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PD25-09 RISK FACTORS FOR TECHNICAL FAILURE OF RENAL AUTOTRANSPLANT: RESULTS OF 103 CASES FROM A SINGLE INSTITUTION

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2018PD25-09 RISK FACTORS FOR TECHNICAL FAILURE OF RENAL AUTOTRANSPLANT: RESULTS OF 103 CASES FROM A SINGLE INSTITUTION Mohamed Eltemamy, Ahmed Elshafei, Rathika Ramkumar, Alvin Wee, Stuart Flechner, and Venkatesh Krishnamurthi Mohamed EltemamyMohamed Eltemamy More articles by this author , Ahmed ElshafeiAhmed Elshafei More articles by this author , Rathika RamkumarRathika Ramkumar More articles by this author , Alvin WeeAlvin Wee More articles by this author , Stuart FlechnerStuart Flechner More articles by this author , and Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1336AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal autotransplantation (RA) is an accepted therapeutic option for select indications. We sought to analyze factors associated with technical failure in RA patients. METHODS We reviewed 103 patients who underwent RA from 2004 to 2017. Satisfactory outcome (SO) was defined as post-operative patent vasculature on ultrasound and/ or normal nuclear scan. Unsatisfactory outcomes (UO) included Compromised grafts (CG) (partial infarction on radiographic studies more than 20%) and lost grafts (LG) (nephrectomy or absent perfusion on radiographic studies). RESULTS Median age was 39 years (IQR: 32-47). Females were 71 (69%) and males were 32 (31%). Median follow up time was 9.5 months (IQR: 2.5-30) Indications for RA were renovascular diseases (n=27), Ureteric pathology (n=30), intractable nephrolithiasis (n=30), flank pain (n= 15) and pancreatic neoplasm (n=1). 89 (86.4%) patients had a SO while 14 (13.6%) had a UO (CG= 7, LG= 7). There was no statistically significant difference between UO and SO in median preoperative creatinine (p=0.2), preoperative positive urine culture (p=0.32), history of stone disease (P=0.27) and prior urinary tract instrumentation (p=0.11). However, presence of ureteric stent or nephrostomy tube (PCN) at time of RA was significantly higher in UO (42.9% vs. 16.9%, p=0.04). Also, multiple arterial anastomoses were more frequent in UO (42.9% vs 18.2%, p=0.03). Other operative variables including median blood loss (p=0.23) and type of urinary reconstruction (p=0.6) were not significantly different. Median creatinine at last follow up was higher in UO compared to SO (1.08 mg/dl vs 0.86 mg/dl, p= 0.005). On logistic regression model, the presence of a stent or PCN at time of surgery (OR 4.19, 95% CI 1.2-14.71, p=0.03) and multiple arterial anastomoses (OR 3.89, 95 CI 1.11-13.63, p=0.03) were independent predictors of UO. CONCLUSIONS The presence of a stent or PCN at time of surgery and multiple arterial anastomoses were associated with graft compromise or loss. While the correlation between number of arteries and outcomes is sound, the stronger correlation of stents and PCN at time of surgery with worse outcomes is unclear. Our hypothesis is that ureteric stents and PCNs harbor infections despite appropriate antibiotic treatment. Consequently, these kidneys are more prone to technical failure after RA suggesting the need for an alternative approach with respect to those indwelling devices. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e549-e550 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Mohamed Eltemamy More articles by this author Ahmed Elshafei More articles by this author Rathika Ramkumar More articles by this author Alvin Wee More articles by this author Stuart Flechner More articles by this author Venkatesh Krishnamurthi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The no-reflow phenomenon: mechanisms and therapeutic targets

The phenomenon of «no-reflow» refers to a state of myocardial tissue hypoperfusion or absence of perfusion after eliminating the cause of the occlusion of the coronary artery. Two main pathogenetic mechanisms may contribute to the development of no-reflow phenomenon after primary percutaneous coronary intervention in patients with myocardial infarction: ischemic-reperfusion injury of the microcirculatory vessels and embolization of the distal arterial bed with fragments of thrombus and atherosclerotic plaque. In this review, we describe the pathophysiological mechanisms of no-reflow, risk factors for no-reflow phenomenon, the principles of diagnosis and therapeutic targets.

Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis

BackgroundNecrotizing enterocolitis (NEC) is a devastating inflammatory disease of the intestinal tract that represents a significant source of morbidity and mortality in preterm infants. Imaging of the abdomen is valuable for timely diagnosis and close monitoring of disease progression in NEC. Bowel ultrasound (US) is increasingly being recognized as an important imaging tool for evaluating NEC that provides additional detail than plain abdominal radiographs.ObjectiveTo identify bowel US findings associated with surgical management or death in infants with NEC.Materials and methodsWe searched Embase, PubMed, and the Cumulative Index to Nursing and Allied Health Literature for studies investigating the association between bowel US findings and surgical management or death in NEC. Selected articles were evaluated for quality of study methodology using the Newcastle-Ottawa Scale, and aggregate statistics for odds ratio (OR) and 95% confidence interval were calculated.ResultsOf 521 articles reviewed, 11 articles comprising 748 infants were evaluated for quality. Nine of the studies were retrospective and from single-center experiences. Pooled analysis showed that focal fluid collections (OR 17.9, 3.1–103.3), complex ascites (OR 11.3, 4.2–30.0), absent peristalsis (OR 10.7, 1.7–69.0), pneumoperitoneum (OR 9.6, 1.7–56.3), bowel wall echogenicity (OR 8.6, 3.4–21.5), bowel wall thinning (OR 7.11.6–32.3), absent perfusion (OR 7.0, 2.1–23.8), bowel wall thickening (OR 3.9, 2.4–6.1) and dilated bowel (OR 3.5, 1.8–6.8) were associated with surgery or death in NEC. In contrast, portal venous gas (OR 3.0, 0.8–10.6), pneumatosis intestinalis (OR 2.1, 0.9–5.1), increased bowel perfusion (OR 2.6, 0.6–11.1) and simple ascites (OR 0.54, 0.1–2.5) were not associated with surgery or death.ConclusionThis meta-analysis identified several bowel US findings that are associated and not associated with surgery or death in NEC. Bowel US may be useful for early identification of high-risk infants with NEC who may benefit from more aggressive treatment, including surgery. Future studies are needed to determine whether the addition of bowel US in NEC evaluation would improve outcomes.

Structural and functional evidence for the scaffolding effect of alveolar blood vessels

ABSTRACT A contribution of pulmonary blood distension to alveolar opening was first proposed more than 100 years ago. To investigate the contribution of blood distension to lung mechanics, we studied control mice (normal perfusion), mice after exsanguination (absent perfusion) and mice after varying degrees of parenchymal resection (supra-normal perfusion). On inflation, mean tracheal pressures were higher in the bloodless mouse (4.0 ± 2.5 cm H2O); however, there was minimal difference between conditions on deflation (0.7 ± 0.9 cm H2O). To separate the peripheral and central mechanical effects of blood volume, multi-frequency lung impedance data was fitted to the constant-phase model. The presence or absence of blood had no effect on central airway resistance (p > .05). In contrast, measures of tissue damping (G), tissue elastance (H) and hysteresivity (η) demonstrated a significant increase in bloodless mice relative to control mice (p < .001). After varying amount of surgical resection and associated supra-normal perfusion of the remaining lung, there was an increase in G and H. Although the absolute difference in G and H increased with the amount of parenchymal resection, the proportional contribution of blood was identical in all conditions. The presence of blood in the pulmonary vasculature resulted in a constant 64 ± 5% reduction in tissue damping (G) and a 55 ± 4% reduction in tissue elastance (H). This nearly-constant contribution of blood to lung hysteresivity was only reduced by positive end-expiratory pressure (PEEP). To identify a distinct structural subset of vessels in the lung potentially contributing to these observations, vascular casting and scanning electron microscopy of the lung demonstrated morphologically distinct vascular rings at the alveolar opening. Our results suggest that intravascular blood distension, likely attributable to a subset of vessels in the alveolar entrance ring, contributes a measurable scaffolding effect to the functional recruitment of the peripheral lung.

Value of combining dynamic contrast enhanced ultrasound and optoacoustic tomography for hypoxia imaging

Optoacoustic imaging (OAI) can detect haemoglobin and assess its oxygenation. However, the lack of a haemoglobin signal need not indicate a lack of perfusion. This study uses a novel method to assist the co-registration of optoacoustic images with dynamic contrast enhanced ultrasound (DCE-US) images to demonstrate, in preclinical tumour models, the value of combining haemoglobin imaging with a perfusion imaging method, showing that a lack of a haemoglobin signal does not necessarily indicate an absence of perfusion. DCE-US was chosen for this particular experiment because US is extremely sensitive to microbubble contrast agents and because microbubbles, like red blood cells but unlike currently available optical contrast agents, do not extravasate. Significant spatial correlations were revealed between the DCE-US properties and tumour blood-oxygen saturation and haemoglobin, as estimated using OAI. It is speculated that DCE-US properties could be applied as surrogate biomarkers for hypoxia when planning clinical radiotherapy or chemotherapy.

AMC-Bio-Artificial Liver culturing enhances mitochondrial biogenesis in human liver cell lines: The role of oxygen, medium perfusion and 3D configuration

BackgroundHuman liver cell lines, like HepaRG and C3A, acquire higher functionality when cultured in the AMC-Bio-Artificial Liver (AMC-BAL). The three main differences between BAL and monolayer culture are the oxygenation (40% vs 20%O2), dynamic vs absent medium perfusion and 3D vs 2D configuration. Here, we investigated the background of the differences between BAL-cultures and monolayers. MethodsWe performed whole-genome microarray analysis on HepaRG monolayer and BAL-cultures. Next, mitochondrial biogenesis was studied in monolayer and BAL-cultures of HepaRG and C3A. The driving forces for mitochondrial biogenesis by BAL-culturing were investigated in representative culture models differing in oxygenation level, medium flow or 2D vs 3D configuration. ResultsGene-sets related to mitochondrial energy metabolism were most prominently up-regulated in HepaRG-BAL vs monolayer cultures. This was confirmed by a 2.4-fold higher mitochondrial abundance with increased expression of mitochondrial OxPhos complexes. Moreover, the transcript levels of mitochondria-encoded genes were up to 3.6-fold induced and mitochondrial membrane potential activity was 8.3-fold increased in BAL vs monolayers. Culturing with 40% O2, dynamic medium flow and/or in 3D increased the mitochondrial abundance and expression of mitochondrial complexes vs standard monolayer culturing. The stimulatory effect of the BAL culture on mitochondrial biogenesis was confirmed in C3A cells in which mitochondrial abundance increased 2.2-fold with induction of mitochondria-encoded genes. Conclusions and general significanceThe increased functionality of liver cell lines upon AMC-BAL culturing is associated with increased mitochondrial biogenesis. High oxygenation, medium perfusion and 3D configuration contribute to the up-regulation of the mitochondrial biogenesis.

Advantages of abdominal ultrasound in the management of infants with necrotizing enterocolitis.

Fifty-one consecutive infants with stage Ia to IIIa NEC were prospectively included in the study between 2013 and July 2016. At least one abdominal US examination was performed in each patient. According to abdominal color Doppler US, neonates with NEC Ia stage in most cases (80%) found increased bowel wall perfusion. For the stage IIa typical signs were intramural gas and decreased bowel peristalsis. Patients in IIb stage had bowel wall thinning (less than 1mm), decreased or absence of bowel peristalsis and absence of perfusion. In stage IIIa 71% of the cases had absence of bowel peristalsis and intramural gas. Absence of perfusion and bowel wall thinning less than 1mm was found in 86% of neonates. One patient had portal venous gas. Nine patients with IIb and seven neonates with IIIa stage of NEC had laparotomy. In all 16 cases, US signs of bowel wall necrosis were verified intraoperative. US provides an opportunity to image the bowel loops in cross section with dynamic evaluation of perfusion and peristalsis. Our study shows that abdominal US examination in neonates with NEC can highlight the presence of intestinal necrosis before the onset of intestinal perforation. Surgically intervening earlier in the clinical pathway of NEC may lead to improved outcomes.

A New Proposal for Management of Severe Frostbite in the Austere Environment

Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations.

Embryonic Stem Cells Cultured in Microfluidic Chambers Take Control of Their Fate by Producing Endogenous Signals Including LIF.

It is important to understand the role played by endogenous signals in shaping stem cell fate decisions to develop better culture systems and to improve understanding of development processes. In this study, we describe the behavior of mouse embryonic stem cells (mESCs) inside microfluidic chambers (microchambers) operated under conditions of minimal perfusion. mESCs inside microchambers formed colonies and expressed markers of pluripotency in the absence of feeders or pluripotency-inducing signals such as leukemia inhibitory factor (LIF), while mESCs in standard cultureware differentiated rapidly. In a series of experiments, we demonstrate that remarkable differences in stem cell phenotype are due to endogenous production of LIF and other growth factors brought upon by cultivation in confines of a microchamber in the absence of perfusion (dilution). At the protein level, mESCs produced ∼140 times more LIF inside microchambers than under standard culture conditions. In addition, we demonstrate that pluripotent phenotype of stem cells could be degraded by increasing the height (volume) of the microchamber. Furthermore, we show that inhibition of LIF in microchambers, via the JAK/STAT3 pathway, leads to preferential differentiation into mesoderm that is driven by bone morphogenetic protein (BMP)-4. Collectively, we demonstrate for the first time that it is possible to design a cell culture system where stem cell fate is controlled solely by the endogenous signals. Our study may help shift the paradigm of stem cell cultivation away from relying on expensive exogenous molecules such as growth factors and toward designing culture chambers for harnessing endogenous signals. Stem Cells 2016;34:1501-1512.

Effect of Ischemia Duration and Door-to-Balloon Time on Myocardial Perfusion in ST-Segment Elevation Myocardial Infarction: An Analysis From HORIZONS-AMI Trial (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction).

This study sought to investigate the effect of treatment delay on microvascular reperfusion in ST-segment elevation myocardial infarction (STEMI) patients from the large, multicenter, prospective HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) trial. Despite restoration of epicardial blood flow during primary percutaneous coronary intervention (PCI), one-third of patients do not obtain myocardial perfusion due to impairment in the microvascular circulation. We examined the effect of symptom onset-to-balloon time (SBT) and door-to-balloon time (DBT) on myocardial reperfusion during primary PCI in STEMI, utilizing resolution of ST-segment elevation (STR) and the myocardial blush grade (MBG). The primary analysis was the relationships between SBT ≤2, >2 to 4, and >4 h and DBT ≤1, >1 to 1.5, >1.5 to 2, and >2 h with MBG and STR. Clinical risk was assessed using a modified version of the Thrombolysis In Myocardial Infarction risk score for STEMI. In 2,056 patients, absent microvascular perfusion (MBG 0/1) and STR (STR <30%) after primary PCI was significantly more common in patients with longer SBT, in patients with both low and high clinical risk profiles. By multivariable analysis, SBT (p < 0.0001), anterior infarction (p < 0.0001), reference vessel diameter (p = 0.005), lesion minimum lumen diameter (p < 0.0001), hyperlipidemia (p = 0.03), and current smoking (p = 0.001) were independent predictors of MBG 0/1, whereas SBT (p = 0.007), anterior infarction (p < 0.0001), and history of renal insufficiency (p = 0.0002) were independent predictors of absent STR. DBT (p < 0.0001) was an independent predictor of MBG 0/1. MBG 0/1 and STR<30% identified patients with increased 3-year mortality. The present study suggests that delay in mechanical reperfusion therapy during STEMI is associated with greater injury to the microcirculation.

Abstract 16907: A Light-powered Symbiosis With a Primordial Chloroplast Attenuates Myocardial Injury in the Absence of Blood Perfusion

Objective: The treatment for acute myocardial infarction (MI) is prompt revascularization. Our goal is to develop a novel therapy that mimics perfusion, but is not reliant on restitution of blood flow. We hypothesized that targeted delivery of a photosynthetic agent to the ischemic heart would restore myocardial energetics, attenuate damage, and improve long-term performance. Methods: Ten-week old male Wistar rats were used for the ischemia-reperfusion model. The left anterior descending artery (LAD) was temporarily ligated 2mm below the left atrial appendage via a left thoracotomy. Following ligation, animals were randomized to receive direct intramyocardial injection of 200μL PBS (n=7), 10x10 6 photosynthetic Synechecoccus elongatus (SE) of equivalent volume (n=10), or sham surgery (n=7). A light source illuminated the ischemic region for 1 hr after injection. The LAD tourniquet was subsequently removed and the heart reperfused. Ventricular function, geometry, and hemodynamics were assessed 4 weeks after surgery with MRI and LV catheterization. Results: Myocardial injury was attenuated by the photosynthetic agent: troponin-I concentration in peripheral blood was significantly lower in SE treated animals compared with controls 24 hrs post MI (6.5±4.8 vs. 16.5±10.5 ng/mL, P =0.05). Four weeks after MI, the mean LV ejection fraction was significantly greater in SE treated rats compared with controls (36.9±4.7 vs. 48.3±10.5%, P =0.02). Similarly, SE treated animals demonstrated a decreased end-systolic volume (327±133 vs. 487±140 μL, P =0.03) and a steeper slope of the end-systolic pressure-volume relationship (0.35±0.12 vs. 0.19±0.08, P =0.01). Histologic analyses revealed no evidence of intramyocardial abscess formation or persistent SE. Furthermore, the photosynthetic agent prevented upregulation of genes associated with hypoxia (downregulated Hsp-1b 11 fold). Conclusions: Delivery of a photosynthetic agent to ischemic myocardium creates a localized symbiotic relationship that safely attenuates myocardial injury and improves long-term ventricular function in a rat model of ischemia-reperfusion. Energizing myocardium with light in the absence of perfusion is a completely novel strategy for treating cardiac ischemia.

Impact of Nonalcoholic Fatty Liver Disease on Myocardial Perfusion in Nondiabetic Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Limited data exist on the role of nonalcoholic fatty liver disease (FLD) as a potential independent risk factor in the setting of acute coronary syndromes. The aim of this study was to evaluate the impact of FLD on myocardial perfusion and inhospital major adverse cardiac events (MACE) in the setting of ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). We examined 186 consecutive nondiabetic patients (mean age 58 ± 11 years and 76% men) who underwent primary PCI for STEMI by ultrasound within 72 hours of admission. FLD was graded according to a semiquantitative severity score as mild (score <3) or moderate to severe (score ≥3). Myocardial perfusion was determined by measuring myocardial blush grade (MBG) and ST-segment resolution (STR) analysis. Patients were divided into 2 groups according to FLD score (<3 or ≥3). There were no differences with regard to postprocedural Thrombolysis In Myocardial Infarction 3 flow grade between the 2 groups (89% vs 83%, p = 0.201). Patients with FLD score ≥3 were more likely to have absent myocardial perfusion (MBG 0/1, 37% vs 12%, p <0.0001), absent STR (27% vs 9%, p = 0.001), and higher inhospital MACE rate (31% vs 8%, p <0.0001). By multivariate analysis, FLD ≥3 score was found to be an independent predictor of absent MBG 0/1 (odds ratio [OR] 2.856, 95% confidence interval [CI] 1.214 to 6.225, p = 0.033), absent STR (OR 2.862, 95% CI 1.242 to 6.342, p = 0.031), and inhospital MACE (OR 2.454, 95% CI 1.072 to 4.872, p = 0.048). In conclusion, we found that despite similar high rates of Thrombolysis In Myocardial Infarction 3 after primary PCI, patients with FLD score ≥3 are more likely to have impaired myocardial perfusion which may contribute to adverse inhospital outcome.

Evaluation of cardiac masses by real-time perfusion imaging echocardiography.

BackgroundDiagnosis of cardiac masses is still challenging by echocardiography and distinguishing tumors from thrombi has important therapeutical implications. We sought to determine the diagnostic value of real-time perfusion echocardiography (RTPE) for cardiac masses characterization.MethodsWe prospectively studied 86 patients, 23 with malignant tumors (MT), 26 with benign tumors (BT), 33 with thrombi and 6 with pseudotumors who underwent RTPE. Mass perfusion was analyzed qualitatively and blood flow volume (A), blood flow velocity (β), and microvascular blood flow (A x β) were determined by quantitative RTPE.ResultsLogistic regression models showed that the probability of having a tumor increased by 15.8 times with a peripheral qualitative perfusion pattern, and 34.5 times with a central perfusion pattern, in comparison with the absence of perfusion. Using quantitative RTPE analysis, thrombi group had parameters of blood flow lower than tumor group. A values for thrombi, MT, and BT were 0.1 dB (0.01-0.22), 2.78 dB (1–7) and 2.58 dB (1.44-5), respectively; p < 0.05, while A x β values were 0.0 dB/s−1 (0.01–0.14), 2.00 dB/s−1 (1–6), and 1.18 dB/s−1 (0.52–3), respectively; p < 0.05. At peak dipyridamole stress, MT had greater microvascular blood volume than BT [A = 4.18 dB (2.14-7.93) versus A = 2.04 dB (1.09-3.55); p < 0.05], but no difference in blood flow [Axβ = 2.46 dB/s−1 (1.42–4.59) versus Axβ = 1.55 dB/s [1] (0.51-4.08); p = NS]. An A value >3.28 dB at peak dipyridamole stress predicted MT (AUC = 0.75) and conferred 5.8-times higher chance of being MT rather than BT.ConclusionRTPE demonstrated that cardiac tumors have greater microvascular blood volume and regional blood flow when compared with thrombi. Dipyridamole stress was useful in differentiating MT from BT.

Moderated Poster Session 5.

), and its variation gradients (D=D3-D1) as an estimation of the intensity of the cell inflammatory response. For each laboratorial parameter the increasing D values were graded in 50%. MCE study was performed at D3 post ACS with a C256 and 512 Sequoia (Acuson Siemens, Germany) ultrasound machines after intravenous SonoVue® (Bracco, Rovi)continuous infusion during 3´, intermitent digital MCE imag- ing acquisition, Dt=175 ms, Tec imaging condition, and PCI software, with the acquisition of destruction/perfusion sequential images. The MCE pat- tern was classsified in 16 LV wall segments as normal (P0), late filling (P1), heterogeneous (P2) and absence of perfusion (P3), the mean value/pt, per- cent distrubution (%) and the correspondent segmental perfusion index (SPI) were calculated. Results: We observed a direct relationship between SPI and hs-CRP (r=0.44; p=0.01) and DCD40 (r=0.51; p=0.01). Linear regression and multiple corre- lation analysis were applied between hs-CRP and the different MCE pat- terns, with P1/pt (r=0.37; p=0.01), P2/pt (r=0.53; p<0.01) and between CD40 and P1/pt (r=0.42; p=0.01) and P2/pt (r=0.56; p<0.01). Conclusions: In this study we obtained a direct relationship between the intensity of the cell inflammatory response post ACS evaluated by serum markers and the extension of the LV myocardial ischemic area by MCE. This relationship was more significant for the late filling and patchy MCE pat- terns, revealing the presence of a greater myocardial area at risk post ACS by this new non invasive technique.

A New Approach Using Manganese-Enhanced MRI to Diagnose Acute Mesenteric Ischemia in a Rabbit Model: Initial Experience.

Purpose. Manganese-enhanced MRI (MEMRI) has been applied to a wide range of biological and disease research. The purpose of the study was to use MEMRI to diagnose the acute mesenteric ischemia (AMI). Methods. The institutional experimental animal ethics committee approved this study. To optimize the dose of Mn2+ infusion, a dose-dependent curve was obtained using Mn2+-enhanced T 1 map MRI by an intravenous infusion 2.5–20 nmol/g body weight (BW) of 50 nmol/L MnCl2. The eighteen animals were divided into control, sham-operated, and AMI groups. AMI models were performed by ligating the superior mesenteric artery (SMA). T 1 values were measured on T 1 maps in regions of the small intestinal wall and relaxation rate (ΔR 1) was calculated. Results. A nonlinear relationship between infused MnCl2 solution dose and increase in small intestinal wall ΔR 1 was observed. Control animal exhibited significant Mn2+ clearance over time at the dose of 15 nmol/g BW. In the AMI model, ΔR 1 values (0.95 ± 0.13) in the small intestinal wall were significantly lower than in control group (2.05 ± 0.19) after Mn2+ infusion (P < 0.01). Conclusion. The data suggest that MEMRI shows potential as a diagnostic technique that is directly sensitive to the poor or absent perfusion in AMI.

Application of high-frequency ultrasonography in closing small blood vessels.

One of the most common treatments performed in phlebological and aesthetic medicine clinics is closing small blood vessels in the lower extremities, so-called telangiectasias and reticular vessels. Currently, there are several methods that allow for closing the dilated vessels and obtaining desirable effects, both therapeutic and aesthetic. Unfortunately, despite applying various methods and instruments, the effects of treatments are frequently not satisfactory. The factor that largely contributes to decreasing the efficacy of such procedures is complicated anatomy of the venous system and the lack of a method to precisely specify the vessel's course, its diameter, location in the skin etc. High-frequency ultrasonography is a method enabling accurate determination of the vessels’ course as well as the measurement of their basic parameters, such as diameter, depth in the skin and presence or absence of perfusion. Thanks to ultrasound imaging with the use of high-frequency transducers, an adequate treatment method and procedure parameters may be selected, which entails enhancing the efficacy of the procedure itself. Ultrasonography may be also used for monitoring the performed procedures.

Diversity of Retinal Vascular Anomalies in Patients with Familial Exudative Vitreoretinopathy

To describe the diversity of clinical findings associated with familial exudative vitreoretinopathy (FEVR) using wide-field angiography and to update the current classification system. Retrospective case series at a single tertiary referral vitreoretinal practice. A total of 174 eyes of 87 subjects were studied. A retrospective chart review was conducted of patients with a diagnosis of FEVR between January 2011 and January 2013 at a single tertiary care retina practice. Data were collected from patient charts, including sex, gestational age at birth, age at presentation, referring diagnosis, family history, prior ocular surgery, clinical presentation, and diagnostic imaging in each eye. Inclusion criteria included clinical diagnosis of FEVR in patients referred to our clinic for evaluation of decreased vision. Patients were excluded if a diagnosis of FEVR could not be made. Clinical and angiographic findings. A total of 87 subjects met the inclusion criteria for this study. A broad spectrum of previously undescribed clinical and angiographic findings were associated with FEVR on wide-field angiography. These findings can be grossly divided into anatomic and functional changes. Anatomic changes include aberrant circumferential peripheral vessels, venous and arterial tortuosity, late-phase disc leakage, central and peripheral telangiectasias, capillary anomalies, and capillary agenesis. Functional changes include venous-venous shunting, delayed arteriovenous transit, and delayed or absent choroidal perfusion on fluorescein angiography. Familial exudative vitreoretinopathy has a wide range of unrecognized or under-recognized clinical and angiographic findings that are easily identified using wide-field fluorescein angiography. These novel findings have led to an update of the original FEVR classification scheme and more complete characterization of early stages of FEVR.

Symptom Relief After Large-Volume Thoracentesis in the Absence of Lung Perfusion

The physiologic basis for relief from dyspnea after therapeutic thoracentesis remains poorly understood. Here, we describe the case of a 46-year-old man with large recurrent pleural effusion with absent perfusion to the affected lung who experienced dramatic dyspnea relief after large-volume thoracentesis. This patient's improvement in breathlessness cannot be attributed to improved gas exchange and suggests the primary physiologic basis for the relief in dyspnea is a change in respiratory system mechanics or work of breathing.

Specialist hospital study shows that septic shock and drowsiness predict mortality in children under five with diarrhoea

To evaluate the clinical characteristics and outcome in children hospitalised with diarrhoea, comparing those developed septic shock with those who did not. We carried out a retrospective chart review on children aged 0-59 months admitted to the Dhaka Hospital, International Centre for Diarrhoeal Diseases Research, Bangladesh, with diarrhoea between October 2010 and September 2011. They were included if they had severe sepsis defined as tachycardia plus hyperthermia or hypothermia or an abnormal white blood cell count plus poor peripheral perfusion in absence of dehydration. Patients unresponsive to fluid and boluses, who required inotropes, were categorised as having septic shock (n = 88). The controls were those without septic shock (n = 116). Death was significantly higher among the children with septic shock (67%) than the controls (14%) (p < 0.001). A logistic regression analysis, adjusted for potential confounders, found that children with septic shock were more likely to be drowsy on admission and received blood transfusions and mechanical ventilation (all p < 0.05). Children hospitalised for diarrhoea with septic shock were more likely to die, be drowsy on admission and receive blood transfusions and mechanical ventilation. A randomised clinical trial on inotropes in children with diarrhoea, severe sepsis and drowsiness may expedite their use and prevent mechanical ventilation and deaths.

A prospective comparison of intestinal sonography and abdominal radiographs in a neonatal intensive care unit

No study reported in the literature comprehensively compares findings on neonatal abdominal radiographs with sonography. To compare the findings on abdominal radiographs and sonograms in infants in intensive care, to better understand how the various intestinal gas patterns on radiographs relate to the spectrum of appearances on sonography and, second, to evaluate the ability of sonography to differentiate necrotizing enterocolitis from other intestinal pathology. We prospectively evaluated sonograms and radiographs, blinded to the other modality and to clinical information. Patients' charts were reviewed by a third blinded reader and used as a reference standard for diagnosis. We made associations between sonographic findings, radiographic intestinal gas patterns and clinical diagnoses. We included 75 infants with gestational ages between 23 weeks and 41 weeks. Sonographic abnormalities were present in infants with all radiographic intestinal gas patterns, including normal patterns. We only saw absent intestinal perfusion and fluid collections on sonography (suggesting intestinal necrosis and sealed perforation) in infants with intestinal dilatation with elongation on radiographs. Separation of intestinal loops on radiographs was most commonly caused by reasons other than intestinal wall thickening. Increased intestinal echogenicity or free fluid with echoes on sonography correlated with a diagnosis of necrotizing enterocolitis, whereas anechoic free fluid correlated with absence of necrotizing enterocolitis. Sonography is complementary to radiographs in infants with suspected intestinal pathology, with a spectrum of appearances seen on each modality. Some sonographic findings either strongly suggest necrotizing enterocolitis or supply evidence against this diagnosis.