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.

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)

Descending aortic intramural hematoma with pulmonary embolism: A case report / 中国胸心血管外科临床杂志

@#Aortic intramural hematoma and pulmonary embolism are two rapidly progressive and life-threatening diseases. A 65-year-old male patient with descending aortic intramural hematoma and pulmonary embolism underwent pulmonary embolectomy and descending aortic stent-graft placement, with good postoperative results.

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&#x0026;#x003C;0.001). Compared with the control group, the noDR group had significantly higher AVD(P&#x0026;#x003C;0.05). VLD of both layers in patients of mNPDR group was significant decreased compared with that of noDR group(all P&#x0026;#x003C;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.

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)

Relação entre a Relação Fibrinogênio/Albumina e a Perfusão Microvascular em Pacientes Submetidos à Intervenção Coronária Percutânea Primária para Infarto do Miocárdio com Elevação do Segmento ST: Um Estudo Prospectivo / Relationship between the Fibrinogen/Albumin Ratio and Microvascular Perfusion in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Elevated Myocardial Infarction: A Prospective Study

Resumo Fundamento A contagem corrigida de quadros TIMI (CTFC), o grau de blush miocárdico (MBG) e a resolução do segmento ST (STR) são parâmetros utilizados para avaliar a reperfusão em nível microvascular em pacientes submetidos à intervenção coronária percutânea primária (ICPp). A relação fibrinogênio/albumina (FAR) tem sido associada a eventos trombóticos em pacientes com infarto do miocárdio com elevação do segmento ST (IAMCSST) e insuficiência venosa crônica. Objetivos Investigar a relação do FAR com CTFC, MBG e STR.Métodos: O estudo incluiu 167 pacientes consecutivos que foram submetidos a ICPp com sucesso para IAMCSST e alcançaram fluxo TIMI-3. Os casos foram divididos em dois grupos, FAR alto (> 0,0765) e FAR baixo (≤ 0,0765), de acordo com o valor de corte desse parâmetro na análise característica do operador do receptor (ROC). STR, CTFC e MBG foram utilizados para avaliar a reperfusão miocárdica. Valores de p<0,05 foram considerados estatisticamente significativos. Resultados O valor CTFC, escore SYNTAX, relação neutrófilos/linfócitos, lipoproteína de baixa densidade, glicose e pico de cTnT foram significativamente maiores, enquanto STR, MBG e FEVE foram menores no grupo FAR alto. A análise de correlação de Spearman revelou relação significativa entre FAR e STR (r=-0,666, p<0,001), MBG (-0,523, p<0,001) e CTFC (r=0,731, p≤0,001). De acordo com a análise de regressão logística, FAR, glicose, pico de cTnT e dor até o tempo de Balão foram os preditores independentes mais importantes de MBG 0/1, CTFC>28 e STR<50%). A análise ROC revelou que o ponto de corte o valor de FAR≥0,0765 foi preditor de STR incompleto com sensibilidade de 71,9% e especificidade de 69,8%, MBG0/1 com sensibilidade de 72,6% e especificidade de 68,6%, e CTFC>28 com sensibilidade de 76% e uma especificidade de 65,8%. Conclusões A FAR é um importante preditor independente de perfusão microvascular em pacientes submetidos a ICPp por IAMCSST.

Abstract Background Correct TIMI frame count (CTFC), myocardial blush grade (MBG), and ST-segment resolution (STR) are parameters used to evaluate reperfusion at the microvascular level in patients that have undergone primary percutaneous coronary intervention (pPCI). Fibrinogen-to-albumin ratio (FAR) has been associated with thrombotic events in patients with ST-elevation myocardial infarction (STEMI) and chronic venous insufficiency. Objectives To investigate the relationship of FAR with CTFC, MBG, and STR. Methods: The study included 167 consecutive patients who underwent successful pPCI for STEMI and achieved TIMI-3 flow. The cases were divided into two groups, high (>0.0765) and low FAR (≤0.0765), according to the cut-off value of this parameter in the receiver operator characteristic analysis (ROC). STR, CTFC, and MBG were used to evaluate myocardial reperfusion. P values<0.05 were considered statistically significant. Results CTFC value, SYNTAX score, neutrophil/lymphocyte ratio, low-density lipoprotein, glucose, and peak cTnT were significantly higher, whereas STR, MBG, and LVEF were lower in the high FAR group. Spearman's correlation analysis revealed a significant relationship between the FAR and STR (r=-0.666, p<0.001), MBG (-0.523, p<0.001), and CTFC (r=0.731, p≤0.001). According to the logistic regression analysis, FAR, glucose, peak cTnT, and pain to balloon time were the most important independent predictors of MBG 0/1, CTFC>28, and STR<50%).ROC analysis revealed that the cut-off value of FAR≥0.0765 was a predictor of incomplete STR with a sensitivity of 71.9 % and a specificity of 69.8 %, MBG0/1 with a sensitivity of 72.6 % and a specificity of 68.6 %, and CTFC >28 with a sensitivity of 76 % and a specificity of 65.8 %. Conclusions FAR is an important independent predictor of microvascular perfusion in patients undergoing pPCI for STEMI.

A rat model of dual-flow liver machine perfusion system

Purpose: As clinical liver perfusion systems use portal vein and artery flow, dual perfusion techniques are required even in small animal models in order to reproduce clinical setting. The aim of this study was to construct a new dual-flow perfusion system in rat model and optimized the oxygen supply to ensure the aerobic metabolization. Methods: The dual-flow circuit was fabricated using rat liver and whole blood samples as perfusates. The oxygen supply was controlled according to the amount of dissolved oxygen in the perfusate. Perfusate parameters and adenosine triphosphate (ATP) levels were analyzed to evaluate organ function and metabolic energy state. Stored whole blood also tested the suitability as perfusate. Results: Stored blood showed decrease oxygen delivery and liver function compared to fresh blood. Using fresh blood as perfusate with air only, the dissolved oxygen levels remained low and anaerobic metabolism increased. In contrast, with oxygen control at living body level, anaerobic metabolism was well suppressed, and tissue ATP content was increased. Conclusions: We developed a new dual-flow system that enable to reproduce the clinical settings. The perfusion system showed the possibility to improve the energy metabolic state of the perfused organ under appropriate partial pressure of oxygen.

Associação de Nível de Renda e Doença Isquêmica do Coração: Papel Potencial da Caminhabilidade / Association of Income Level and Ischemic Heart Disease: Potential Role of Walkability

Resumo Fundamento O nível socioeconômico tem sido associado à doença isquêmica do coração (DIC). Bairros de alta renda podem expor os indivíduos a um ambiente construído que promova caminhadas para atividades diárias (caminhabilidade). Faltam dados sobre a associação entre renda e DIC em países de renda média. Também é incerto se a caminhabilidade medeia essa associação. Objetivos Investigar se a renda está associada à DIC em um país de renda média e se a caminhabilidade dos bairros medeia a associação entre renda e DIC. Métodos O presente estudo transversal avaliou 44.589 pacientes encaminhados para imagem de perfusão miocárdica (SPECT-MPI). A renda e a caminhabilidade foram derivadas do setor censitário residencial dos participantes. A pontuação quantitativa da caminhabilidade combinou as seguintes 4 variáveis: conectividade viária, densidade residencial, densidade comercial e uso misto do solo. A DIC foi definida pela presença de perfusão miocárdica anormal durante um estudo SPECT-MPI. Utilizamos modelos ajustados com efeitos mistos para avaliar a associação entre nível de renda e DIC e realizamos uma análise de mediação para medir o percentual da associação entre renda e DIC mediada pela caminhabilidade. Consideramos valores de p abaixo de 0,01 como estatisticamente significativos. Resultados Dos 26.415 participantes, aqueles que residiam no setor censitário do tercil de menor renda eram mais fisicamente inativos (79,1% versus 75,8% versus 72,7%) quando comparados aos setores censitários do tercil de maior renda (p < 0,001). A renda foi associada à DIC (odds ratio: 0,91 [intervalo de confiança de 95%: 0,87 a 0,96] para cada aumento de 1000,00 dólares internacionais na renda), para homens e mulheres igualmente (p para interação = 0,47). Os setores censitários com maior renda estiveram associados a uma melhor caminhabilidade (p < 0,001); no entanto, a caminhabilidade não mediou a associação entre renda e DIC (porcentagem mediada = −0,3%). Conclusões A renda foi independentemente associada a maior prevalência de DIC em um país de renda média, independentemente de gênero. Embora a caminhabilidade tenha sido associada à renda do setor censitário, ela não mediou a associação entre renda e DIC.

Abstract Background Socioeconomic status has been linked to ischemic heart disease (IHD). High-income neighborhoods may expose individuals to a walking-promoting built environment for daily activities (walkability). Data from the association between income and IHD is lacking in middle-income countries. It is also uncertain whether walkability mediates this association. Objectives To investigate whether income is associated with IHD in a middle-income country and whether neighborhood walkability mediates the income-IHD association. Methods This cross-sectional study evaluated 44,589 patients referred for myocardial perfusion imaging (SPECT-MPI). Income and walkability were derived from participants' residential census tract. Walkability quantitative score combined 4 variables: street connectivity, residential density, commercial density, and mixed land use. IHD was defined by abnormal myocardial perfusion during a SPECT-MPI study. We used adjusted mixed effects models to evaluate the association between income level and IHD, and we performed a mediation analysis to measure the percentage of the income-IHD association mediated by walkability. We considered p values below 0.01 as statistically significant. Results From 26,415 participants, those living in the lowest-income tertile census tract were more physically inactive (79.1% versus 75.8% versus 72.7%) when compared to higher-income tertile census tracts (p < 0.001). Income was associated with IHD (odds ratio: 0.91 [95% confidence interval: 0.87 to 0.96] for each 1,000.00 international dollars increase in income) for both men and women equally (p for interaction = 0.47). Census tracts with a higher income were associated with better walkability (p < 0.001); however, walkability did not mediate the income-IHD association (percent mediated = −0.3%). Conclusions Income was independently associated with higher prevalence of IHD in a middle-income country irrespective of gender. Although walkability was associated with census tract income, it did not mediate the income-IHD association.

Development status and new challenges of heart transplantation / 器官移植

Heart transplantation is the primary therapeutic option for patients with end-stage heart failure. The shortage of donors has been the main limiting factor for the increasing quantity of heart transplantation. With persistent updating and introduction of novel technologies, the donor pool has been increasingly expanded, such as using the heart from older donors, donors infected with hepatitis C virus, donors dying from drug overdose or donation after cardiac death (DCD) donors, etc. Meantime, the proportion of recipients with advanced age, multiple organ dysfunction, mechanical circulatory support and human leukocyte antigen antibody sensitization has been significantly increased in recent years. The shortage of donors, complication of recipients' conditions, individualized management of immunosuppressive therapy and prevention and treatment of long-term cardiac allograft vasculopathy are all challenges in the field of heart transplantation. In this article, novel progresses on donor pool expansion, improving the quality of recipients, strengthening the diagnosis and treatment of rejection, and preventing cardiac allograft vasculopathy were reviewed, aiming to prolong the survival and enhance the quality of life of patients with end-stage heart failure on the waiting list or underwent heart transplantation.

Numerical Study on the Process of Human Brain Cooling Treated by Hemoperfusion Mild Hypothermia / 中国医疗器械杂志

Mild hypothermia, as a common means of intraoperative nerve protection, has been used in clinical practice. Compared with the traditional methods such as freezing helmet and nasopharyngeal cooling, hypothermic blood perfusion is considered to be a promising treatment for mild hypothermia, but it lacks experimental and theoretical verification of its cooling effect. In this study, the commercial finite element simulation software COMSOL combined the Pennes equation with the cerebrovascular network model to construct a new simplified human brain model, which was further used to simulate the cooling process of cerebral hypothermic blood perfusion. When the hypothermic blood perfusion was 33 ℃, the human brain could enter the mild hypothermic state within 4 minutes. By comparing with helmet cooling, the feasibility and efficiency of the blood perfusion scheme were verified. By comparing with the calculation results based on Pennes equation, the rationality of the model constructed in this study were verified. This model can non-intrusively predict the changes of brain temperature during surgery, and provide a reference for the setting of treatment parameters such as blood temperature, so as to provide personalized realization of safer and more effective mild hypothermia neuro protection.

Physical exercise suppresses hepatocellular carcinoma progression by alleviating hypoxia and attenuating cancer stemness through the Akt/GSK-3β/β-catenin pathway / 中西医结合学报

OBJECTIVE@#Physical exercise, a common non-drug intervention, is an important strategy in cancer treatment, including hepatocellular carcinoma (HCC). However, the mechanism remains largely unknown. Due to the importance of hypoxia and cancer stemness in the development of HCC, the present study investigated whether the anti-HCC effect of physical exercise is related to its suppression on hypoxia and cancer stemness.@*METHODS@#A physical exercise intervention of swimming (30 min/d, 5 d/week, for 4 weeks) was administered to BALB/c nude mice bearing subcutaneous human HCC tumor. The anti-HCC effect of swimming was assessed in vivo by tumor weight monitoring, hematoxylin and eosin (HE) staining, and immunohistochemistry (IHC) detection of proliferating cell nuclear antigen (PCNA) and Ki67. The expression of stemness transcription factors, including Nanog homeobox (NANOG), octamer-binding transcription factor 4 (OCT-4), v-Myc avian myelocytomatosis viral oncogene homolog (C-MYC) and hypoxia-inducible factor-1α (HIF-1α), was detected using real-time reverse transcription polymerase chain reaction. A hypoxia probe was used to explore the intratumoral hypoxia status. Western blot was used to detect the expression of HIF-1α and proteins related to protein kinase B (Akt)/glycogen synthase kinase-3β (GSK-3β)/β-catenin signaling pathway. The IHC analysis of platelet endothelial cell adhesion molecule-1 (CD31), and the immunofluorescence co-location of CD31 and desmin were used to analyze tumor blood perfusion. SMMC-7721 cells were treated with nude mice serum. The inhibition effect on cancer stemness in vitro was detected using suspension sphere experiments and the expression of stemness transcription factors. The hypoxia status was inferred by measuring the protein and mRNA levels of HIF-1α. Further, the expression of proteins related to Akt/GSK-3β/β-catenin signaling pathway was detected.@*RESULTS@#Swimming significantly reduced the body weight and tumor weight in nude mice bearing HCC tumor. HE staining and IHC results showed a lower necrotic area ratio as well as fewer PCNA or Ki67 positive cells in mice receiving the swimming intervention. Swimming potently alleviated the intratumoral hypoxia, attenuated the cancer stemness, and inhibited the Akt/GSK-3β/β-catenin signaling pathway. Additionally, the desmin+/CD31+ ratio, rather than the number of CD31+ vessels, was significantly increased in swimming-treated mice. In vitro experiments showed that treating cells with the serum from the swimming intervention mice significantly reduced the formation of SMMC-7721 cell suspension sphere, as well as the mRNA expression level of stemness transcription factors. Consistent with the in vivo results, HIF-1α and Akt/GSK-3β/β-catenin signaling pathway were also inhibited in cells treated with serum from swimming group.@*CONCLUSION@#Swimming alleviated hypoxia and attenuated cancer stemness in HCC, through suppression of the Akt/GSK-3β/β-catenin signaling pathway. The alleviation of intratumoral hypoxia was related to the increase in blood perfusion in the tumor. Please cite this article as: Xiao CL, Zhong ZP, Lü C, Guo BJ, Chen JJ, Zhao T, Yin ZF, Li B. Physical exercise suppresses hepatocellular carcinoma progression by alleviating hypoxia and attenuating cancer stemness through the Akt/GSK-3β/β-catenin pathway. J Integr Med. 2023; 21(2): 184-193.

Application of Three-dimensional Computed Tomography Bronchography and Angiography Combined with Perfusion Area Identification Technique in Uniport Thoracoscopic Complex Segmentectomy / 中国肺癌杂志

BACKGROUND@#With the extensive application of segmental lung resection in the treatment of early-stage lung cancer, how to complete segmentectomy more accurately and minimally invasively has become a research hotspot. The aim of this study is to explore the application of three-dimensional computed tomography bronchography and angiography (3D-CTBA) combined with perfusion area recognition technique in single-hole thoracoscopic complex segmentectomy.@*METHODS@#From January 2021 to January 2022, the clinical data of 112 consecutive patients undergoing single-port thoracoscopic complex segmentectomy in the Department of Thoracic Surgery, Xuanwu Hospital, Capital Medical University were retrospectively analyzed. The three-dimensional reconstruction combined with perfusion area identification technique was used to perform the operation and the clinical data were analyzed.@*RESULTS@#The average operation time was (141.1±35.4) min; the initial time of intersegmental plane display was (12.5±1.7) s; the maintenance time of intersegmental plane was (114.3±10.9) s; the intersegmental plane was clearly displayed (100%); the amount of bleeding was [10 (10, 20)] mL; the total postoperative drainage volume was (380.5±139.7) mL; the postoperative extubation time was (3.9±1.2) d; and the postoperative hospitalization time was (5.2±1.6) d. Postoperative complications occurred in 8 cases.@*CONCLUSIONS@#The advantages of 3D-CTBA combined with perfusion area recognition technique are fast, accurate and safe in identifying intersegmental boundary in single-port thoracoscopic complex segmentectomy, which could provide guidances for accuratding resection of tumors, shortening operation time and reducing surgical complications.

Application of a novel artificial perfusate based on oxygen-carrying nanoparticles in normothermic machine perfusion for porcine liver preservation after cardiac death / 浙江大学学报·医学版

OBJECTIVE@#To investigate the efficacy of a novel artificial perfusate based on oxygen-carrying perfluoronaphthalene-albumin nanoparticles in normothermic machine perfusion (NMP) for preservation of porcine liver donation after cardiac death.@*METHODS@#Artificial perfusate with perfluoronaphthalene-albumin nanoparticles was prepared at 5% albumin (w/v) and its oxygen carrying capacity was calculated. The livers of 16 Landrace pigs were isolated after 1 h of warm ischemia, and then they were divided into 4 groups and preserved continuously for 24 h with different preservation methods: cold preservation with UW solution (SCS group), NMP preservation by whole blood (blood NMP group), NMP preservation by artificial perfusate without nanoparticles (non-nanoparticles NMP group) and NMP preservation by artificial perfusate containing nanoparticles (nanoparticles NMP group). Hemodynamics, tissue metabolism, biochemical indices of perfusate and bile were monitored every 4 h after the beginning of NMP. Liver tissue samples were collected for histological examination (HE and TUNEL staining) before preservation, 12 h and 24 h after preservation.@*RESULTS@#The oxygen carrying capacity of nanoparticles in 100 mL artificial perfusate was 6.94 μL/mmHg (1 mmHg=0.133 kPa). The hepatic artery and portal vein resistance of nanoparticles NMP group and blood NMP group remained stable during perfusion, and the vascular resistance of nanoparticles NMP group was lower than that of blood NMP group. The concentration of lactic acid in the perfusate decreased to the normal range within 8 h in both nanoparticles NMP group and blood NMP group. There were no significant differences in accumulated bile production, alanine aminotransferase and aspartate aminotransferase in perfusate between nanoparticles NMP group and blood NMP group (all P>0.05). After 24 h perfusion, the histological Suzuki score in blood NMP group and nanoparticles NMP group was lower than that in SCS group and non-nanoparticles NMP group (all P<0.05), and the quantities of TUNEL staining positive cells in blood NMP group and non-nanoparticles NMP group was higher than those in nanoparticles NMP group and SCS group 12 h and 24 h after preservation (all P<0.05).@*CONCLUSION@#Artificial perfusate based on oxygen-carrying nanoparticles can meet the oxygen supply requirements of porcine livers donation after cardiac death during NMP preservation, and it may has superiorities in improving tissue microcirculation and alleviating ischemia-reperfusion injury.

Quantitative assessment of choriocapillaris perfusion in patients with diabetic retinopathy using ultra-high-speed swept source optical coherence tomography angiography / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To evaluate the characteristics of choriocapillary blood flow in different patients with diabetic retinopathy(DR)based on the measurement of choriocapillaris(CC)perfusion density(PFD)using ultra-high-speed swept-source optical coherence tomography angiography(SS-OCTA)METHODS: The cross-sectional observational study was conducted on 139 cases(139 eyes)who admitted to the Second People's Hospital of Hefei, including 115 DR cases(115 eyes)and 24 control cases(24 eyes). The color retinal images were graded according to the Early Treatment Diabetic Retinopathy Study(ETDRS)scale, and the DR eyes were classified into non-DR group, nonproliferative diabetic retinopathy(NPDR)group, NPDR combined with diabetic macular edema(DME)group and proliferative diabetic retinopathy(PDR)group. The ultra-high-speed SS-OCTA was used to scan a 3mm×3mm region centered on the macular central fovea, the CC perfusion area was measured by the built-in software, and PFD was calculated. Multivariable linear regressions were used to evaluate the correlation between PFD of CC and DR degree.RESULTS: The degree of DR had a correlation with blood perfusion of CC after adjusting for various confounding factors. When compared to the control group, the PFD of CC in the central fovea of the NPDR group decreased by 9.358 units(95%CI -18.484～-0.232, P=0.045)and 9.284 units in the paracentral fovea(95%CI -18.487～-0.090, P=0.048); In the NPDR combined with DME group, the central fovea CC PFD decreased by 18.173 units(95%CI -28.583～-7.762, P=0.001), while the paracentral fovea decreased by 17.032 units(95%CI -27.521～-6.544, P=0.002); In the PDR group, the central fovea CC PFD decreased by 28.309 units(95%CI -39.978～-16.640, P&#x003C;0.001), while the paracentral fovea decreased by 25.841 units(95%CI -37.597～-14.085, P&#x003C;0.001).CONCLUSION: The macular perfusion can be objectively quantified by the measurement of CC PFD with ultra-high-speed SS-OCTA. The CC PFD in the macular region was significantly reduced in more advanced stages of DR. Furthermore, future research should focus on longitudinal studies in the causal relationship between CC perfusion and DR progression.