Effect of local papaverine on arteriovenous fistula maturation in patients with end-stage renal disease / Efeito da papaverina local na maturação de fístulas arteriovenosas em pacientes com doença renal terminal

Abstract Background: Arteriovenous fistula (AVF) maturation is one of the main concerns in patients with end-stage renal disease (ESRD) and finding a strategy for increasing success rate and accelerating fistula maturation is valuable. The aim of this study was to evaluate the effects of papaverine injection on AVF maturation and success rate. Method: This study was a randomized clinical trial that involved 110 patients with ESRD that were referred for AVF construction. Patients were allocated in papaverine group and control group with block randomization according to age and sex. In the case group, papaverine (0.1 or 0.2 cc) was injected locally within the subadventitia of artery and vein after proximal and distal control during AVF construction and in the control group, AVF construction was done routinely without papaverine injection. Results: Maturation time in case and control groups was 37.94 ± 11.49 and 44.23 ± 9.57 days, respectively (p=0.004). Hematoma was not seen in the case group but occurred in one patient in the control group. One patient of the case group developed venous hypertension. Four functional fistulas, 1 (1.8%) in the case group and 3 (5.5%) in the control group, failed to mature (p=0.618). Maturation rate did not differ between the two groups statistically (p=0.101). Conclusion: Local papaverine injection increased vessel diameter and blood flow, increasing shearing stress in both arterial and venous segment of recently created AVF. In this way, papaverine probably can decrease AVF maturation time without an increase in complications.

Resumo Introdução: A maturação da fístula arteriovenosa (FAV) é uma das principais preocupações em pacientes com doença renal terminal (DRT). Assim, é importante identificar estratégias para aumentar as taxas de sucesso e acelerar a maturação da fístula. O objetivo do presente estudo foi avaliar os efeitos da infiltração de papaverina sobre a maturação da FAV e suas taxas de sucesso. Método: O presente ensaio clínico randomizado incluiu 110 pacientes com DRT encaminhados para colocação de FAV. Os pacientes foram randomizados em bloco em função de idade e sexo e alocados nos grupos caso ou controle. Os indivíduos no grupo caso receberam infiltração local de papaverina (0,1 ou 0,2 ml) no plano da sub-adventícia da artéria e veia após o controle proximal e distal durante a construção da FAV. No grupo controle, a construção da FAV foi realizada rotineiramente sem infiltração de papaverina. Resultados: Os tempos de maturação dos grupos caso e controle foram 37,94 ± 11,49 e 44,23 ± 9,57 dias, respectivamente (p = 0,004). Foi observado hematoma em apenas um paciente do grupo controle. Um paciente do grupo caso desenvolveu hipertensão venosa. Quatro fístulas funcionais, uma (1,8%) no grupo caso e três (5,5%) no grupo controle, não amadureceram (p = 0,618). A taxa de maturação não diferiu estatisticamente entre os dois grupos (p = 0,101). Conclusão: A infiltração local de papaverina aumentou o diâmetro do vaso e o fluxo sanguíneo, elevando a tensão de cisalhamento nos segmentos arterial e venoso da FAV recentemente criada. Desta forma, a papaverina provavelmente consegue reduzir o tempo de maturação da FAV sem aumentar as complicações.

Varicocele and Testicular Pain: A Review

Varicocele is the dilatation of the scrotal portion of pampiniform plexus and the internal spermatic venous system. About 15% of men suffer from scrotal varicocele and 2% to 10% of them complain of pain. The probable mechanisms for pain include compression of the surrounding neural fibers by the dilated venous complex, elevated testicular temperature, increased venous pressure, hypoxia, oxidative stress, hormonal imbalances, and the reflux of toxic metabolites of adrenal or renal origin. Testicular pain associated with varicoceles is typically described as a dull, aching, or throbbing pain in the testicle, scrotum, or groin; rarely, it can be acute, sharp, or stabbing. The management of testicular pain associated with varicocele starts with a conservative, non-surgical approach and a period of observation. Varicocelectomy in carefully selected candidates with clinically palpable varicocele resolves nearly 80% of all cases of testicular pain. Microsurgical techniques for varicocelectomy have gained popularity with minimal complication rates and favorable outcomes. The grade of varicocele, the nature and duration of pain, body mass index, prior conservative management, and the type of surgical method used, are predictors for the success of varicocelectomy.

The New Cutoff Value of the Hepatic Venous Pressure Gradient on Predicting Long-Term Survival in Cirrhotic Patients

BACKGROUND: This study aimed to determine the prognostic role of the categorized hemodynamic stage (HS) based on the hepatic venous pressure gradient (HVPG) in patients with portal hypertension. METHODS: Of 1,025 cirrhotic patients who underwent HVPG measurement, data on 572 non-critically-ill patients were collected retrospectively between 2008 and 2013. The following two HS categorizations were used: HS-1 (6–9, 10–12, 13–16, 17–20, and > 20 mmHg; designated as groups 1–5, respectively) and HS-2 (6–12, 13–20, and > 20 mmHg). Clinical characteristics, mortality rates, and prognostic predictors were analyzed according to the categorized HS. RESULTS: During the mean follow-up period of 25 months, 86 (15.0%) patients died. The numbers of deaths in HS-1 groups were 7 (6.3%), 7 (6.9%), 30 (18.0%), 20 (15.6%), and 22 (34.4%), respectively (P 20 mmHg; HR, 5.45) and intermediate model for end-stage liver disease (MELD) score (HVPG, 13–20 mmHg; HR, 3.86 and HVPG > 20 mmHg; HR, 8.77; P < 0.05). CONCLUSION: Categorizing HVPG values according to HS-2 is a useful prognostic modality in patients with portal hypertension and can play an independent role in predicting the prognosis in patients with hypoalbuminemia and an intermediate MELD score.

Clinical characteristics of nontraumatic chylothorax in pediatric patients

PURPOSE: To evaluate clinical characteristics of pediatric nontraumaitc chylothorax and to suggest appropriate therapeutic managements. METHODS: We retrospectively reviewed medical records of 22 patients with nontraumatic chylothorax from January 2005 to December 2018 in the Children's Hospital of Seoul National University. We analyze their etiology, treatment, complications and outcome. RESULTS: Of the 22 patients, 16 were diagnosed before 1 year old and 6 after 1 year old. The causes of chylothorax under 1-year-old children were related to congenital factors (n=9), unknown causes (n=5), and high central venous pressure (n=2). The causes of chylothorax over 1-year-old children were related to congenital factors (n=3), unknown causes (n=1), high venous pressure (n=1), and lymphoma (n=1). All patients had dietary modification. Eight of them were cured by dietary modification, but there was no improvement in over 1-year-old children. Medication was added to patients refractory to dietary modification. Four patients with medication were improved and 5 were improved by surgical management. Nutritional, immunological and other complications occurred in many patients. Five death cases were reported. Four patients were under 1 year old and 1 was over 1 year old. The causes of nontraumatic chylothorax in dead patients were high central venous pressure (n=3), congenital (n=1), and unknown (n=1). CONCLUSION: Nontraumatic chylothorax more frequently occurs in under 1-year-old children. The most common cause is congenital factors. Stepwise management is effective in many patients, but specific treatment is needed in some cases. The prognosis is related to the onset of age and underlying diseases.

Fluid Dynamics of Small Diameter Tubes Used in Membrane-tube Type Glaucoma Shunt Devices

PURPOSE: To investigate the outflow characteristics of silicone tubes with intraluminal stents used in membrane-tube (MT) type glaucoma shunt devices. METHODS: The silicone tubes used in MicroMT (internal diameter of 100 µm with a 7-0 nylon intraluminal stent) and Finetube MT (internal diameter of 200 µm with a 5-0 nylon intraluminal stent) were connected to a syringe-pump that delivered a continuous flow of distilled water at flow rates of 2, 5, 10, and 25 µL/min. The pressures and resistances of tubes were measured at a steady flow rate with full-length, half-length, and absence of intraluminal stents. RESULTS: The mean outflow resistance of the two types of tubes ranged from 3.0 ± 1.9 to 3.8 ± 1.7 mmHg/µL/min with a full-length intraluminal stent, 1.8 ± 1.1 to 2.2 ± 1.1 mmHg/µL/min with a half-length intraluminal stent, and 0.1 ± 0.0 to 0.2 ± 0.0 mmHg/µL/min without an intraluminal stent. Theoretically, for a physiologic state with a flow rate of 2 µL/min and episcleral venous pressure of 6 mmHg, the mean pressures of tubes were expected to be 13.2 ± 3.0, 10.5 ± 2.4, and 6.4 ± 0.2 mmHg in MicroMT with full-length, half-length, and absence of intraluminal stents, respectively, and 12.5 ± 3.9, 9.6 ± 2.4, and 6.2 ± 0.2 mmHg in Finetube MT with full-length, half-length, and absence of intraluminal stents, respectively. The pressure variance also decreased with intraluminal stent retraction (p < 0.01). CONCLUSIONS: The small diameter tubes of 100 and 200 µm internal diameters, with 7-0 and 5-0 nylon intraluminal stents, respectively, used in the MT-type glaucoma shunt device showed safe and effective outflow characteristics.

Segmental Liver Stiffness Evaluated with Magnetic Resonance Elastography Is Responsive to Endovascular Intervention in Patients with Budd-Chiari Syndrome

OBJECTIVE: To assess segmental liver stiffness (LS) with MRI before and after endovascular intervention in patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Twenty-three patients (13 males and 10 females; mean age, 42.6 ± 12.6 years; age range, 31–56 years) with BCS as a primary liver disease were recruited for this study. Two consecutive magnetic resonance elastography (MRE) examinations were performed before the endovascular treatment. Fifteen patients who underwent endovascular intervention treatment also had follow-up MRE scans within three days after the procedure. LS was measured in three liver segments: the right posterior, right anterior, and left medial segments. Inter-reader and inter-exam repeatability were analyzed with intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Segmental LS and clinical characteristics before and after the intervention were also compared. RESULTS: Within three days of the endovascular intervention, all three segmental LS values decreased: LS of the right posterior segment = 7.23 ± 0.88 kPa (before) vs. 4.94 ± 0.84 kPa (after), LS of the right anterior segment = 7.30 ± 1.06 kPa (before) vs. 4.77 ± 0.85 kPa (after), and LS of the left medial segment = 7.22 ± 0.87 kPa (before) vs. 4.87 ± 0.72 kPa (after) (all p = 0.001). There was a significant correlation between LS changes and venous pressure gradient changes before and after treatments (r = 0.651, p = 0.009). The clinical manifestations of all 15 patients significantly improved after therapy. The MRE repeatability was excellent, with insignificant variations (inter-reader, ICC = 0.839–0.943: inter-examination, ICC = 0.765–0.869). Bland-Altman analysis confirmed excellent agreement (limits of agreement, 13.4–19.4%). CONCLUSION: Segmental LS measured by MRE is a promising repeatable quantitative biomarker for monitoring the treatment response to minimally invasive endovascular intervention in patients with BCS.

Functional performance of different venous limb options in simulated neonatal/pediatric cardiopulmonary bypass circuits

Abstract Objective: Hemodilution is a concern in cardiopulmonary bypass (CPB). Using a smaller dual tubing rather than a single larger inner diameter (ID) tubing in the venous limb to decrease prime volume has been a standard practice. The purpose of this study is to evaluate these tubing options. Methods: Four different CPB circuits primed with blood (hematocrit 30%) were investigated. Two setups were used with two circuits for each one. In Setup I, a neonatal oxygenator was connected to dual 3/16" ID venous limbs (Circuit A) or to a single 1/4" ID venous limb (Circuit B); and in Setup II, a pediatric oxygenator was connected to dual 1/4" ID venous limbs (Circuit C) or a single 3/8" ID venous limb (Circuit D). Trials were conducted at arterial flow rates of 500 ml/min up to 1500 ml/min (Setup I) and up to 3000 ml/min (Setup II), at 36°C and 28°C. Results: Circuit B exhibited a higher venous flow rate than Circuit A, and Circuit D exhibited a higher venous flow rate than Circuit C, at both temperatures. Flow resistance was significantly higher in Circuits A and C than in Circuits B (P<0.001) and D (P<0.001), respectively. Conclusion: A single 1/4" venous limb is better than dual 3/16" venous limbs at all flow rates, up to 1500 ml/min. Moreover, a single 3/8" venous limb is better than dual 1/4" venous limbs, up to 3000 ml/min. Our findings strongly suggest a revision of perfusion practice to include single venous limb circuits for CPB.

Presence of Sarcopenia and Its Rate of Change Are Independently Associated with Long-term Mortality in Patients with Liver Cirrhosis

BACKGROUND: Sarcopenia is associated with a poor prognosis in patients with liver cirrhosis. However, it is not known whether the rate of skeletal muscle depletion is also associated with a poor prognosis. We investigated the prognostic impact of the rate of skeletal muscle depletion in patients with liver cirrhosis. METHODS: We included retrospectively all patients with liver cirrhosis who underwent both multiple computed tomography scans and hepatic venous pressure gradient (HVPG) measurements. RESULTS: A total of 131 patients with liver cirrhosis were enrolled. The mean age of the patients was 53.7 years and alcoholic liver disease was the most common cause (61.8%). Sixty-four patients (48.9%) were diagnosed with sarcopenia. The median changes in skeletal muscle area per year (ΔSMA/y) were −0.89%. During a median follow-up period of 46.2 months (range, 3.4–87.6), 45 patients (34.4%) died. In multivariate analyses, age, Child-Pugh score, HVPG, presence of sarcopenia and ΔSMA/y were independently associated with mortality. Cumulative mortality was significantly higher in patients with ΔSMA/y <−2.4% than those with ΔSMA/y ≥−2.4% (log-rank test, P < 0.001). CONCLUSION: Both the presence and rate of change of sarcopenia are independently associated with long-term mortality in patients with liver cirrhosis.

Glaucoma secundario a presión venosa epiescleral elevada en síndrome de Crest / Secondary glaucoma as elevated episcleral venous pressure in Crest syndrome

El glaucoma secundario a presión venosa epiescleral elevada asociada a enfermedad de Crest es una entidad rara, frecuentemente refractaria a la terapia médica y quirúrgica. Debemos ser exhaustivos en la anamnesis, en la exploración y en la solicitud de exámenes de imagen en aras de encontrar la posible causa para lograr un manejo exitoso del paciente con esta enfermedad, tanto desde el punto de vista sistémico como oftalmológico. La cirugía antiglaucomatosa puede ser complicada en estos casos(AU)

Secondary glaucoma as elevated episcleral venous pressure associated to Crest syndrome is a rare condition often refractory to clinical or surgical therapy. Exhaustive anamnesis, exploration and imaging should be conducted to find the possible cause and thus implement successful management of the sufferer, both systemically and ophthalmologically. Glaucoma surgery may be complicated in these cases(AU)

Reduction of venous pressure during the resection of liver metastases compromises enteric blood flow: IGFBP-1 as a novel biomarker of intestinal barrier injury

OBJECTIVES: Disruption of the intestinal barrier and bacterial translocation commonly occur when intestinal blood flow is compromised. The aim of this study was to determine whether liver resection induces intestinal damage. METHODS: We investigated intestinal fatty-acid binding protein and insulin-like growth factor binding protein levels in the plasma of patients who underwent liver resection. RESULTS: We show that liver resection is associated with significant intestinal barrier injury, even if the Pringle maneuver is not performed. CONCLUSION: We propose the use of insulin-like growth factor binding protein-1 as a novel biomarker of intestinal damage in such situations.

Coronary perfusion pressure during antegrade cardioplegia in on-pump CABG patients

Abstract Objective: The aim of this study was to investigate whether aortic tension estimated by palpation and cardioplegia infusion line pressure provide results equivalent to those obtained with direct aortic intraluminal pressure measurement. Methods: Sixty consecutive patients who underwent coronary artery bypass graft surgeries with extracorporeal circulation were analyzed. Sanguineous cardioplegic solution in a ratio of 4:1 was administered using a triple lumen antegrade cannula. After crossclamping, cardioplegia was infused and aortic root pressure was recorded by surgeon (A) considering the aortic tension he felt in his fingertips. At the same time, another surgeon (B) recorded his results for the same measurement. Concomitantly, the anesthesiologist recorded intraluminal pressure in the aortic root and the perfusionist recorded delta pressure in cardioplegia infusion line. None of the participants involved in these measurements was allowed to be informed about the values provided by the other examiners. Results: The Bland-Altman test showed that a considerable variation between aortic wall tension was found as measured by palpation and by intraluminal pressure, with a bias of -9.911±18.75% (95% limits of agreement: -46.7 to 26.9). No strong correlation was observed between intraluminal pressure and cardioplegia line pressure (Spearman's r=0.61, 95% confidence interval 0.5-0.7; P<0.0001). Conclusion: These findings reinforce that cardioplegia infusion should be controlled by measuring intraluminal pressure, and that palpation and cardioplegia line pressure are inaccurate methods, the latter should always be used to complement intraluminal measurement to ensure greater safety in handling the cardioplegia circuit.

Observational Cohort Study of Hepatic Encephalopathy After Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Abstract: Introduction and aim. Hepatic encephalopathy (HE) is a common complication of transjugular intrahepatic portosystemic shunting (TIPS). It is associated with a reduced quality of life and poor prognosis. The aim of this study was to compare two groups of patients who did and did not develop overt HE after TIPS. We looked for differences between these groups before TIPS. Material and methods. A study of 895 patients was conducted based on a retrospective analysis of clinical data. Data was analyzed using Fisher’s exact test, χ2, Mann Whitney test, unpaired t-test and logistic regression. After the initial analyses, we have looked at a regression models for the factors associated with development of HE after TIPS. Results. 257 (37.9%) patients developed HE after TIPS. Patients’ age, pre-TIPS portal venous pressure, serum creatinine, aspartate transaminase, albumin, presence of diabetes mellitus and etiology of portal hypertension were statistically significantly associated with the occurrence of HE after TIPS (p < 0.01). However, only the age, pre-TIPS portal venous pressure, serum creatinine, presence of diabetes mellitus and etiology of portal hypertension contributed to the regression model. Patients age, serum creatinine, presence of diabetes mellitus and portal vein pressure formed the model describing development of HE after TIPS for a subgroup of patients with refractory ascites. Conclusion. We have identified, using a substantial sample, several factors associated with the development of HE after TIPS. This could be helpful in further research.

Cerebellar Hemorrhage due to a Direct Carotid–Cavernous Fistula after Surgery for Maxillary Cancer

Infratentorial cerebral hemorrhage due to a direct carotid–cavernous fistula (CCF) is very rare. To our knowledge, only four such cases have been reported. Cerebellar hemorrhage due to a direct CCF has not been reported. We describe a 63-year-old female who presented with reduced consciousness 3 days after undergoing a maxillectomy for maxillary cancer. Computed tomography showed a cerebellar hemorrhage. Magnetic resonance angiography showed a left-sided direct CCF draining into the left petrosal and cerebellar veins through the left superior petrosal sinus (SPS). Her previous surgery had sacrificed the pterygoid plexus and facial vein. Increased blood flow and reduced drainage could have led to increased venous pressure in infratentorial veins, including the petrosal and cerebellar veins. The cavernous sinus has several drainage routes, but the SPS is one of the most important routes for infratentorial venous drainage. Stenosis or absence of the posterior segment of the SPS can also result in increased pressure in the cerebellar and pontine veins. We emphasize that a direct CCF with cortical venous reflux should be precisely evaluated to determine the hemodynamic status and venous drainage from the cavernous sinus.

Rifaximin and Propranolol Combination Therapy Is More Effective than Propranolol Monotherapy for the Reduction of Portal Pressure: An Open Randomized Controlled Pilot Study

BACKGROUND/AIMS: Non-selective beta blockers (NSBBs) are currently the only accepted regimen for preventing portal hypertension (PHT)-related complications. However, the effect of NSBBs is insufficient in many cases. Bacterial translocation (BT) is one of the aggravating factors of PHT in cirrhosis; therefore, selective intestinal decontamination by rifaximin is a possible therapeutic option for improving PHT. We investigated whether the addition of rifaximin to propranolol therapy can improve hepatic venous pressure gradient (HVPG) response. METHODS: Sixty-four cirrhosis patients were randomly assigned to propranolol monotherapy (n=48) versus rifaximin and propranolol combination therapy (n=16). Baseline and post-treatment HVPG values, BT-related markers (lipopolysaccharide [LPS], LPS-binding protein [LBP], interleukin-6 [IL-6], and tumor necrosis factor α [TNF-α]), serological data, and adverse event data were collected. HVPG response rate was the primary endpoint. RESULTS: Combination therapy was associated with better HVPG response rates than monotherapy (56.2% vs 87.5%, p=0.034). In combination therapy, posttreatment BT-related markers were significantly decreased (LPS, p=0.005; LBP, p=0.005; IL-6, p=0.005; TNF-α, p=0.047). CONCLUSIONS: Rifaximin combination therapy showed an additive effect in improving PHT compared to propranolol monotherapy. These pilot data suggest that the addition of rifaximin to NSBBs could be a good therapeutic option for overcoming the limited effectiveness of NSBBs.

Transient elastography versus hepatic venous pressure gradient for diagnosing portal hypertension: a systematic review and meta-analysis

BACKGROUND/AIMS: Transient elastography (TE) has been proposed as a promising noninvasive alternative to hepatic venous pressure gradient (HVPG) for detecting portal hypertension (PH). However, previous studies have yielded conflicting results. We gathered evidence from literature on the clinical usefulness of TE versus HVPG for assessing PH. METHODS: We conducted a systematic review by searching databases for relevant literature evaluating the clinical usefulness of non-invasive TE for assessing PH in patients with cirrhosis. A literature search in Ovid Medline, EMBASE and the Cochrane Library was performed for all studies published prior to December 30, 2015. RESULTS: Eight studies (1,356 patients) met our inclusion criteria. For the detection of PH (HVPG ≥6 mmHg), the summary sensitivity and specificity were 0.88 (95% confidence interval [CI] 0.86-0.90) and 0.74 (95% CI 0.67-0.81), respectively. Regarding clinically significant PH (HVPG ≥10 mmHg), the summary sensitivity and specificity were 0.85 (95% CI 0.63-0.97) and 0.71 (95% CI 0.50-0.93), respectively. The overall correlation estimate of TE and HVPG was large (0.75, 95% CI: 0.65; 0.82, P<0.0001). CONCLUSIONS: TE showed high accuracy and correlation for detecting the severity of PH. Therefore, TE shows promise as a reliable and non-invasive procedure for the evaluation of PH that should be integrated into clinical practice.

Metodología físico-matemática de evaluación del pH y la presión de dióxido de carbono arteriales y venosos en la unidad de cuidados intensivos / Physical-mathematical assessment methodology ph dioxide pressure and arterial and venous carbon in the intensive care unit

ResumenIntroducción:La dinámica cardíaca ha sido caracterizada a partir de la teoría de los sistemas dinámicos y la geometría fractal, permitiendo generar metodologías de aplicación clínica.Objetivo:desde los sistemas dinámicos, se desarrollará una metodología de evaluación de los pH y presiones de dióxido de carbono arteriales y venosos para pacientes de la Unidad de Cuidados Intensivos.Materiales y Métodos:se escogieron 10 pacientes con diversas patologías de la Unidad de Cuidados Intensivos Postqui rúrgicos del Hospital Militar Central, registrando pH y presiones de dióxido de carbono arteriales y venosas durante su tiempo de estancia; posteriormente se construyeron atractores, determinando su tipo de trayectoria y estableciendo los valores máximos y mínimos de estas variables en el mapa de retardo.Resultados:se encontró un comportamiento caótico de las variables evaluadas, hallando valores mínimos y máximos de 7,01 y 7,59 para pH arterial, 6,97 y 7,53 para pH venoso, 14,40 y 73,70 para presión arterial de dióxido de carbono, y 19,20 y 97,90 para presión venosa de dióxido de carbono.Conclusiones:La evaluación de los valores máximos y mínimos del atractor en el mapa de retardo constituye un nuevo método, objetivo y reproducible, para la evaluación matemática de cada una de las variables estudiadas, de utilidad para el seguimiento de pacientes en UCI.

SummaryIntroduction:Cardiac dynamics has been characterized from the theory of dynamical systems and fractal geometry, allowing to generate methodologies with clinical application. Objective: from dynamic systems, a methodology for evaluating the arterial and venous pH and dioxide of carbon pressures for patient in Intensive Care Unit will be developed.Materials and Methods:10 patients with various pathologies were selected from Post-surgical Intensive Care Unit of the Central Military Hospital, recording arterial and venous pH and dioxide of carbon pressures of during its stay; attractors were built subsequently, determining the type of path and setting the maximum and minimum values of these variables on the delay map.Results:chaotic behavior of the variables evaluated was found, finding maximum and minimum values of 7,01 and 7,59 for arterial pH values, 6,97 and 7,53 for venous pH, 14,40 and 73,70 for arterial dioxide of carbon pressure, and 19,20 and 97,90 for venous dioxide of carbon pressure.Conclusions:The evaluation of the maximum and minimum values of the attractor on the delay map is a new method, objective and reproducible for the mathematical evaluation of each of the variables studied, useful for monitoring patients in Intensive Care Unit.

Hepatic Venous Pressure Gradient Predicts Long-Term Mortality in Patients with Decompensated Cirrhosis

PURPOSE: The present study aimed to investigate the role of hepatic venous pressure gradient (HVPG) for prediction of long-term mortality in patients with decompensated cirrhosis. MATERIALS AND METHODS: Clinical data from 97 non-critically-ill cirrhotic patients with HVPG measurements were retrospectively and consecutively collected between 2009 and 2012. Patients were classified according to clinical stages and presence of ascites. The prognostic accuracy of HVPG for death, survival curves, and hazard ratios were analyzed. RESULTS: During a median follow-up of 24 (interquartile range, 13-36) months, 22 patients (22.7%) died. The area under the receiver operating characteristics curves of HVPG for predicting 1-year, 2-year, and overall mortality were 0.801, 0.737, and 0.687, respectively (all p17 mm Hg, respectively (p=0.015). In the ascites group, the mortality rates at 1 and 2 years were 3.9% and 17.6% with HVPG 17 mm Hg, respectively (p=0.044). Regarding the risk factors for mortality, both HVPG and model for end-stage liver disease were positively related with long-term mortality in all patients. Particularly, for the patients with ascites, both prothrombin time and HVPG were independent risk factors for predicting poor outcomes. CONCLUSION: HVPG is useful for predicting the long-term mortality in patients with decompensated cirrhosis, especially in the presence of ascites.

The agreement and clinical value of hepatic vein pressure gradient and portal vein pressure in patients with portal hypertension / 中华肝脏病杂志

<p><b>OBJECTIVE</b>To evaluate the agreement and correlation between hepatic vein pressure gradient (HVPG) and portal vein pressure (PVP) in patients with portal hypertension,and explore their clinical value.</p><p><b>METHODS</b>A total of 46 patients with portal hypertension were directly measured the free hepatic pressure, wedged hepatic pressure, portal vein pressure before and after TIPS therapy. The agreement and correlation of HVPG and PVP were analyzed, and explore their clinical value.</p><p><b>RESULTS</b>There is no significant agreement or correlation between HVPG and PVP in 5 patients, whose third hilar have large communicating branches between portal vein and Inferior vena cava, or with obvious umbilical vein opened. The HVPGs were significantly agreed with portal vein pressure in other 41 patients. There is no significant difference of HVPG or PVP between earlyTIPS and not early-TIPS groups. In addition, the portal vein pressures after TIPS were significantly decreased compared with that before TIPS.</p><p><b>CONCLUSION</b>The HVPG can well show the PVP except these with obvious communicating branches between portal vein and Inferior vena cava in third hilar, and TIPS can effectively decrease the portal vein pressure in patients with portal hypertension.</p>

Importancia médica del glucocáliz endotelial: Parte 2: su papel en enfermedades vasculares y complicaciones de la diabetes mellitus / Medical significance of endothelial glycocalyx: Part 2: Its role in vascular diseases and in diabetic complications

El glucocáliz endotelial es una capa constituida por glucosaminoglicanos, proteoglicanos y glucoproteínas que cubre al endotelio en su cara luminal. La participación del deterioro del glucocáliz endotelial parece esencial en los pasos iniciales de la fisiopatología de la aterosclerosis, de las complicaciones microangiopáticas de la diabetes mellitus y de la enfermedad venosa crónica. Los factores de riesgo de la aterosclerosis como la hipercolesterolemia, la hiperglucemia, la inflamación, el exceso de sodio y las fuerzas de tensión alteradas causan deterioro del glucocáliz. Esto provoca disfunción endotelial y permite la filtración de lipoproteínas (LDL) y de leucocitos al espacio subendotelial, iniciando la formación de la placa de ateroma. En la diabetes el glucocáliz adelgazado, principalmente por estrés oxidativo, posibilita la filtración de proteínas (albuminuria) y el trastorno endotelial de la microangiopatía. La hipertensión venosa crónica altera las fuerzas de tensión y daña el glucocáliz, lo que permite la filtración de leucocitos a las partes más profundas de la pared venosa, iniciando la inflamación y el deterioro morfológico y funcional de las venas que lleva a la enfermedad venosa crónica. El tratamiento con glucosaminoglicanos (sulodexida) logra prevenir o revertir el daño al glucocáliz endotelial y algunas de sus consecuencias; es eficaz en la enfermedad venosa crónica, especialmente con úlceras venosas. También ha sido útil en aterosclerosis obliterante de miembros inferiores y en la nefropatía diabética con albuminuria.

Endothelial glycocalyx is a layer composed by glycosaminoglycans, proteoglycans and glycoproteins attached to the vascular endothelial luminal surface. Shredding of glycocalyx appears as an essential initial step in the pathophysiology of atherosclerosis and microangiopathic complications of diabetes mellitus, as well as in chronic venous disease. Atherosclerosis risk factors, as hypercholesterolemia (LDL), hyperglycemia, inflammation, salt excess and altered shear stress can damage glycocalyx. This lead to endothelial dysfunction and allows LDL and leukocytes to filtrate to the subendothelial space initiating atheroma plaque formation. Degradation of glycocalyx in diabetes mellitus is mainly due to oxidative stress and enables protein filtration (albuminuria) and endothelial disorder of microangiopathy. Chronic venous hypertension brings to altered shears stress which results in shredded glycocalyx, this allows leukocytes to migrate into venous wall and initiate inflammation leading to morphologic and functional venous changes of the chronic venous disease. Treatment with glycosaminoglycans (sulodexide) prevents or recovers the damaged glycocalyx and several of its consequences. This drug improves chronic venous disease and promotes healing of chronic venous ulcers. It has also been useful in peripheral arterial obstructive disease and in diabetic nephropathy with albuminuria.