to 70% of patients, and it is estimated that complications may occur in approximately one in 10 pregnant women. They have been associated with complications and adverse pregnancy outcomes, depending on their size and location in the uterus, they can manifest in different ways. We present the case of a 30-year-old woman, pregnant in the third trimester, who consulted for abdominal pain, with obstetric ultrasound scans during her prenatal check-up reporting uterine myomatosis, who presented intestinal ischemia due to small bowel volvulus versus extrinsic compression.

Acute arterial ischemia in COVID-19 / Isquemia arterial aguda em pacientes com COVID-19

Abstract Since the coronavirus pandemic set in in Spain in March 2020, a noteworthy increase in the incidence of acute limb ischemia (ALI) has been observed. It has been recently discovered that SARS-CoV 2 may lead to ALI secondary to arterial thrombosis. Elevation of D-dimer (DD) in patients with coronavirus infection (COVID-19) indicates that a hypercoagulable state causes acute arterial thrombosis. A remarkably high DD elevation has been reported to be a poor prognosis factor in COVID-19. The ways in which SARS-CoV 2 results in arterial thrombosis may be multiple. On the other hand, surgical revascularization for ALI is associated with poor outcomes in COVID-19 patients, probably in relation to hypercoagulability. Here, we describe two ALI cases in patients who required urgent surgical treatment for limb salvage and were positive for the novel coronavirus infection (COVID 19).

Resumo Desde que a pandemia pelo novo coronavírus se estabeleceu na Espanha, em março de 2020, um aumento notável da incidência de isquemia aguda de membros foi observado. Recentemente, descobriu-se que o coronavírus 2 causador da síndrome respiratória aguda grave (SARS-CoV-2) pode ocasionar isquemia aguda de membros secundária à trombose arterial. A elevação do D-dímero em pacientes acometidos pela doença do novo coronavírus (COVID-19) indica o estado de hipercoagulabilidade como causa da trombose arterial aguda. Vale destacar que a alta elevação do D-dímero foi relatada como um fator de prognóstico reservado na COVID-19. Há diversas maneiras pelas quais o SARS-CoV-2 pode resultar em trombose arterial. Em pacientes com COVID-19, a revascularização cirúrgica para isquemia aguda de membros está associada a desfechos desfavoráveis, provavelmente relacionados a hipercoagulabilidade. Descrevemos dois casos de isquemia aguda de membros de pacientes que necessitaram de tratamento cirúrgico de urgência para salvamento de membro e que haviam testado positivo para COVID-19.

Síndrome de hiperviscosidade em paciente com mieloma múltiplo / Hyperviscosity syndrome in multiple myeloma patients

O mieloma múltiplo é uma neoplasia progressiva e incurável de células B, caracterizado pela proliferação desregulada e clonal de plasmócitos na medula óssea. A síndrome de hiperviscosidade é uma das complicações relacionadas às gamopatias monoclonais, sendo considerada emergência oncológica. O objetivo deste estudo foi descrever o quadro clínico de um paciente diagnosticado com mieloma múltiplo que apresentou síndrome de hiperviscosidade, avaliando a prevalência de sinais e sintomas, bem como características fisiopatológicas dessa entidade clínica. Foi revisado o prontuário de um paciente internado na enfermaria da Clínica Médica do Hospital Regional do Cariri (CE) no período de junho a julho de 2018. Além disso, foi realizada revisão de literatura em base de dados (PubMed®) direcionada ao tema proposto. O diagnóstico de mieloma múltiplo foi comprovado por mielograma, sendo prontamente iniciada a corticoterapia e avaliada a resposta clínica após essa terapêutica. Apesar de incomum e menos frequentemente relacionada ao mieloma múltiplo, a síndrome de hiperviscosidade está relacionada a uma grande taxa de mortalidade quando apresenta diagnóstico tardio. A terapia de primeira linha indicada para a síndrome de hiperviscosidade foi a plasmaferese, no entanto, as condições clínicas (instabilidade hemodinâmica) impossibilitaram sua realização. O desfecho deste caso foi o óbito do paciente. Concluiu-se que o diagnóstico precoce e a intervenção terapêutica estão diretamente relacionados à ocorrência de menor incidência de complicações relacionadas ao mieloma múltiplo e à síndrome de hiperviscosidade.

Multiple myeloma is a progressive and incurable B-cell neoplasm characterized by unregulated and clonal proliferation of plasmocytes in the bone marrow. Hyperviscosity syndrome is one of the complications related to monoclonal gammopathies and is considered an oncological emergency. The aim of this study was to describe the clinical condition of a patient diagnosed with multiple myeloma who presented hyperviscosity syndrome, evaluating the prevalence of symptoms and signs, as well as the pathophysiological characteristics of this clinical entity. The medical records of a patient admitted to the Internal Medicine ward of the Hospital Regional do Cariri (CE) from June to July of 2018 were reviewed. In addition, we conducted a literature review in a database (PubMed®) directed to the theme proposed. The diagnosis of multiple myeloma was confirmed by myelogram, and corticosteroid therapy was promptly initiated and the clinical response was evaluated after this therapy. Although uncommon and less frequently related to multiple myeoloma, hyperviscosity syndrome is related to a high mortality rate when diagnosed late. The first line therapy indicated to hyperviscosity syndrome was plasmapheresis; however, the clinical conditions (hemodynamic instability) precluded its performance. The outcome of this case was the patient's death. Thus, it was concluded that early diagnosis and therapeutic intervention are directly related to the occurrence of lower incidence of complications related to multiple myeloma and hyperviscosity syndrome.

Embolia colesterínica en miembro superior izquierdo asociado a fístula arteriovenosa / Cholesterol embolism in the left upper limb associated with venous artery fistula

RESUMEN El embolismo por cristales de colesterol (ECC) es una complicación de la enfermedad arterioesclerótica en la que el desprendimiento de fragmentos de placa de ateroma, principalmente de grandes arterias, provoca oclusión de pequeños vasos. Esta entidad, también llamada ateroembolia o síndrome de los dedos del pie azules, es más frecuente en pacientes de edad avanzada y después de procedimientos invasivos intravasculares. Se manifiesta con cianosis, livedo reticularis, necrosis y úlceras asociado a manifestaciones renales y gastrointestinales. Se presenta un paciente trasplantado renal y portador de fístula arteriovenosa trombosada izquierda con ateroembolia localizada en mano homolateral.

ABSTRACT The cholesterol crystal embolism (ECC) is a complication of arteriosclerotic disease in which the detachment of fragments of atheromatous plaque mainly from large arteries, causes occlusion of small vessels. This entity, also called atheroembolism or blue toe syndrome, is more common in elderly patients and after intravascular invasive procedures. It manifests with cyanosis, livedo reticularis, necrosis and ulcers associated with renal and gastrointestinal manifestations. We present a renal transplant patient with a left thrombosed arteriovenous fistula with atheroembolism located in homolateral hand.

Efeito da infusão da solução M& G na proteção do tecido renal de ratos Wistar submetidos a isquemia e reperfusão programada / Effect of infusion of M& G solution for protection of renal tissue in Wistar rats subjected to programmed ischemia-reperfusion

Resumo Contexto A isquemia e reperfusão (I/R) renal está envolvida diretamente com insuficiência renal aguda, ocorrendo em casos como infarto por embolização ou trombose, quadros de septicemia e transplante renal. Esse processo é complexo, envolvendo respostas imunes inatas e adaptativas, presença de infiltrado celular, produção e liberação de citocinas e quimiocinas. Também desencadeia respostas celulares e liberação de espécies reativas de oxigênio, além de resultar em apoptose e, em alguns casos, necrose celular. Nesse contexto, é imprescindível a avaliação dos mecanismos de proteção ao tecido renal. Objetivos O objetivo foi testar a solução desenvolvida M&G, avaliando sua capacidade protetora no rim por meio de análise morfométrica e presença e expressão de citocinas inflamatórias (TNF-alfa, VEGF, HIF e IL-8). Métodos Foram selecionados 18 ratos Wistar, divididos em três grupos: Sham (S), Controle (C) e Estudo (E). O grupo S foi submetido ao processo cirúrgico sem o clampeamento arterial. No grupo C, foi clampeada a aorta acima e abaixo da artéria renal esquerda, sem a infusão de solução preservadora. No grupo E, além do clampeamento, realizou-se a punção da aorta e a infusão contínua da solução M&G por 20 minutos a 15 °C. Realizou-se a avaliação morfológica e imuno-histoquímica com os marcadores. Resultados Identificaram-se diferenças morfológicas entre o grupo S comparado aos grupos C e E. Na análise dos marcadores, houve redução na intensidade de expressão do TNF e na expressão do VEGF no grupo E. Não houve diferenças com HIF e IL-8 entre os grupos. Conclusões A solução M&G apresentou redução da presença e expressão de TNF-alfa e tendência de redução do VEGF.

Abstract Background Renal ischemia-reperfusion (I/R) is directly associated with acute renal failure and can occur in conditions such as infarction caused by embolization or thrombosis, septicemia, and kidney transplantation. The process is complex, involving innate and adaptive immune responses, presence of cellular infiltrate, and production and release of cytokines and chemokines. It also triggers cell responses and release of reactive oxygen species, in addition to causing apoptosis and, in some cases, cell necrosis. Against this background, evaluation of renal tissue protection mechanisms is essential. Objectives The objective of this study was to test the M&G solution, developed in prior research, evaluating its capacity to protect the kidneys using morphometric analysis and by assaying the presence and expression of inflammatory cytokines (TNF-alpha, VEGF, HIF, and IL-8). Methods Eighteen Wistar rats were divided into three groups: Sham (S), Control (C), and Experimental (E). The S group underwent the surgical operation, but without arterial clamping. In group C, the aorta was clamped above and below the left renal artery, without infusion of the preservation solution. In group E, in addition to clamping, the aorta was punctured and M&G solution was infused continuously for 20 minutes at 15o C. Morphological analysis and immunohistochemical assessment of markers were then conducted. Results Morphological differences were identified in group S compared with groups C and E. Analysis of markers revealed reduced intensity of expression of TNF and of VEGF in group E. There were no differences in HIF or IL-8 between groups. Conclusions The M&G solution was associated with a reduction in presence and expression of TNF-alpha and a trend to reduced VEGF.

Falla intestinal. Artículo de revisión / Intestinal failure Review article

La falla intestinal (FI) se define como la disminución de la función del intestino por debajo de lo mínimo necesario para la absorción de los macronutrientes y / o agua y electrolitos, de tal manera que se requiere de la suplementación intravenosa (SIV) para mantener la salud y el crecimiento. Desde el punto de vista funcional se clasifica en tres tipos. FI tipo I: condición aguda, de corto duración y generalmente auto limitada, FI tipo II: estado agudo prolongado, a menudo en pacientes metabólicamente inestables, que requieren cuidado multidisciplinario y SIV durante períodos de una semana o meses, acompañada de complicaciones sépticas, metabólicas y nutricionales y FI tipo III: condición crónica, en pacientes metabólicamente estables, que requieren SIV durante meses o años. Su manejo requiere de terapia nutricional y en casos seleccionados cirugía autóloga de reconstrucción(AU)

Intestinal failure (FI) is defined as the decrease in intestinal function below the minimum necessary for the absorption of macronutrients and / or water and electrolytes, in such a way that intravenous supplementation (IVS) is required to maintain health and growth. From a functional point of view, it is classified into three types. FI type I: acute condition, of short duration and generally self-limited, FI type II: prolonged acute state, often in metabolically unstable patients, requiring multidisciplinary care and SIV for periods of a week or months, accompanied by septic, metabolic and nutrition and FI type III: chronic condition, in metabolically stable patients, who require SIV for months or years. Its management requires nutritional therapy and in selected cases autologous reconstruction surgery(AU)

Úlcera gastroduodenal isquémica como complicación de la quimioembolización transarterial hepática de hepatocarcinoma / Ischemic gastroduodenal ulcer as a complication of hepatic hepatocarcinoma transarterial chemoembolization

La quimioembolización transarterial hepática es uno de los tratamientos del carcinoma hepatocelular irresecable en el que se han descrito de forma infrecuente lesiones isquémicas asociadas. Ante la aparición de sintomatología gastrointestinal alta inusual o que exceda el denominado síndrome postquimiembolización tras el procedimiento debe valorarse la realización de una gastroscopia para descartar la aparición de dichas complicaciones. Las variantes anatómicas con origen común de arterias gástricas y hepáticas pueden favorecer la migración de las microesferas hacia territorio gástrico obligando a valorar la eventual modificación de la técnica para prevenirlo.

Transarterial hepatic chemoembolization is one of the treatments of unresectable hepatocellular carcinoma in which associated ischemic lesions have been described infrequently. When unusual upper gastrointestinal symptoms or exceeding the so-called post-chemoembolization syndrome after the procedure, the performance of a gastroscopy should be assessed to rule out the occurrence of these complications. The anatomical variants with common origin of gastric and hepatic arteries can favor the migration of the microspheres into gastric territory, forcing the possible modification of the technique to prevent it.

Genetic approach in amyotrophic lateral sclerosis

The superoxide dismutase type 1 (SOD1) gene is the first responsible gene mapped in amyotrophic lateral sclerosis type 1 (ALS1), and it codes for the enzyme SOD1, the function of which is to protect against damage mediated by free radicals deriving from oxygen. Its pathophysiological mechanism in ALS1 is related to ischemia. Several molecular studies of the SOD1 gene show that point mutations are the most frequent. The most common mutations in familial cases are p.A4V, p.I113Y, p.G37R, p.D90A and p.E100G, which account for more than 80% of cases, although intronic mutations have also been described as responsible for ALS1. Sporadic cases are explained by mutations in other genes such as SETX and C9orf72. ALS1 is a complex disease with genetic heterogeneity. On the other hand, familial and sporadic cases have a different etiology, which is explained by molecular heterogeneity and multiple pathogenic mechanisms that lead to ALS1; oxidative stress and ischemia are not the only cause. In Mexico, ALS molecular genetics studies are scarce. Clinical studies show an increase in cytokines such as adipsin in cerebrospinal fluid.

Cholesterol crystal embolism to the gastrointestinal tract: a catastrophic case

Cholesterol crystal embolism is a rare and easily overlooked cause of colonic ischemia. The gastrointestinal tract is the third most common organ system affected by cholesterol emboli, second only to kidney and skin. Here we present a catastrophic case of gastrointestinal cholesterol crystal embolism leading to extensive post-operative bowel infarction and ultimately death. For a practicing pathologist, careful attention to the vessels of any ischemic bowel and recognition of the subtle but distinct angular imprint of cholesterol crystals facilitates prompt identification of the atheroemboli. In some cases, early identification may help mitigate further tissue damage. In more acute and severe cases, identification of the cholesterol crystal emboli may be important primarily for documentation of procedural complications.

Curativo com filme e gel de biopolímero de celulose bacteriana no tratamento de feridas isquêmicas após revascularização de membros inferiores / Bacterial cellulose biopolymer film and gel dressing for the treatment of ischemic wounds after lower limb revascularization

RESUMO Objetivo: avaliar o uso do curativo de filme e gel de biopolímero de celulose bacteriana no tratamento de pacientes com feridas isquêmicas submetidos à revascularização dos membros inferiores. Métodos: ensaio clínico randomizado realizado no ambulatório de Angiologia e Cirurgia Vascular do Hospital das Clínicas da Universidade Federal de Pernambuco, entre janeiro de 2017 e dezembro de 2018. Foram acompanhados 24 pacientes após revascularização de membros inferiores, divididos em dois grupos: Experimental, tratado com filme e gel de biopolímero de celulose bacteriana, e Controle, tratado com ácidos graxos essenciais. Os pacientes foram acompanhados em consultas semanais para troca dos curativos e o processo de cicatrização das feridas foi avaliado em um período de 90 dias. Resultados: a redução da área das feridas isquêmicas no período de 30 dias foi de 4,3cm2 (55%), em média, para o grupo experimental, e de 5,5cm2 (48,5%) para o grupo controle (p>0,05). A taxa de cicatrização completa, em 90 dias, foi de 34,8%, sendo 50% no grupo experimental e 18,2% no grupo controle (p=0,053). Conclusão: o filme de biopolímero de celulose bacteriana associada a gel pode ser utilizado como curativo no tratamento de feridas isquêmicas de pacientes submetidos à revascularização de membros inferiores

ABSTRACT Objective: to evaluate the use of a bacterial cellulose biopolymer film and gel dressing in the treatment of patients with ischemic wounds submitted to lower limb revascularization. Methods: we conducted a randomized clinical trial in the Angiology and Vascular Surgery outpatient clinic of the Clinics Hospital of the Federal University of Pernambuco, between January 2017 and December 2018. We followed 24 patients after lower limb revascularization, divided into two groups: Experimental, treated with bacterial cellulose biopolymer film and gel, and Control, treated with essential fatty acids. Patients attended weekly appointments to change dressings and had their wound healing processes evaluated over a period of 90 days. Results: the reduction of the ischemic wounds' areas after 30 days was 4.3cm2 (55%) on average for the experimental group, and the 5.5cm2 (48.5%) for the control group (p>0.05). The complete healing rate at 90 days was 34.8%, 50% in the experimental group and 18.2% in the control group (p=0.053). Conclusion: the bacterial cellulose biopolymer film associated with gel can be used as a dressing in the treatment of ischemic wounds of patients undergoing revascularization of the lower limbs.

New determinants for casual peripheral mechanism of neurogenic lung edema in subarachnoid hemorrhage due to ischemic degeneration of vagal nerve, kidney and lung circuitry. Experimental study

Abstract Purpose: To evaluate whether there is a relationship between renal artery vasospasm related low glomerular density or degeneration and neurogenic lung edema (NLE) following subarachnoid hemorrhage. Methods: This study was conducted on 26 rabbits. A control group was formed of five animals, a SHAM group of 5 to which saline and a study group (n=16) injected with homologous blood into the sylvian cisterna. Numbers of degenerated axons of renal branches of vagal nerves, atrophic glomerulus numbers and NLE scores were recorded. Results: Important vagal degeneration, severe renal artery vasospasm, intrarenal hemorrhage and glomerular atrophy observed in high score NLE detected animals. The mean degenerated axon density of vagal nerves (n/mm2), atrophic glomerulus density (n/mm3) and NLE scores of control, SHAM and study groups were estimated as 2.40±1.82, 2.20±1.30, 1.80±1.10, 8.00±2.24, 8.80±2.39, 4.40±1.14 and 154.38±13.61, 34.69±2.68 and 12.19±1.97 consecutively. Degenerated vagal axon, atrophic glomerulus and NLE scores are higher in study group than other groups and the differences are statistically meaningful (p<0.001). Conclusion: Vagal complex degeneration based glomerular atrophy have important roles on NLE following SAH which has not been extensively mentioned in the literature.

Rehabilitación neuropsicológica de un caso con sintomatología de afasia de conducción y anómica por evento isquémico / Neuropsychological rehabilitation in a case of conduction and anomic aphasia symptomatology by ischemic event

El tema de la rehabilitación de las afasias es explorado con frecuencia en la literatura de las últimas décadas, debido a que es una de las secuelas más comunes del daño cerebral y de las que más presenta variaciones dependiendo del caso, por lo cual los profesionales a cargo de los pacientes que sufren de esta condición se ven en la necesidad de buscar métodos eficaces para tratarlos. El objetivo de esta investigación es mostrar el diseño de un único caso con sintomatología de afasia de conducción y anomia pura. Se trata de un paciente masculino de 62 años de edad, con nivel académico de doctorado, diagnóstico de afasia de conducción y anomia a causa de un evento isquémico con 18 meses de evolución. Recibió tratamiento neuropsicológico en base a modelos histórico-culturales y neurocognitivos en dos periodos diferentes, una hora por semana. Se llevó a cabo una evaluación neuropsicológica antes y después del programa de rehabilitación, además se hizo uso de líneas bases en ambos periodos y se tomó en cuenta la perspectiva del paciente y su esposa. El rendimiento en la primera y segunda evaluación muestra un mejor desempeño en algunas áreas del lenguaje, mientras que en las líneas bases y en la apreciación del paciente y su esposa se observaron cambios importantes, concluyendo que el programa tuvo efectos favorables en la comunicación del paciente en el hogar.

The subject of aphasia rehabilitation is frequently explored in recent literature since it is one of the most common forms of brain damage and presents an assortment of variations depending on the specific case, making it so that professionals who are in charge of patients with this condition find themselves in need of effective treatment methods. This article aims to present the design for the single case study rehabilitation of a patient with conduction aphasia and pure anomia. The patient in question is a 62-year-old male with a P.h.D. level education, diagnosed with conduction aphasia and anomia caused by an ischemic event with an 18-month evolution, he received neuropsychological treatment following the historic-cultural and neurocognitive models, spanning two different treatment periods, one hour a week. A neuropsychological evaluation was made before and after the rehabilitation program, as well as using a baseline for both periods and taking into account the perspective of both the patient and his wife. Patient performance in the first and second evaluations shows improvement in some language areas, while the baselines, as well as the patient and his wife's assessment speak of important changes, concluding that the program had favorable effects on the patient's communication at home

Effects of different periods of gastric ischemia on liver as a remote organ

Abstract Purpose: To evaluate the hepatic changes associated with gastric ischemia. Methods: Thirty male rabbits were studied, distributed in 3 groups (n=10). Group 1: ligature and section of the gastric vasculature and removal of the liver after three hours; Group 2: ligature and section of the gastric vasculature and removal of the liver after 6 hours; Group 3: ligature and section of the gastric vasculature and removal of the liver after 12 hours. Blood samples were collected immediately before surgery and after the determined time of ischemia in each group to evaluate the hepatic function. After the death of the rabbits, the liver was removed for macro and microscopic study. Results: An increase in aminotransferases and bilirubin occurred in groups 2 and 3. Total protein and albumin diminished in all of the animals. All of the rabbits from groups 2 and 3 presented hepatocellular necrosis. Conclusion: The devascularization of the stomach for a period of above three hours is associated with hepatic morphological and functional disorders.

The role of the exogenous supply of adenosine triphosphate in the expression of Bax and Bcl2L1 genes in intestinal ischemia and reperfusion in rats

Abstract Purpose: To investigate the role of the exogenous supply of adenosine triphosphate (ATP) in the expression of Bax and Bcl2L1 genes in intestinal ischemia and reperfusion (IR) in rats. Methods: The study was designed as a randomized controlled trial with a blinded assessment of the outcome. Eighteen adult male Wistar-EPM1 rats were housed under controlled temperature and light conditions (22-23°C, 12 h light/dark cycle). The animals were randomly divided into 3 groups: 1. Sham group (SG): no clamping of the superior mesenteric artery; 2. Ischemia and reperfusion group (IRG): 3. Ischemia and reperfusion plus ATP (IRG + ATP). ATP was injected in the femoral vein before and after ischemia. Afterwards, intestinal segments were appropriately removed and processed for Endothelial Cell Biology Rat RT2 Profiler PCR Array. Results: ATP promoted the upregulation of Bcl2L1 gene expression, whereas it did not have significant effects on Bax gene expression. In addition, the relation of Bax/Bcl2L1 gene expression in the IRG group was 1.39, whereas it was 0.43 in the IRG + ATP group. Bcl2L1 plays a crucial role in protecting against intestinal apoptosis after ischemia and reperfusion. Increased Bcl2L1 expression can inhibit apoptosis while decreased Bcl2L1 expression can trigger apoptosis. Conclusion: Adenosine triphosphate was associated with antiapoptotic effects on the rat intestine ischemia and reperfusion by upregulating of Bcl2L1 gene expression.

Rivastigmine prevents injury induced by ischemia and reperfusion in rat liver

Abstract Purpose: To evaluate whether pre-treatment with rivastigmine is able to attenuate the I/R induced lesions in rat liver. Methods: SHAM animals or those submitted to I/R, non-treated or pre-treated with rivastigminine (2mg/kg) either 50 or 15 minutes before ischemia, were used. After I/R protocol, these animals were killed and their livers were harvested to measurement of the mitochondrial swelling as well as the malondialdehyde (MDA), nitrite and nitrate tissue concentration. Blood was also harvested for serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) determinations. Results: I/R promoted a significant increase of mitochondrial swelling in the studied animals. This increase of mitochondrial swelling was partially prevented by rivastigmine, but only if administered 50 minutes before ischemia. No significant modification of MDA, nitrite or nitrate tissue concentrations was observed in consequence of I/R, followed or not by rivastigmine treatments. In addition, I/R elevated both AST and ALT. These elevations of serum enzymes were not reversed by the different rivastigmine treatments. Conclusions: Rivastigmine administered 50 minutes before ischemia attenuates I/R-induced mitochondrial swelling, that indicates liver injury. This protective effect may be related to a greater stimulation of α7nAChR present in the Kupffer cells by the non-methabolized ACh, leading to an attenuation of I/R-induced inflammation.

Neurolitic block of the lumbar sympathetic chain improves chronic pain in a patient with critical lower limb ischemia / Bloqueio neurolítico da cadeia simpática lombar melhora dor crônica em paciente portadora de isquemia crítica de membro inferior

Abstract Background and objectives Sympathectomy is one of the therapies used in the treatment of chronic obstructive arterial disease (COAD). Although not considered as first-line strategy, it should be considered in the management of pain difficult to control. This clinical case describes the evolution of a patient with inoperable COAD who responded properly to the lumbar sympathetic block. Case report A female patient, afro-descendant, 69 years old, ASA II, admitted to the algology service due to refractory ischemic pain in the lower limbs. The patient had undergone several surgical procedures and conservative treatments without success. Vascular surgery considered the case as out of therapeutic possibility, unless limb amputation. At that time, sympathectomy was indicated. After admission to the operating room, the patient was monitored, positioned and sedated. The blockade was performed with the aid of radioscopy, bilaterally, at L2-L3-L4 right and L3 left levels. On the right side, at each level cited, 3 mL of absolute alcohol with 0.25% bupivacaine were injected without vasoconstrictor, and on the left side only local anesthetic. The procedure was performed uneventfully. The patient was discharged with complete remission of the pain. Conclusion Neurolitic block of the lumbar sympathetic chain is an effective and safe treatment option for pain control in patients with critical limb ischemia patients in whom the only possible intervention would be limb amputation.

Resumo Justificativa/objetivos A simpatectomia é uma das terapêuticas usadas no tratamento dadoença arterial obstrutiva crônica (DAOP). Embora não seja considerada como estratégia de primeira linha, deve ser lembrada no manejo dos quadros de dor de difícil controle. Este caso clínico descreve a evolução de uma paciente portadora de DAOP inoperável que respondeu adequadamente ao bloqueio simpático lombar. Relato de caso Paciente do sexo feminino, parda, 69 anos, estado físico II, acompanhada no serviço de algologia devido a dor isquêmica refratária em membros inferiores. A paciente já havia sido submetida a diversas abordagens cirúrgicas e tratamentos conservadores, sem sucesso. A cirurgia vascular considerou o caso como fora de possibilidade terapêutica, a não ser amputação do membro. Nesse momento, foi indicada simpatectomia. Após admissão no centro cirúrgico, a paciente foi monitorada, posicionada e sedada. O bloqueio foi feito com auxílio da radioscopia, bilateralmente, nos níveis L2-L3-L4 à direita e L3 à esquerda. Do lado direito, em cada nível citado, foram injetados 3 mL de álcool absoluto com bupivacaína 0,25% sem vasoconstritor e do lado esquerdo somente o anestésico local. O procedimento foi feito sem intercorrências. A paciente recebeu alta com completa remissão da dor. Conclusão O bloqueio neurolítico da cadeia simpática lombar é uma opção de tratamento eficaz e segura para controle da dor em pacientes portadores de isquemia crítica, nos quais a única intervenção possível seria a amputação do membro.

Embolectomía tardía en isquemia aguda de miembros inferiores / Late embolectomy in acute lower limb ischemia

La isquemia aguda es la interrupción brusca del aporte sanguíneo a un determinado territorio del organismo. Su causa más frecuente, la embolia arterial, consiste en la oclusión también brusca de una arteria sana por material trombótico formado en un territorio proximal al del accidente y que desencadena un cuadro que, de no diagnosticarse y tratarse adecuadamente, puede comprometer la vida del paciente. Existe una estrecha relación entre la gravedad del cuadro isquémico y el tiempo transcurrido de manera que si no se toman medidas agresivas a tiempo raramente se resuelve de manera satisfactoria. La revascularización es considerada menos efectiva después de 8 a 10 h de isquemia, tiempo después del cual muchos se abstienen de operar debido al temido síndrome de reperfusión; sin embargo, algunos refieren éxitos con embolectomías tardías. Se presenta un caso de embolismo arterial a miembro inferior derecho por arritmia cardiaca, que llegó al servicio de Cirugía Vascular del Hospital Provincial "Dr. Antonio Luaces Iraola", con 72 h de evolución. Se le realizó embolectomía femoral con catéter de Fogarty con resultados satisfactorios, lo que apoya la hipótesis de que se debe intentar reperfundir la extremidad siempre que se demuestre viabilidad de los tejidos y no exista gangrena, independientemente del tiempo transcurrido(AU)

Acute ischemia is the sudden interruption of the blood flow in a specific area of the body. Its most common cause is arterial embolism consisting of abrupt occlusion of a healthy artery by thrombotic residues formed in an area near the stroke and unleashing a clinical picture that should be adequately diagnosed and treated to avoid death. There is close relationship between the severity of ischemia and the time elapsed because if no aggressive actions are taken in due time, the results are rarely satisfactory. Revascularization is considered less effective 8 to 10 hours after ischemia. After this time many surgeons refrain from performing surgery due to the frightening reperfusion syndrome. However some had documented successful results with late embolectomy. Here is a case of arterial embolism in right lower limb owing to cardiac arrhythmia. The patient arrived to the Vascular Surgery service after 72 hours of the event; he was performed femoral embolectomy with Fogarty catheter and the achieved results were satisfactory, which supports the hypothesis of trying to reperfusing the affected limb whenever tissue viability exists and gangrene is not present, regardless of time elapsed(AU)

Isquemia e reperfusão por circulação retrógrada: estudo comparativo experimental / Ischemia and reperfusion by retrograde flow: experimental comparative study

Contexto: Isquemia crítica de membro inferior sem leito distal tem opções restritas para tratamento. Desviar o fluxo de maneira retrógrada através da circulação venosa é alternativa amparada em evidências de inúmeros trabalhos publicados. Objetivos: Comparar o comportamento de variáveis clínicas e laboratoriais em extremidades de suínos submetidas a isquemia e a isquemia com reperfusão por circulação retrógrada entre si e em relação e a um grupo controle. Métodos: Dez suínos foram separados em dois grupos. No grupo 1 (n=5), controle, avaliaram-se padrões fisiológicos de variáveis como fluxo ao Doppler, temperatura, gasometria, lactato, creatinoquinase (CK) e pressão arterial. No grupo 2 (n=5), após um período médio de isquemia de 27 minutos e 30 segundos, consequente à interrupção do fluxo nas artérias femorais, os animais foram submetidos a arterialização venosa no membro posterior esquerdo e a manutenção da isquemia no direito. As variáveis foram analisadas separadamente durante momentos 0, 2, 3, 4 e 6 horas após a reperfusão para efeito de comparação entre si e com o grupo controle. Resultados: A análise das variáveis mostrou, em ambos os procedimentos, queda de BE e pO2 , com elevação significativa de lactato e CK em relação ao grupo controle. Nos membros isquêmicos arterializados, encontramos fluxo ao Doppler e maiores pressões arteriais e temperaturas quando comparadas ao membro em isquemia. Conclusões: A análise comparativa das extremidades em isquemia e isquemia arterializada mostrou, em relação ao grupo controle, um quadro de acidose metabólica, com significativo aumento de lactato e CK, que sugerem dano celular e sinais de reperfusão retrógrada nas extremidades arterializadas

Background: There are few options for treating critical ischemia in limbs with no distal patency. Diverting flow through the venous circulation is an option supported by evidence from numerous published studies. Objectives: To compare the behavior of clinical and laboratory variables between the hind limbs of pigs subjected to ischemia and to ischemia with reperfusion by retrograde circulation and between these intervention groups and a control group. Methods: Ten pigs were divided into 2 groups. In group 1 (n=5), controls, patterns of physiological variables such as flow according to Doppler ultrasound, temperature, blood gas analysis results, lactate, creatine kinase, and blood pressure were evaluated. In group 2 (n=5), after an initial ischemia period with mean duration of 27 minutes and 30 seconds, provoked by interrupting flow through the femoral arteries, the animals were subjected to venous arterialization of the left hind limb while the right hind limb was maintained in ischemia. Variables were analyzed separately for each hind leg at 0, 2, 3, 4, and 6 hours after reperfusion and compared against each other and the control group. Results: Analysis of variables from both procedures showed decreases in BE and PO2 and significant increases in lactate and creatine kinase, in relation to the control group. In arterialized ischemic limbs, we observed flow on Doppler ultrasound, and arterial pressures and temperatures were higher than in the ischemic limbs. Conclusions: Comparative analysis of the extremities in ischemia and arterialized ischemia showed, in relation to the control group, metabolic acidosis with significant increases in lactate and creatine kinase, suggesting cellular damage, and there were signs of retrograde reperfusion in arterialized extremities.