Perfusion Volume Research Articles

Avoid Always and Never

Avoid <i>Always</i> and <i>Never</i>

Monitoring perfusion and oxygen saturation in port-wine stains during vascular targeted photodynamic therapy.

BackgroundVascular targeted photodynamic therapy (V-PDT) is a safe and effective therapeutic modality for port-wine stains (PWS) by targetedly damaging the dilated and malformed blood vessels. This study aims to monitor and quantify the changes in oxygen saturation (StO2), blood volume fraction (BVF) and perfusion in PWS lesions before and during V-PDT.MethodsMicrovascular parameters (i.e., StO2 and BVF) and skin perfusion were measured noninvasively by using diffuse reflectance spectroscopy (DRS) and laser Doppler imaging (LDI), respectively. The change in StO2, BVF and perfusion that occurred in the PWS lesions of 26 patients were monitored and investigated before and during V-PDT in vivo with the systematic administration of the porphyrin-based photosensitizer HiPorfin.ResultsThe mean StO2 (P<0.05), BVF (P<0.05), and perfusion (P<0.001) in PWS lesions of all subjects significantly increased by 6%, 34%, and 113%, respectively, 3 min after the initiation of V-PDT. The StO2 increased first and fluctuated during V-PDT. The overall trend of BVF change was consistent with the perfusion change. The BVF and the perfusion of PWS lesions increased after the initiation of V-PDT, and then gradually decreased.ConclusionsV-PDT is an effective therapeutic modality in treating PWS. Results showed that LDI and DRS permitted the noninvasive monitoring of the changes in StO2, BVF, and perfusion in PWS lesions during V-PDT, and these methods can be useful in facilitating our understanding of the basic physiological mechanisms during V-PDT.

Diagnostic performance of dynamic volume perfusion CT for differentiation of head and neck cancer from healthy tissue and post-therapeutic changes.

Post-therapeutic tissue is bradytrophic and thus has low perfusion values in PCT. In contrast, malignant tissue is expected to show higher perfusion values as cancer growth partially depends on angiogenesis. This prospective study investigates perfusion computed tomography (PCT) for the post-therapeutic detection of cancer in the head and neck region. 85 patients underwent PCT for 1) initial work-up of head and neck cancer (HNC; n=22) or 2) for follow-up (n=63). Regions of interest (ROIs) were placed in confirmed tumour, a corresponding location of benign tissue, and reference tissue. Perfusion was calculated using a single input maximum slope algorithm. Statistical analysis was performed with the Mann-Whitney U-test. PCT allowed significant differentiation of malignant tissue from post-therapeutic tissue after treatment for HNC (p=0.018). Significance was even greater after normalization of perfusion values (p=0.007). PCT allowed highly significant differentiation of HNC from reference tissue (p<0.001). PCT provides significantly distinct perfusion values for malignant and benign as well as post-therapeutically altered tissue in the head and neck area, thus allowing differentiation of cancer from healthy tissue. Our results show that PCT in conjunction with a standard algorithm is a potentially powerful HNC diagnostic tool.

A prospective randomized controlled clinical study on the optimal treatment interval of pulsed dye laser in treating hypertrophic scar after burn

Objective: To observe the influence of different treatment intervals of pulsed dye laser (PDL) in treating hypertrophic scar after burn, and to explore the optimal treatment interval. Methods: From May 2018 to March 2019, 20 burn patients who met the inclusion criteria and were admitted to the First Affiliated Hospital of Air Force Medical University were included in this prospective randomized controlled study. Patients were divided into 1 week group (4 patients, 2 males and 2 females, aged 27 (4, 67) years, 19 scars), 2 weeks group (5 patients, 2 males and 3 females, aged 9 (3, 55) years, 15 scars), 3 weeks group (5 patients, 4 males and 1 female, aged 26 (19, 45) years, 15 scars), and 4 weeks group (6 patients, 4 males and 2 females, aged 31 (14, 48) years, 13 scars), according to the random number table, and treated with PDL with the treatment intervals of 1 week, 2 weeks, 3 weeks, and 4 weeks, respectively, with total treatment cycle of 3 months. Before the first treatment and three months after the first treatment, the Vancouver Scar Scale (VSS) was conducted and the decreased value of VSS score was calculated; the laser Doppler blood flow meter was used to measure scar blood perfusion and the proportion of change in blood perfusion volume was calculated. Data were statistically analyzed with Kruskal-Wallis test, Wilcoxon rank sum test, Wilcoxon symbolic rank sum test, Bonferroni correction, and Fisher's exact probability test. Results: The VSS scores of patients in 1 week group, 2 weeks group, 3 weeks group, and 4 weeks group in three months after the first treatment were significantly lower than those before the first treatment (Z=-3.74, -3.47, -2.69, -3.25, P<0.01). There were no statistically significant differences in the decreased values of VSS scores in three months after the first treatment among the patients in 4 groups (H=2.35, P>0.05). Three months after the first treatment, the blood perfusion volumes of patients in 2 weeks group and 3 weeks group were significantly lower than those before the first treatment (Z=-2.95, -2.50, P<0.05 or P<0.01). The proportions of changes in blood perfusion volume of patients in 1 week group, 2 weeks group, 3 weeks group, and 4 weeks group were respectively -0.02 (-1.05, 0.69), -0.29 (-0.75, 0.18), -0.11 (-0.55, 0.23), 0.05 (-0.61, 0.75). There were statistically significant differences among the 4 groups (H=9.39, P<0.05). The proportions of changes in blood perfusion volume of patients in 2 weeks group was statistically higher than that of 1 week group (Z=2.76, P<0.01). Conclusions: PDL treatment can reduce the VSS score and blood perfusion volume of scar. One treatment every two weeks or three weeks improve the scar blood perfusion volume more significantly, and can be recommended as the appropriate treatment interval of PDL for hypertrophic scar after burn.

Quantitative assessment of pulmonary artery occlusion using lung dynamic perfusion CT

Quantitative measurement of lung perfusion is a promising tool to evaluate lung pathophysiology as well as to assess disease severity and monitor treatment. However, this novel technique has not been adopted clinically due to various technical and physiological challenges; and it is still in the early developmental phase where the correlation between lung pathophysiology and perfusion maps is being explored. The purpose of this research work is to quantify the impact of pulmonary artery occlusion on lung perfusion indices using lung dynamic perfusion CT (DPCT). We performed Lung DPCT in ten anesthetized, mechanically ventilated juvenile pigs (18.6–20.2 kg) with a range of reversible pulmonary artery occlusions (0%, 40–59%, 60–79%, 80–99%, and 100%) created with a balloon catheter. For each arterial occlusion, DPCT data was analyzed using first-pass kinetics to derive blood flow (BF), blood volume (BV) and mean transit time (MTT) perfusion maps. Two radiologists qualitatively assessed perfusion maps for the presence or absence of perfusion defects. Perfusion maps were also analyzed quantitatively using a linear segmented mixed model to determine the thresholds of arterial occlusion associated with perfusion derangement. Inter-observer agreement was assessed using Kappa statistics. Correlation between arterial occlusion and perfusion indices was evaluated using the Spearman-rank correlation coefficient. Our results determined that perfusion defects were detected qualitatively in BF, BV and MTT perfusion maps for occlusions larger than 55%, 80% and 55% respectively. Inter-observer agreement was very good with Kappa scores > 0.92. Quantitative analysis of the perfusion maps determined the arterial occlusion threshold for perfusion defects was 50%, 76% and 44% for BF, BV and MTT respectively. Spearman-rank correlation coefficients between arterial occlusion and normalized perfusion values were strong (− 0.92, − 0.72, and 0.78 for BF, BV and MTT, respectively) and were statically significant (p < 0.01). These findings demonstrate that lung DPCT enables quantification and stratification of pulmonary artery occlusion into three categories: mild, moderate and severe. Severe (occlusion ≥ 80%) alters all perfusion indices; mild (occlusion < 55%) has no detectable effect. Moderate (occlusion 55–80%) impacts BF and MTT but BV is preserved.

Structural and microvascular changes in the retina and choroid in patients with chronic kidney disease

To study the main structural and microvascular changes in the retina and choroid in patients with diabetic retinopathy (DR) and chronic kidney disease (CKD), and their relationship with impaired renal function.The study included 158 patients (304 eyes). The 1st group consisted of 50 patients with CKD (97 eyes); group 2 - 65 patients with DR (119 eyes), group 3 - 43 patients with CKD and DR (86 eyes). All study patients underwent complete ophthalmological examination, including optical coherence tomography (OCT) and OCT angiography (OCTA) of the macular region.The analysis of structural parameters in groups of patients showed a decrease in the thickness of the ganglion cell layer and the inner plexiform layer of the retina in patients with DR (70.85±14.49 μm), with the lowest value in the CKD+DR group (65.84±15.34 μm) in comparison with the CKD group (75.64±10.32 μm). In the groups of patients with CKD, the thickness of the choroid (207.3±40.36 μm) was significantly reduced in comparison with the group of patients with DR (258.8±26.63 μm) and correlated with the stage of the disease. Patients in the CKD+DR group had the lowest perfusion and vascular density in the macular region (31.23±10.91% and 13.15±2.73 mm), an increase in the area and perimeter of the foveal avascular zone (0.55±0.26 mm2, 3.30±0.84 mm). Pronounced correlations of decrease in choroidal thickness, vascular density, and perfusion volume with low glomerular filtration rate and CKD stage, as well as urea and creatinine levels were determined. An increase in the area of the foveal avascular zone correlated with lower retinal capillary density, decreased perfusion volume, and the stage of both DR and CKD.Structural and hemodynamic disorders of the retina and choroid can be recognized as significant biomarkers for non-invasive diagnosis of microvascular complications of diabetes mellitus and impaired renal function.Изучить основные структурные и микроваскулярные изменения сетчатки и хориоидеи у пациентов с диабетической ретинопатией (ДР) и хронической болезнью почек (ХБП) и их взаимосвязь с нарушением функции почек.В исследование включены 158 пациентов (304 глаза): 1-я группа — 50 пациентов с ХБП (97 глаз); 2-я группа — 65 пациентов с ДР (119 глаз), 3-я группа — 43 пациента с ХБП+ДР (86 глаз). Пациентам проведено полное офтальмологическое обследование, включающее оптическую когерентную томографию (ОКТ) и ОКТ с ангиографией (ОКТА) макулярной области.Анализ структурных показателей в группах пациентов показал снижение толщины слоя ганглиозных клеток и внутреннего плексиформного слоя сетчатки у пациентов с ДР (70,85±14,49 мкм), с самым низким значением в группе ХБП+ДР (65,84±15,34 мкм) по сравнению с группой ХБП (75,64±10,32 мкм). В группах пациентов с ХБП толщина хориоидеи (207,3±40,36 мкм) была значимо снижена по сравнению с группой пациентов с ДР (258,8±26,63 мкм) и коррелировала со стадией заболевания. У пациентов в группе ХБП+ДР выявлены самые низкие показатели плотности перфузии и сосудов макулярной области (31,23±10,91% и 13,15±2,73 мм соответственно), увеличение площади и периметра фовеальной аваскулярной зоны (0,55±0,26 мм2 и 3,30±0,84 мм соответственно). Определены выраженные корреляции снижения толщины хориоидеи, плотности сосудов и объема перфузии с низкой скоростью клубочковой фильтрации и стадией ХБП, уровнем мочевины и креатинина. Увеличение площади фовеальной аваскулярной зоны коррелировало с более низкой плотностью капилляров сетчатки, сниженным объемом перфузии и стадией как ДР, так и ХБП.Структурные и гемодинамические нарушения сетчатки и хориоидеи могут быть значимыми биомаркерами неинвазивной диагностики микроваскулярных осложнений сахарного диабета и нарушения функции почек.

Relationship between Cerebral Perfusion on Arterial Spin Labeling (ASL) MRI with Brain Volumetry and Cognitive Performance in Mild Cognitive Impairment and Dementia due to Alzheimer's Disease.

Context:Cerebral blood flow (CBF) measurement using arterial spin labelling (ASL) MRI sequences has recently emerged as a prominent tool in dementia research.Aims:To establish association between quantified regional cerebral perfusion and gray matter (GM) volumes with cognitive measures in mild cognitive impairment (MCI) and early Alzheimer's Dementia (AD), using three dimensional fast spin echo pseudo-continuous ASL MRI sequences.Settings and Design:Hospital-based cross-sectional study.Methods and Material:Three age-matched groups, i.e., 21 cognitively normal healthy controls (HC), 20 MCI and 19 early AD patients diagnosed using neuropsychological tests and who consented for multimodality 3T MRI were recruited for the study.Statistical Analysis Used:Statistical parametric mapping and regions of interest (ROI) multivariate analysis of variance was used to ascertain differences between patients and controls on MRI-volumetry and ASL. Linear regression was used to assess relationship between CBF with GM atrophy and neuropsychological test measures.Results:Compared to HC, patients with MCI and AD had significantly lower quantified perfusion in posterior cingulate and lingual gyri, over hippocampus in MCI, with no differences noted between MCI and AD. Atrophy over the middle temporal gyrus and hippocampus differentiated AD from MCI. No significant positive correlations were noted between perfusion and GM volumes in ROI with the exception of temporal neocortex. Significantly positive coefficient b-value (p < 0.01) were apparent between global cognition with CBF in precuneus, temporal neocortex and precuneus volume, with negative b-values noted between medial temporal CBF for global cognition and recall scores.Conclusions:ROI-based CBF measurements differentiated MCI and AD from HC; volumetry of medial and neocortical temporal GM separates AD from MCI. Correlations between CBF and neuropsychology are variable and require further longitudinal studies to gauge its predictive utility on cognitive trajectory in MCI.

Brain Perfusion, Hippocampal Volumetric, and Diffusion-weighted Imaging Findings in Children with Prolonged Febrile Seizures and Focal Febrile Seizures.

ABSTRACTBackground:The current study was conducted to describe the findings of brain perfusion, hippocampal volumetric, and diffusion-weighted imaging (DWI) in children aged six months to seven years with febrile status epilepticus (FSE) and focal febrile seizures (FFS) when compared with age and gender-matched controls.Materials and Methods:This cross-sectional study was conducted among children aged six months to seven years presenting with FSE or FFS within 72 h of the seizure. Cases were subjected to magnetic resonance imaging (MRI) brain and sleep-deprived electroencephalography. Age and gender-matched children who were subjected to MRI brain for nonepileptic indications served as their control. Hippocampal volumes, T2 values, cerebral blood flow, and diffusion characteristics were compared between the cases and controls and also between those with FSE and FFS.Results:A total of 31 cases (FFS = 20, FSE = 11) and 30 controls were enrolled. There was no significant difference between right and left hippocampal volumes and T2 relaxometry values between cases and controls and also between children with FSE and FFS. Similarly, the cerebral blood flow was also comparable in cases and controls. There was a single case of FSE with hippocampal malrotation; one child showed diffusion restriction in the hippocampus after prolonged (>60 min) FSE.Conclusion:Children with FSE and FFS had comparable hippocampal volume and brain perfusion to healthy children. However, one child with FSE had hippocampal malrotation and another had diffusion restriction. The study findings need to be interpreted in the context of small sample size, and lack of follow-up neuroimaging.

Biventricular Physiology of Iatrogenic Atrial Septal Defects Following Transcatheter Mitral Valve Edge-to-Edge Repair.

The study sought to assess the acute hemodynamic effects of iatrogenic atrial septal defect (iASD) closure following transcatheter mitral valve edge-to-edge repair (TMVR). The potential hemodynamic and clinical consequences of an iASD following TMVR are currently subject to controversial debates. In 21 patients with relevant left-to-right shunt flow (50% [IQR: 38% to 60%] of systemic perfusion volume) across an iASD following TMVR, interventional closure was performed with recordings of left ventricular (LV) and right ventricular (RV) pressure-volume loops during iASD occlusion. iASD occlusion led to a volume shift from the RV (RV end-diastolic volume index: pre 102 [IQR: 80 to 120] ml/m2, post 92 [IQR: 70 to 111] ml/m2; p<0.001) to the LV (LV end-diastolic volume index: pre 91 [IQR: 74 to 124] ml/m2, post 97 [IQR: 77 to 127] ml/m2; p<0.001) with reduced RV (3.49 [IQR: 2.07 to 3.58] l/min/m2 vs. 2.68 [IQR: 2.07 to 3.58] l/min/m2; p<0.001) but increased LV cardiac index (2.25 [IQR: 1.80 to 3.28] l/min/m2 vs. 2.77 [IQR: 1.90 to 3.34] l/min/m2; p=0.039). Although RV end-diastolic pressure decreased (pre 5.0 [IQR: 4.0 to 8.5] mmHg, post 4.5 [IQR: 3.0 to 8.3] mmHg; p=0.024), LV end-diastolic pressure remained unchanged (pre 11.0 [IQR: 9.5 to 14.0] mmHg, post 13.0 [IQR: 9.0 to 15.5] mmHg; p=0.142). LV transmural pressure increased (7.0 [IQR: 4.0 to 11.0] mmHg vs. 11.0 [IQR: 7.0 to 15.0] mmHg; p=0.001) and LV eccentricity index decreased (p<0.001). The change in LV transmural pressure correlated significantly with the change in LV-to-RV end-diastolic volume ratio (r=0.674; p=0.018). Right heart failure symptoms declined at 1-month follow-up (71% vs. 35%; p=0.003) as did New York Heart Association functional class (≥III: 48% vs. 25%; p<0.001). iASD closure following TMVR leads to a volume shift from the RV to the LV with reduced pulmonary but increased systemic cardiac index and with favorable biventricular interaction at maintained LV filling pressure, resulting in a decline in heart failure symptoms at 1-month follow-up.

Application of ultrasonic shear wave elastography and contrast-enhanced ultrasound in the differential diagnosis of patients with benign and malignant thyroid lesions.

Thyroid nodules are a common thyroid disorder. The aim of the present study was to observe the application value of ultrasonic shear wave elastography (SWE) and contrast-enhanced ultrasound (CEUS) in the differential diagnosis of patients with benign and malignant thyroid lesions. Eighty-two patients with thyroid nodules (96 thyroid nodules) at our hospital were enrolled. All patients underwent ultrasonic SWE and CEUS examination. With surgical pathology as the gold standard, the Young's modulus, CEUS imaging features, and quantitative parameters were compared between the benign and malignant groups. The diagnostic efficiency of SWE, CEUS, and their combination was analyzed by receiver-operating characteristic curve (ROC). The average of the Young's modulus in the malignant group was significantly higher than that of the benign group (P<0.05). There were significant differences in the CEUS images of nodules between the benign and malignant groups in terms of boundary conditions, morphology, perfusion intensity, homogeneous enhancement, and perfusion defects (P<0.05), while there were no significant difference in initial increase time, peak intensity, time to peak, and area under the curve (P>0.05). The curve sharpness in the benign group was significantly lower than that of the malignant group (P<0.05). ROC analysis found that the diagnostic sensitivity and specificity of SWE, CEUS, and their combination were 90.1% and 81.6%, 67.8% and 75.4%, and 97.3% and 71.5%, respectively. Compared with CEUS, the sensitivity and specificity of SWE were relatively higher in the differential diagnosis of benign and malignant thyroid lesions, and a combination of both can improve the diagnostic sensitivity of SWE alone to a certain extent.

Study on the acupoints belonging to the three yin meridians of foot reflecting the variation pattern of uterine qi and blood in women with moderate constitution

To observe the blood perfusion volume variation pattern in the body surface microcirculation at the Yuan-Primary and the Xi-Cleft points during the menstrual cycle in female college students with moderate constitution under normal physiological state of the uterus; to explore the specific laws of the body surface microcirculation at the Yuan-Primary and Xi-Cleft points in response to the uterine qi and blood changes under normal physiological conditions, and to provide the experimental basis for the specificity of acupoints reflecting the uterine function. Forty-three healthy and moderate constitution female college students with regular menstrual cycles, without dysmenorrhea and not yet giving birth were recruited. Bilateral Yuan-Primary points [Taichong (LR 3), Taibai (SP 3) and Taixi (KI 3)] and Xi-Cleft points [Zhongdu (LR 6), Diji (SP 8) and Shuiquan (KI 5)], belonging to the three yin meridians of foot and adjacent to the spinal cord segment of the uterus, were selected as the detection acupoints; the crossing point of the three yin meridians of foot [Sanyinjiao (SP 6)], the uterus-related meridian acupoint [Xuehai (SP 10)], the uterus-non-related meridian acupoint [Xuanzhong (GB 39)], and the non-meridian non-acupoint point were selected as the control points. The laser speckle blood flow imaging technique was used to monitor the blood perfusion volume in skin microcirculation at the above points at the menstrual, follicular, ovulatory, and luteal phases of the subjects. The blood perfusion volume in the body surface microcirculation at the right Zhongdu (LR 6) at the ovulatory phase was higher than that at the menstrual, follicular and luteal phases (all P<0.05); there was no significant difference in the microcirculation blood perfusion volume at the other points among different phases (all P<0.05). The blood perfusion volume in the body surface microcirculation at Zhongdu (LR 6), the Xi-Cleft point of the Liver Meridian, shows a specific response to qi and blood changes in the uterus of women with moderate constitution.

MRI wrist in early rheumatoid arthritis: reduction in inflammation assessed quantitatively during treatment period correlates best with clinical improvement.

To investigate (a) which MR features of inflammation (synovitis, tenosynovitis, perfusion) correlate with clinical/serological features in early rheumatoid arthritis (ERA) before, during and after 1year of treatment and (b) whether quantitative or semi-quantitative measures of inflammation on magnetic resonance imaging (MRI) provides the highest correlation in this regard. One hundred one ERA patients (76 females, 25 males, mean age, 53 ± 12years) underwent clinical/serological testing and 3T dynamic contrast-enhanced MRI of the most symptomatic wrist. Seventy-seven of the 101 patients completed 1year of treatment, followed by repeat MR examination. Clinical/serological parameters were correlated with semi-quantitative/quantitative MR measures of inflammation at baseline, during and after 1year of treatment. Spearman's correlation was applied. Quantitative measures of inflammation correlated better with clinical/serological parameters than semi-quantitative measures, with the highest correlations being for relative change during treatment. Pain reduction correlated with reduced tenosynovitis volume (r = 0.41). Reduction in disease activity correlated with reduction in synovitis volume (r = 0.66) or synovial perfusion parameters (r = 0.58). Decrease in early morning stiffness correlated with decrease in perfusion parameters (r = 0.46). Reduction in ESR and CRP correlated with decrease in synovial volume (r = 0.40 and r = 0.41, respectively). In ERA patients, quantitative assessment of inflammation on MRI correlated better with clinical parameters than semi-quantitative assessment. Relative change during treatment yielded the highest correlation. Decrease in tenosynovitis correlated best with reduction in pain while decrease in synovitis volume and perfusion correlated best with reduction in disease activity, early morning stiffness (perfusion), or serological parameters (synovitis volume).

Methylene blue usage for determining accessory artery ligation in donor kidneys.

Objectives. We present a technique for determining whether to ligate or preserve accessory arteries in donor kidneys before implantation. Methods. Forty-three living-related donor kidneys in patients from January 2014 to February 2018 at our institution were included, all of which had dual arteries without the same stem. Among them, 19 cases of accessory arterial blood supply were evaluated using methylene blue (MB) perfusion, and accessory arteries supplying less than 10% of the total MB perfusion volume were ligated. The other 24 cases were assessed using a conventional method in which arteries with diameters less than 2mm were ligated. The back-table surgical time, Doppler ultrasonography index, renal function and complications were compared between the 2 groups. Results. All patients underwent successful kidney transplantation. The back-table surgical time in the MB group was longer than that in the conventional group (42.70 ± 4.70min vs 34.64 ± 5.30min, P < .05). The serum creatinine level in the MB group was significantly lower than that in the conventional group 1month after the operation (103.15 ± 19.26μmol/L vs 119.17 ± 28.32μmol/L, P < .05). No differences in the Doppler ultrasonography index or postoperative complications were noted. Conclusions. MB perfusion provides an easy and effective method to make decisions regarding arterial ligation and helps preserve renal function without increasing the number of complications after transplantation.

Type II Diabetes Mellitus

Hyperosmotic hyperglycemic nonketotic (HHNK) state (also known as hyperosmolar hyperglycemic state) is a significant acute complication of type 2 diabetes mellitus, especially for those over 65 years of age. It is characterized by extreme hyperglycemia and hyperosmolarity with little ketosis. The main clinical effect of extreme hyperosmolarity is somnolence or confusion. The absence of severe ketonemia is attributed to residual insulin secretion that is sufficient to restrain lipolysis. HHNK state is marked by extreme dehydration, with both a marked deficit of free water and serious compromise of intravascular volume and tissue perfusion. Most patients with HHNK state have hypotension, extremely dry mucous membranes, and gross elevation of urea nitrogen and creatinine. Urinary tract infection, pneumonia, stroke, myocardial infarction, and sepsis may precipitate HHNK state. Elderly patients are particularly vulnerable because their thirst mechanisms are less sensitive to a rising serum osmolality. Fluid replacement is the most important component of therapy for HHNK state. Restoration of circulating volume is an urgent first priority and is accomplished by relatively rapid intravenous infusion of 2 L of 0.9% normal saline followed by 0.45% normal saline. Later, when plasma glucose levels have declined to 250 to 300 mg/dL, 5% dextrose in water is given. Insulin treatment is started soon after administration of isotonic saline. Potassium must be added to intravenous fluids to prevent hypokalemia caused by insulin action but should not be started until hypokalemia is proven, because potassium levels can be high initially. The mortality from the HHNK state is high, ranging from 10 to 20%, and is most often from the precipitating illness. This review contains 6 figures, 7 tables, and 73 references. Key words: dehydration, fluid deficit, hyperglycemia, hyperglycemic nonketotic state, hyperosmolar, hyperosmotic insulin, potassium, type 2 diabetes mellitus

Type II Diabetes Mellitus

Hyperosmotic hyperglycemic nonketotic (HHNK) state (also known as hyperosmolar hyperglycemic state) is a significant acute complication of type 2 diabetes mellitus, especially for those over 65 years of age. It is characterized by extreme hyperglycemia and hyperosmolarity with little ketosis. The main clinical effect of extreme hyperosmolarity is somnolence or confusion. The absence of severe ketonemia is attributed to residual insulin secretion that is sufficient to restrain lipolysis. HHNK state is marked by extreme dehydration, with both a marked deficit of free water and serious compromise of intravascular volume and tissue perfusion. Most patients with HHNK state have hypotension, extremely dry mucous membranes, and gross elevation of urea nitrogen and creatinine. Urinary tract infection, pneumonia, stroke, myocardial infarction, and sepsis may precipitate HHNK state. Elderly patients are particularly vulnerable because their thirst mechanisms are less sensitive to a rising serum osmolality. Fluid replacement is the most important component of therapy for HHNK state. Restoration of circulating volume is an urgent first priority and is accomplished by relatively rapid intravenous infusion of 2 L of 0.9% normal saline followed by 0.45% normal saline. Later, when plasma glucose levels have declined to 250 to 300 mg/dL, 5% dextrose in water is given. Insulin treatment is started soon after administration of isotonic saline. Potassium must be added to intravenous fluids to prevent hypokalemia caused by insulin action but should not be started until hypokalemia is proven, because potassium levels can be high initially. The mortality from the HHNK state is high, ranging from 10 to 20%, and is most often from the precipitating illness. This review contains 6 figures, 7 tables, and 73 references. Key words: dehydration, fluid deficit, hyperglycemia, hyperglycemic nonketotic state, hyperosmolar, hyperosmotic insulin, potassium, type 2 diabetes mellitus

Type II Diabetes Mellitus

Hyperosmotic hyperglycemic nonketotic (HHNK) state (also known as hyperosmolar hyperglycemic state) is a significant acute complication of type 2 diabetes mellitus, especially for those over 65 years of age. It is characterized by extreme hyperglycemia and hyperosmolarity with little ketosis. The main clinical effect of extreme hyperosmolarity is somnolence or confusion. The absence of severe ketonemia is attributed to residual insulin secretion that is sufficient to restrain lipolysis. HHNK state is marked by extreme dehydration, with both a marked deficit of free water and serious compromise of intravascular volume and tissue perfusion. Most patients with HHNK state have hypotension, extremely dry mucous membranes, and gross elevation of urea nitrogen and creatinine. Urinary tract infection, pneumonia, stroke, myocardial infarction, and sepsis may precipitate HHNK state. Elderly patients are particularly vulnerable because their thirst mechanisms are less sensitive to a rising serum osmolality. Fluid replacement is the most important component of therapy for HHNK state. Restoration of circulating volume is an urgent first priority and is accomplished by relatively rapid intravenous infusion of 2 L of 0.9% normal saline followed by 0.45% normal saline. Later, when plasma glucose levels have declined to 250 to 300 mg/dL, 5% dextrose in water is given. Insulin treatment is started soon after administration of isotonic saline. Potassium must be added to intravenous fluids to prevent hypokalemia caused by insulin action but should not be started until hypokalemia is proven, because potassium levels can be high initially. The mortality from the HHNK state is high, ranging from 10 to 20%, and is most often from the precipitating illness. This review contains 6 figures, 7 tables, and 73 references. Key words: dehydration, fluid deficit, hyperglycemia, hyperglycemic nonketotic state, hyperosmolar, hyperosmotic insulin, potassium, type 2 diabetes mellitus

Application of Perfusion Single Photon Emission Computed Tomography of the Myocardium in Pain-Free Myocardial Ischemia

This literature review provides data on the use of single-photon emission computed tomography of myocardium in silent myocardial ischemia. The presence of silent myocardial ischemia increases the risk of cardiovascular complications several times and may be the first manifestation of coronary heart disease. Assessing the state of morphofunctional processes in the myocardium is the main goal of diagnostic imaging using singlephoton emission computed tomography of the myocardium. This allows to get three-dimensional image of left ventricle with information about distribution of perfusion volume across myocardium, makes it possible to more accurately differentiate such condition as silent myocardial ischemia. Conducting single-photon emission computed tomography in ECG synchronization mode allows you to visualize the kinetics of the myocardial walls in different phases of the cardiac cycle and thereby simultaneously assess the functional state of the left ventricular myocardium. Indicators of contractile function of the left ventricular myocardium in areas of transient hypoperfusion can be predictors of cardiac events after myocardial infarction and independent predictors of perioperative cardiac events in patients undergoing cardiac surgery. Performing single-photon emission computed tomography in ECG-synchronization mode allows visualizing kinetics of myocardial walls in different phases of cardiac cycle and thereby simultaneously assessing functional state of left ventricle myocardium. In combination with physical exercise and pharmacological tests, it helps to identify coronary stenosis among patients with silent myocardial ischemia. Perfusion single-photon emission computed tomography of myocardium is a necessary tool for stratification and assessment of prognosis of cardiac diseases in asymptomatic patients.

Normothermic regional cerebro-myocardial perfusion in newborns undergoing aortic arch repair

Introduction Regardin the data of Andropoulos et al. perfusion volume speed should be individually chosen based on deep oxymetria and transcranial dopplerography [1]. Luciani et al. showed advantages of cerebral and myocardial perfusion under moderate hypothermia in comparison to standard perfusion [2]. They showed that standard perfusion and low cerebro-myocardial flow are predictors of myocardial dysfunction. We eventually have come to a decision to abstain from cardioplegia and hypothermia that way, first, removing myocardial dysfunction risk factors; second, shortening perfusion time, and third, preserving brain flow self-regulation. Methods After obtaining the ethics committee approval we prospectively analyzed results of neonatal aortic arch reconstruction in our clinic since July 2015. In this period of time we performed 36 operations for hypoplastic aortic arch in newborn. All the procedures were performed in normothermic (above 34 C) antegrade regional cerebral perfusion and coronary perfusion. We used transcranial doppler, deep cerebral oximetry and ECG to assess perfusion efficacy. Results Mean age was 12.3 (6-23) days, weight – 3.2 (2.4-4.4) kg. Perfusion time was 70 (61.5;83.5) minutes, selective perfusion (antegrade regional cerebral and coronary) time was 28 (24;33.5) minutes. Perfusion flow was 118.5 (106;131.5) ml/kg/minute. Middle cerebral artery flow was 28 (22.5;33.25) cm/s on the right and 24 (18;27) cm/s on the left. ECG and deep cerebral oxygenation was stable through whole perfusion. Four (13.8%) patients required delayed sternal closure. In 6 hours after the operation vasoactive inotropic score was 10 (5;14.5), in 48 hours after the operation it was 5 (3;10). Lactate level was 3.2 (2.8;4.3) mmol/L in 6 hours after the procedure and 2.2 (1.85-3) mmol/L in 48 hours. Creatine phosphokinase (CPK) and creatine phosphokinase myocardial band (CPKMB) levels were 445.5 (302.75;632.5) U/L and 64 (51.25;96.5) U/L, respectively, in 6 hours and decreased to 126 (97;233) U/L and 50 (23;96) U/L in 48 hours after the operation. Troponin I level in 6 hours was 1.35 (0.95;1.5) ng/ml and in 48 hours – 0.62 (0.55;0.76) ng/ml. All patients regained consciousness in 24-48 hours after the operation with no neurologic deficiency. Mean ventilation time was 4.4 (1-11) days, mean ICU stay time was 5.9 (2-22) days. Hospital mortality was 2.8% (1 patient). Discussion Normothermic antegrade regional cerebral perfusion with coronary perfusion is a safe and decent technique in neonatal aortic arch reconstruction. It allows to avoid such detrimental risk factors as circulatory arrest, hypothermia, extensive perfusion and cardioplegia.

Imaging video plethysmography shows reduced signal amplitude in glaucoma patients in the area of the microvascular tissue of the optic nerve head

PurposeTo measure parameters of the cardiac cycle-induced pulsatile light absorption signal (plethysmography signal) of the optic nerve head (ONH) and to compare parameters between normal subjects and patients with different stages of glaucoma.Patients and methodsA recently developed video ophthalmoscope was used to acquire short video sequences (10 s) of the ONH. After image registration and trend correction, the pulsatile changing light absorption at the ONH tissue (excluding large vessels) was calculated. The changing light absorption depends on the pulsatile changing blood volume. Various parameters, including peak amplitude, steepness, time-to-peak, full width at half maximum (FWHM), and pulse duration, were calculated for averaged individual pulses (heartbeats) of the plethysmography signal. This method was applied to 19 healthy control subjects and 91 subjects with ocular hypertension, as well as different stages of primary open-angle glaucoma (17 subjects with ocular hypertension, 24 with preperimetric glaucoma, and 50 with perimetric glaucoma).ResultsCompared to the normal subjects, significant reductions (p < 0.001) in peak amplitude and steepness were observed in the group of perimetric glaucoma patients, but no significant difference was found for time-to-peak, FWHM, and pulse duration. Peak amplitude and steepness showed high correlations with RNFL thickness (p < 0.001).ConclusionsThe presented low-cost video-ophthalmoscope permits measurement of the plethysmographic signal of the ONH tissue and calculation of different blood flow-related parameters. The reduced values of the amplitude and steepness parameters in perimetric glaucoma patients suggest decreased ONH perfusion and blood volume. This outcome is in agreement with results from other studies using OCT angiography and laser speckle flowgraphy, which confirm reduced capillary density in these patients.Registration site: www.clinicaltrials.gov, Trial registration number: NCT00494923

Long-Term Results of Treating With Ethanol Ablation 15 Adult Patients With cT1aN0 Papillary Thyroid Microcarcinoma.

BackgroundCurrently acceptable management options for patients with adult papillary thyroid microcarcinoma (APTM) range from immediate surgery, either unilateral lobectomy or bilateral lobar resection, to active surveillance (AS). An alternative minimally invasive approach, originally employed for eliminating neck nodal metastases, may be ultrasound-guided percutaneous ethanol ablation (EA). Here we present our experience of definitively treating with EA 15 patients with APTM.Patients and MethodsDuring 2010 through 2017, the 15 cT1aN0M0 patients selected for EA were aged 36 to 86 years (median, 45 years). Tumor volumes (n = 17), assessed by sonography, ranged from 25 to 375 mm3 (median, 109 mm3). Fourteen of 15 patients had 2 ethanol injections on successive days; total volume injected ranged from 0.45 to 1.80 cc (median, 1.1 cc). All ablated patients were followed with sonography and underwent recalculation of tumor volume and reassessment of tumor perfusion at each follow-up visit.ResultsThe ablated patients have now been followed for 10 to 100 months (median, 64 months). There were no complications and no ablated patient developed postprocedure recurrent laryngeal nerve dysfunction. All 17 ablated tumors shrank (median 93%) and Doppler flow eliminated. Median tumor volume reduction in 9 identifiable avascular foci was 82% (range, 26%-93%). After EA, 8 tumors (47%) disappeared on sonography after a median of 10 months. During follow-up no new PTM foci and no nodal metastases have been identified.ConclusionsDefinitive treatment of APTM by EA is effective, safe, and inexpensive. Our results suggest that, for APTM patients who do not wish neck surgery and are uncomfortable with AS, EA represents a well-tolerated and minimally invasive outpatient management option.