Reduced Organ Perfusion Research Articles

Kawasaki disease with shock as the primary manifestation: How to distinguish from toxic shock syndrome?: A case report and literature review.

Kawasaki disease (KD) is a vasculitis syndrome of small to medium-sized arteries that has typical clinical characteristics such as fever, rash, cervical lymphadenopathy, conjunctivitis, and mucosal changes. Cardiac manifestations, including coronary artery aneurysms, myocarditis, myocardial infarction, and sudden cardiac death, are the most serious complications observed in KD. On rare occasions, it may accompanied with reduced organ perfusion due to systolic hypotension, a condition known as Kawasaki disease shock syndrome (KDSS). KDSS is a serious complication that can be presented to the emergency department as an initial feature when typical clinical symptoms of KD have not be detected. We report the case of a 12-year-old boy admitted with prolonged fever, bilateral non-purulent conjunctivitis, and signs of shock such as hypotension and tachycardia. Laboratory findings showed elevated inflammatory markers, hypoalbuminemia, and sterile pyuria. He was initially treated with intravenous cefotaxime and vancomycin considering the possible diagnosis of toxic shock syndrome, while the treatment was not effective. Subsequent chest computerized tomography and ultrasound identified pulmonary consolidation and polyserous effusion. Echocardiography revealed mild biatrial dilatation and mild valvular regurgitation with preserved left ventricular function. After a multidisciplinary consultation, a diagnosis of KDSS was made. To prevent coronary artery lesions and other severe complications, the patient immediately received immunoglobulin, corticoid, and acetylsalicylic acid. Soon afterwards, he showed significant improvement, with the temperature dropped to normal and hypotension corrected about 24 hours post-intravenous immunoglobulin therapy. Polyserous effusions also disappeared before discharge. Follow-up echocardiography revealed normal results. Clinicians should maintain a high index of suspicion for KD and consider pulmonary involvement and polyserous effusions as potential complications. For children with KD, any symptoms pointing to infection should be carefully considered. When there is no etiologic evidence, antibiotics should be used with caution. Our case also highlights the importance of considering KDSS as a differential diagnosis in children presenting with prolonged fever and shock. Early recognition, timely treatment, and close monitoring are key to preventing severe complications and ensuring favorable outcomes in patients with KDSS.

HUBUNGAN USIA IBU HAMIL DAN POLA MAKAN DENGAN KEJADIAN PREEKLAMSIA DI KLINIK RAWAT INAP NU MADINAH PUJON KABUPATEN MALANG

Preeclampsia is a pregnancy conflict syndrome in the form of reduced organ perfusion due to vasospasm and endothelial activity. This disease generally occurs in the 3rd trimester of pregnancy, but can occur earlier. To diagnose preeclampsia, the increase in systolic pressure must be 30 mmHg or a systolic pressure above or equal to 140 mmHg or more. Or an increase in diastolic blood pressure increased by 15 mmHg or more, or diastolic pressure above or equal to 90 or more and the presence of proteinuria. The aim of this study was to see the relationship between the age of pregnant women and diet with the incidence of preeclampsia at NU Madinah Pujon Treat Clinics, Malang Regency. The sampling method used total sampling technique, namely the determination of the technique with all the population in this sample sampled. The data obtained were then analyzed using a descriptive statistical approach. By using multiple linear regression models. The t value of the variable age of pregnant women (X1) is 2,547> t table 2,048, meaning that there is a significant relationship between the age of pregnant women (X1) and the incidence of preeclampsia (Y). The t value of the dietary variable (X2) is 5,220> t table 2,048, which means that there is a significant relationship between diet (X2) and the incidence of preeclampsia (Y). The calculated F value of 16,621> from the F value of 0.05 (3.35) means that there is a significant simultaneous or simultaneous relationship between the variables of pregnant age (X1), and diet (X2), with the incidence of preeclampsia (Y). The regression value coefficient (Rsquare) of 0.552 means that the independent relationship variable with the incidence of preeclampsia is ((0.552 x 100) x 100%) 55.2%, while the other 44.8% is obtained by other factors not examined. Judging from the relationship between the two independent variables (X) on the dependent variable (Y) it can be ignored that the dietary variable X2 is more dominant in the incidence of preeclampsia (Y) as evidenced by the value of t count 5.220> t table 2.048.

Association between hypotension and myocardial injury in patients with severe trauma

PurposeDuring resuscitation of patients with severe trauma, guidelines recommend permissive hypotension prior to surgical bleeding control. However, hypotension may be associated with reduced organ perfusion and multiple organ dysfunction, e.g. myocardial injury. The association between hypotension and myocardial injury in trauma patients is underexplored. We hypothesized that hypotension is associated with myocardial injury in this population.Materials and methodsThis retrospective study included patients ≥ 18 years suffering from severe trauma [defined as Injury Severity Score (ISS) ≥ 16] that were treated in the emergency department resuscitation room between 2016 and 2019. Primary endpoint was the incidence of myocardial injury defined as high-sensitive troponin T > 14 ng/l. Main exposure was the duration of arterial hypotension during resuscitation period defined as mean arterial pressure < 65 mmHg.ResultsOut of 368 patients screened, 343 were analyzed (73% male, age: 55 ± 21, ISS: 28 ± 12). Myocardial injury was detected in 143 (42%) patients. Overall in-hospital mortality was 26%. Multivariate binary logistic regression with forced entry of nine predefined covariables revealed an odds ratio of 1.29 [95% confidence interval 1.16–1.44]; p = 0.012) for the association between the duration of hypotension and myocardial injury.ConclusionThe duration of hypotension during resuscitation period is independently associated with the incidence of myocardial injury in patients with severe trauma.

Effect of the loading dose of magnesium sulfate on the Doppler velocimetry parameters in the uterine, umbilical and fetal middle cerebral arteries in severe preeclampsia

Abstract Background Preeclampsia is pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation. Aim of the Work to assess the effect of injecting magnesium sulfate on Doppler parameters of uterine artery, umbilical and fetal middle cerebral arteries (MCA) in women with severe preeclampsia. Patients and Methods This study included eighty pregnant with severe preeclampsia or eclampsia who were given magnesium sulphate therapy in Ain Shams University Maternity hospital. The Study group included 80 pregnant patients Doppler flow velocity parameters (resistance index [RI], pulsatility index [PI] and systolic/diastolic [S/D] ratio) were evaluated in the uterine, fetal umbilical and middle cerebral arteries before and 20 minutes after intravenous administration of 6 grams of magnesium sulfate (Loading dose). Results Magnesium sulfate had significant hemodynamic effects with significant reduction of systolic and diastolic blood pressure. Regarding the Doppler studies, it was found that after administration of magnesium sulfate there was significant reduction in the Doppler velocimetry parameters (Resistance index[RI], Pulsatility index[PI] and systolic/diastolic[S/D] ratio) in the uterine, umbilical and fetal middle cerebral arteries denoting decreased vascular resistance with increased blood flow in these vessels. Conclusion Intravenous administration of magnesium sulfate in pregnant women with severe preeclampsia and eclampsia resulted in a decrease in uterine artery, fetal umbilical and middle cerebral arteries Doppler indices with reduced resistance to blood flow in these vessels.

Pathophysiology of cardiogenic shock.

We describe the pathophysiology of cardiogenic shock (CS), from the main pathways to the inflammatory mechanisms and the proteomic features. Although the classical pathophysiological pathways underlying CS, namely reduced organ perfusion due to inadequate cardiac output and peripheral vasoconstriction, have been well-established for a long time, the role of macro-and micro-hemodynamics in the magnitude of the disease and its prognosis has been investigated extensively only over the last few years. Moreover, to complete the complex picture of CS pathophysiology, the study of cytokine cascade, inflammation, and proteomic analysis has been addressed recently. Understanding the pathophysiology of CS is important to treat it optimally.

Cardiac Rehabilitation in Heart Failure.

Heart failure (HF) is a complex clinical syndrome caused by a structural and/or functional cardiac abnormality, resulting in reduced organ perfusion. The goals of treatment in patients with HF are to improve functional capacity and quality of life, and to reduce mortality. Cardiac rehabilitation (CR) including exercise training is one of the treatment options, and current guidelines recommend CR as safe and effective for patients with HF. CR has been known to improve exercise capacity and quality of life, minimize HF progression, and lower mortality in patients with HF. Improvement of vascular endothelial function, activation of the neurohormonal system, increase of mitochondrial oxygen utilization in peripheral muscles, and increase of chronotropic responses are possible mechanisms of the beneficial effects of exercise-based CR in HF. Although CR has been shown to decrease morbidity and mortality, it is underutilized in clinical practice. Despite the existence of concrete evidence of clinical benefits, the CR participation rates of patients with HF range from only 14% to 43% worldwide, with high dropout rates after enrollment. These low participation rates have been attributed to several barriers, including patient factors, professional factors, and service factors. The motivation for participating in CR and for overcoming the patients' barriers for CR before discharge should be provided to each patient. Current guidelines strongly recommend applying a CR program to all eligible patients with HF.

EFFICACY OF NITROGLYCERINE INFUSION VERSUS SUBLINGUAL NIFEDIPINE IN SEVERE PRE-ECLAMPSIA

Background: Pre-eclampsia is a pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation. The incidence of preeclampsia is estimated to range between 2.5 and 5%. An accurate estimate, as well as its global burden, is difficult to obtain, due to lack of data from several countries and standardization of diagnostic criteria. Objective: To compare between the uses of continuous i.v. administration of nitroglycerine versus sublingual nifedipine in the management of women with severe pre-eclampsia who were being managed with controlled plasma volume expansion and MgSO4 loading and maintenance doses. Patients and Methods: Patients were taken from Sayed Galal Hospital. This study was carried out on 100 women with severe pre-eclampsia who were being managed with controlled plasma volume expansion and MgSO4 loading and maintenance doses. Those women were randomly assigned into two equal groups: Nitroglycerine or nifedipine. Both groups were compared as regard maternal adverse effects of vasodilator therapy, mean arterial pressure changes within one hour after vasodilator therapy, post therapy changes in fetal cardiotocography (CTG) and for feto-maternal complications including gestational age of termination of pregnancy, time of maternal intensive care unit (ICU) stay and the need of neonatal ICU. Results: Statistical analysis of the magnitude and time course of maternal hypotensive responses after initiation of the vasodilator therapy showed that, in nitroglycerine group, a statistically significant decrease in both systolic blood pressure (SBP) and diastolic blood pressure (DBP) started just 5 min. after the initiation of nitroglycerine infusion, while in nifedipine group, the significant decrease in SBP and DBP started 15 min. after oral nifedipine. The SBP and DBP measurements in nitroglycerine group were significantly lower than those in nifedipine group. The feto-maternal safety margin observed was similar in the two study groups. Conclusion: IV infusion of nitroglycerine was effective, safe and alternative therapy for severe pre-eclampsia.

Significance of cord blood nucleated red blood cell count in pregnancies complicated by preeclampsia as a marker for intra uterine growth restriction

Background: Preeclampsia is a pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation which is typically characterized by hypertension, proteinuria, edema and fetal compromise which is a leading cause of intra uterine growth restriction (IUGR). Elevated nucleated red blood cell (NRBC) count is introduced as a potential marker of intra-uterine growth restriction (IUGR) hence determination of NRBC counts is essentially helpful in predicting short term neurodevelopment outcome. Objective of the study Elevated nucleated red blood cell (NRBC) count is introduced as a potential marker of intra-uterine growth restriction (IUGR) in term babies born to preeclamptic mothersMethods: A cross sectional study conducted in a tertiary care hospital to evaluate the significance of cord blood NRBC count in term neonates born with pregnancy complicated by preeclampsia. It included 60 healthy mothers (control group) and 60 mothers with PIH. Collected data was analysed with SPSS software.Results: The nucleated red blood cell in cord blood of newborns in preeclampsia group was significantly higher than in the control group (p value 0.013). IUGR is significantly higher in PIH group (p value 0.008).Conclusions: From the observed data it is concluded that IUGR is an important cause of perinatal morbidity and mortality. The commonest maternal cause for IUGR was pregnancy induced hypertension. The other contributing factors were anemia, lack of awareness (unregistered, unbooked cases) among mothers, poor maternal nutrition and poor weight gain during pregnancy. Infants of preeclamptic women have higher nucleated red blood cell count at birth than control which means that preeclampsia may produce an erythropoietic response in the fetus. The positive correlation between cord nucleated red blood cell counts in preeclamptic patients and control group indicates that may be the hypoperfused placenta plays a role in this correlation.

DIFFERENT REGIMENS OF MAGNESIUM SULFATE FOR MANAGEMENT OF WOMEN WITH SEVERE PREECLAMPSIA

Background: Preeclampsia is serious syndrome that can affect human pregnancy causing serious complications. Preeclampsia is pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation. Objective: To assess the comparative effects of three regimens for the administration of the magnesium sulfate when used for the care of women with severe preeclampsia to determine the minimal effective dose of magnesium sulfate in controlling cases with severe preeclampsia and prevention of eclampsia and to determine whether only loading dose of magnesium sulfate is effective in prevention of eclampsia or not. Patients and Methods: 240 patients were recruited and divided into three groups. Each group contains 80 patients, the first group received only the loading dose of MgSO4 and the second group received loading dose plus 12 hours maintenance dose while the last group received the loading dose and the full maintenance dose of MgSo4 for 24 hours. Results: Although strong evidence supports the use of magnesium sulfate for prevention and treatment of eclampsia, there was no significant difference between occurrence of eclampsia in the three groups after either administration of loading dose of MgSO4 only or administration of loading dose with maintenance dose for 12 hours or maintenance dose for 24 hours in the studied patients. Conclusion: Magnesium sulfate proved to cause many hemodynamic changes as it has vasodilator effect on maternal and fetal blood vessels; however, magnesium sulfate should be given to all patients with severe preeclampsia.

Systemic Consequences of Pulmonary Hypertension and Right-Sided Heart Failure.

Pulmonary hypertension (PH) is a feature of a variety of diseases and continues to harbor high morbidity and mortality. The main consequence of PH is right-sided heart failure which causes a complex clinical syndrome affecting multiple organ systems including left heart, brain, kidneys, liver, gastrointestinal tract, skeletal muscle, as well as the endocrine, immune, and autonomic systems. Interorgan crosstalk and interdependent mechanisms include hemodynamic consequences such as reduced organ perfusion and congestion as well as maladaptive neurohormonal activation, oxidative stress, hormonal imbalance, and abnormal immune cell signaling. These mechanisms, which may occur in acute, chronic, or acute-on-chronic settings, are common and precipitate adverse functional and structural changes in multiple organs which contribute to increased morbidity and mortality. While the systemic character of PH and right-sided heart failure is often neglected or underestimated, such consequences place additional burden on patients and may represent treatable traits in addition to targeted therapy of PH and underlying causes. Here, we highlight the current state-of-the-art understanding of the systemic consequences of PH and right-sided heart failure on multiple organ systems, focusing on self-perpetuating pathophysiological mechanisms, aspects of increased susceptibility of organ damage, and their reciprocal impact on the course of the disease.

Perbedaan Rerata Rasio Kadar Natrium Kalium Maternal Antara Preeklamsia Berat Dan Eklamsia

Background: Preeclampsia is a pregnancy-specific syndrome in the form of reduced organ perfusion due to vasospasm and endothelial activation that occurs after 20 weeks of gestational age. eclampsia is the occurrence of seizures in a woman with preeclampsia, Sodium (Na +) and Potassium (K +) play an important role in preeclampsia and eclampsia.Objective: To see the difference in mean sodium potassium ratio between pregnancy with severe preeclampsia and eclampsia.Methods: The study was analytic descriptive using a cross sectional study design by looking at the medical records of the subjects according to the time and place of the study. Samples are all medical records of pregnant women who suffer from pre-eclampsia and eclampsia in the obstetric and gynecology section of RSUP DR.M.Djamil padang in the period of 15 January 2016 to 31 December 2017, the values of which are sodium, potassium levels and sodium and potassium ratios. Samples were taken from populations that met the inclusion criteria and did not have exclusion criteria. Sampling using a consecuvite sampling technique which was taken from the medical records of RSUP DR. M. Djamil Padang Statistical analysis to assess significance using the T-test.Results: In the Severe preeclampsia and Eclampsia groups it was found that multipara parity had the highest respondents. This is in accordance with the literature where the incidence of preeclampsia is more often found at near term gestational age.Conclusion: There is no significant difference in the average sodium potassium ratio between Severe preeclampsia and EclampsiaKeywords: Severe preeclampsia, eclampsia, sodium and potassium

Perbedaan Rerata Rasio Kadar Natrium Kalium Maternal Antara Preeklamsia Berat Dan Eklamsia

Background : Preeclampsia is a pregnancy-specific syndrome in the form of reduced organ perfusion due to vasospasm and endothelial activation that occurs after 20 weeks of gestational age. eclampsia is the occurrence of seizures in a woman with preeclampsia, Sodium (Na +) and Potassium (K +) play an important role in preeclampsia and eclampsia. Objective : To see the difference in mean sodium potassium ratio between pregnancy with severe preeclampsia and eclampsia. Methods : The study was analytic descriptive using a cross sectional study design by looking at the medical records of the subjects according to the time and place of the study. Samples are all medical records of pregnant women who suffer from pre-eclampsia and eclampsia in the obstetric and gynecology section of RSUP DR.M.Djamil padang in the period of 15 January 2016 to 31 December 2017, the values of which are sodium, potassium levels and sodium and potassium ratios. Samples were taken from populations that met the inclusion criteria and did not have exclusion criteria. Sampling using a consecuvite sampling technique which was taken from the medical records of RSUP DR. M. Djamil Padang Statistical analysis to assess significance using the T-test. Results : In the Severe preeclampsia and Eclampsia groups it was found that multipara parity had the highest respondents. This is in accordance with the literature where the incidence of preeclampsia is more often found at near term gestational age. Conclusion : There is no significant difference in the average sodium potassium ratio between Severe preeclampsia and Eclampsia Keywords: Severe preeclampsia, eclampsia, sodium and potassium

Management of Women with Severe Preeclampsia by Different Regimens of Magnesium Sulfate

Background: Preeclampsia is serious syndrome that can affect human pregnancy causing serious complications. Preeclampsia is pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation. Objective: The aim of our study was to assess the comparative effects of three regimens for the administration of the magnesium sulfate when used for the care of women with severe preeclampsia to determine the effective dose of magnesium sulfate in controlling cases with severe preeclampsia and prevention of eclampsia and to determine whether only loading dose of magnesium sulfate is effective in prevention of eclampsia or not. Patients and methods: The study included 240 pregnant women presenting to the casualty unit diagnosed as cases of severe preeclampsia in the Obstetrics and Gynecology Department, Al-Azhar University Hospital and EL Mahalla General Hospital. A randomized controlled study that compared three regimens for administration of MgSO4 used for these cases. Results: There was no significant difference between occurrence of eclampsia in the three groups after either administration of loading dose of MgSO4 only or administration of loading dose with maintenance dose for 12 hours or maintenance dose for 24 hours in the studied patients. Conclusion: Magnesium sulfate proved to cause many hemodynamic changes as it has vasodilator effect on maternal and fetal blood vessels. Magnesium sulfate should be given to all patients with severe preeclampsia.

Cardiac Output Monitoring in Preterm Infants.

Maintaining optimal circulatory status is a key component of preterm neonatal care. Low-cardiac output (CO) in the preterm neonate leads to inadequate perfusion of vital organs and has been linked to a variety of adverse outcomes with heightened acute morbidity and mortality and adverse neurodevelopmental outcomes. Having technology available to monitor CO allows us to detect low-output states and potentially intervene to mitigate the unwanted effects of reduced organ perfusion. There are many technologies available for the monitoring of CO in the preterm neonatal population and while many act as useful adjuncts to aid clinical decision-making no technique is perfect. In this review, we discuss the relative merits and limitations of various common methodologies available for monitoring CO in the preterm neonatal population. We will discuss the ongoing challenges in monitoring CO in the preterm neonate along with current gaps in our knowledge. We conclude by discussing emerging technologies and areas that warrant further study.

10-Year trend in crystalloid resuscitation: Reduced volume and lower mortality

BackgroundLiberal emergency department (ED) resuscitation after trauma may lead to uncontrolled hemorrhage, reduced organ perfusion, and compartment syndrome. Recent guidelines reduced the standard starting point for crystalloid resuscitation from 2 L to 1 L and emphasized “balanced” resuscitation. The purpose of this study was to characterize how an urban, Level 1 trauma center has responded to changes in crystalloid resuscitation practices over time and to describe associated patient outcomes. MethodsThis is a retrospective review of trauma patients who sustained moderate to severe injury (ISS > 9) and received crystalloid resuscitation in the ED during 1/2004–12/2013 at an urban, Level 1 trauma center. Patient data collected included age, gender, Glasgow Coma Scale (GCS) score, initial systolic blood pressure (SBP), mechanism of injury, regional Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), volume of blood products and crystalloids administered in the ED. Patients who received <2 L of crystalloid were considered low-volume while those who received ≥2 L were high-volume patients. Clinical characteristics and outcomes were compared between high- and low-volume cohorts, and multivariate regression was used to adjust for confounders. Trend analysis examined changes in variables over time. Results1571 moderate to severely injured patients received crystalloid resuscitation; 1282 (82%) were low-volume and 289 (18%) were high-volume. Compared to high-volume patients, low-volume patients presented with a higher median SBP (134 vs. 122 mmHg, p < 0.001) and GCS (15 vs. 14, p < 0.001). Low-volume patients also had lower median ISS (15 vs. 19, p < 0.001). Unadjusted mortality was lower in the low-volume cohort (7% vs. 19%, p < 0.001). Multivariate analysis demonstrated that high-volume patients had increased odds of mortality compared to low-volume patients (AOR 1.88, p = 0.008). Decreased rates of high-volume resuscitation and overall mortality were demonstrated over the 10-year study period. ConclusionsThe observed decrease in high-volume crystalloid resuscitations in the ED paralleled a reduction in mortality over the ten-year period. In addition, adjusted mortality was higher in those receiving high-volume resuscitation.

Association between Intrauterine Growth Restriction and Pregnancy Hypertension

Background: Intrauterine Growth Restriction (IUGR) certainly poses health problems that leads to increase mortality and can cause mental and physiological disturbances to the infants. Reduced organ perfusion is one of the etiologies of IUGR which is caused by placenta obstruction. This happens because of pregnancy hypertension as a risk factor. Furthermore, educational level, employment status, parity, and anemia are also its risk factors. The objective of this study was to analyze the prevalence of IUGR and association between IUGR and pregnancy hypertension. Methods: A case control design was performed using medical records from Neonatology Department of Child Health at Dr. Hasan Sadikin General Hospital Bandung in 2012. Subjects were taken from 149 medical records of the mother who had IUGR and 149 normal birth weight infant information about the characteristics of the mothers and the infants. The data were collected and analyzed by calculating the Odds ratio (OR). Results: The prevalence of IUGR at Dr. Hasan Sadikin General Hospital in 2012 was 149 cases (4.69%). There was association between pregnancy hypertension and IUGR with OR=1.72, 95% CI (1.044–2.836). Conclusions: Pregnancy hypertension is one of the risks that generates IUGR. [ AMJ .2016;3(2):212–5] DOI: 10.15850/amj.v3n2.791

Oral Infection as a Risk Factor for Preeclampsia

Preeclampsia is a common obstetric syndrome affecting approximately 5-10% of pregnant women leading to significant maternal mortality and morbidity. Preeclampsia accounts for 25% of preterm deliveries resulting in adverse neonatal outcome. It is also the third most common direct cause of maternal death in the United Kingdom [1,2]. Preeclampsia is characterized by new onset hypertension exceeding 140/90 mmHg and proteinuria exceeding 300 mg in a 24 hour urine sample, after 20 weeks of gestation in a previously normotensive woman. It is characterized by abnormal vascular response to placentation, reduced organ perfusion, vasospasm, activation of the coagulation system, inflammatory like response, oxidative stress and some perturbation in volume and blood pressure control, affecting the placenta, kidney liver and brain [3-5].

Fluid management: Not just a problem in preeclampsia.

The recently published review on fluid management in pre-eclampsia1 highlights the lack of evidence to support clinical decision making in this area. It is important to appreciate that many of these knowledge gaps are not specific to preeclampsia, but common to all critically ill patients, despite ongoing research. Fluid management in the critically ill has been a constant source of debate, for example keeping patients “wet” versus “dry”, crystalloids versus colloids, pulmonary artery (PA) catheter, or not. The goal directed therapy approach proposes fluid resuscitation aimed at acute physiological goals. However, over the past decade the adverse effects of this aggressive fluid approach has become evident. Although pulmonary edema is a concern, this is usually easily managed with diuretics and transient noninvasive positive pressure ventilation. Excess fluid may also cause edema of other organs and flood the peritoneal cavity, resulting in reduced organ perfusion and even aggravating renal dysfunction and increasing mortality.2,3 Fortunately, there has been progress in some of these areas. The PA line issue seems to have been put to rest with several studies showing a lack of benefit of this technology for routine use.4 Unfortunately, there are no clear guidelines when use of PA catheters is appropriate, and no acceptable alternatives for the assessment of fluid status in the critically ill. The crystalloid–colloid debate has been addressed by several large studies outside of pregnancy. The SAFE study5 and the CRISTAL study6 have shown no difference in outcome using crystalloid versus colloid in large groups of intensive care unit patients. A signal toward improved outcome with albumin in patients with sepsis is being addressed by a large Italian study (ALBIOS). Dopamine no longer has a role in the management of renal dysfunction in the critically ill – although this drug has diuretic properties and glomerular filtration rate improves in proportion to the increase in cardiac output, there is no protective effect on renal function.7 Similar conclusions have been reached in pre-eclamptic women.8

Structural abnormality of the hippocampus and depressive symptoms in a rat model of heart failure

Purpose: Heart failure (HF) affects almost all organs in our body through reduced organ perfusion and resultant neurohumoral alterations. Major depression is more prevalent in HF patients as compared with normal subjects, suggesting the possible interaction between the heart and the brain in HF. However, the mechanism of depressive symptoms in HF remains largely unclear. Several reports showed the association between major depression and structural abnormality of the hippocampus such as grey matter reduction and decreased neurogenesis. In the present study, we thus investigated whether hippocampal grey matter reduction and decreased neurogenesis were observed in association with depressive symptoms in a rat model of HF using magnetic resonance (MR) imaging and histological analysis. Methods: Male Wistar rats were divided into two groups: HF group with permanent ligation of the left coronary artery (n=28) and sham-operated control group (n=25). Four months after the procedure, the following two studies were performed. In the first study, the HF group (n=20) and the sham group (n=17) underwent behavioral tests (open-field test and elevated plus maze test) for assessment of depressive symptoms, followed by structural brain MR image acquisition. The obtained MR images were analyzed to detect regional alterations in grey matter between the two groups as measured by grey matter probability values (a maximum value of 1). In the second study, brains of the both groups (n=8, each) were fixed for histological analysis of neurogenesis by counting the number of bromodeoxyuridine (BrdU)-immunopositive cells in the hippocampus. Results: The HF group showed significantly greater depressive symptoms as compared with the sham group, including decreased time spent in the inner zone (HF group, 4.2±0.7% vs. sham group, 8.7±1.8%, P<0.05) in open-field test and decreased time spent in the open arm (HF group, 2.5±0.6% vs. sham group, 6.6±1.5%, P<0.05) in elevated plus maze test. Analysis of structural brain MR images revealed grey matter reduction in the HF group than in the sham group in several brain regions including the bilateral hippocampus (HF group, 0.480±0.002 vs. sham group, 0.505±0.002, P<0.001). Moreover, the number of BrdU-immunopositive cells in the hippocampus was decreased in the HF group than in the sham group (HF group, 18.3±1.5 vs. sham group, 23.0±1.3, P<0.05). Conclusions: The present study demonstrates for the first time that HF induces structural abnormality of the hippocampus such as grey matter reduction and decreased neurogenesis in association with depressive symptoms.

Interactions between the heart and the brain in heart failure patients assessed by magnetic resonance imaging - interim results from Brain assessment and investigation in Heart Failure Trial (B-HeFT)

Purpose: Heart failure (HF) affects almost all organs in our body through reduced organ perfusion and resultant neurohumoral alterations. Major depression is more prevalent in HF patients as compared with normal subjects, suggesting the possible interactions between the heart and the brain in HF. However, functional and structural brain changes in HF patients remain largely unclear. We thus prospectively performed Brain Assessment and Investigation in Heart Failure Trial (B-HeFT) (UMI08584), in which we investigated the interactions between the two vital organs by magnetic resonance (MR) imaging in Stage B/C HF patients. Methods: Stage B (n=14) and Stage C (n=16) HF patients, who were diagnosed by echocardiography and past HF symptoms, underwent brain and cardiac MR image acquisitions and questionnaires including the Minnesota Living with Heart Failure Questionnaire (Stage C, 38.5±6.5 vs. Stage B, 21.6±4.9, P<0.05) and the Beck depression inventory (Stage C, 11.9±2.3 vs. Stage B, 8.7±1.7, P=0.27). The brain MR images were analyzed to detect regional alterations in grey matter between Stage B and C groups as measured by grey matter probability values (a maximum value of 1). Left ventricular ejection fraction (LVEF), cardiac index (CI) and LV end-diastolic volume (LVEDV) were obtained from the cardiac MR images using Simpson's method. Results: Stage C and B groups did not differ in age (Stage C, 65.4±1.7 vs. Stage B, 63.3±3.7 years) or ischemic origin (Stage C, 50.0 vs. Stage B, 57.1%). Analysis of the cardiac MR images demonstrated significant cardiac remodeling in Stage C than in Stage B group, including reduced LVEF (Stage C, 34.2±4.3 vs. Stage B, 55.0±34.2%, P<0.01), increased LVEDV (Stage C, 194±25 vs. Stage B, 125±11 ml, P<0.05) and a tendency for reduced CI (Stage C, 2.2±0.2 vs. Stage B, 2.6±0.3 ml/m2/min, P=0.19). Analysis of the brain MR images identified grey matter reduction in Stage C as compared with Stage B group not only in regions associated with depressive symptoms such as the right hippocampus (Stage C, 0.559±0.016 vs. Stage B, 0.574±0.018, P<0.05) but also in the bilateral primary motor cortex (Stage C, 0.320±0.017 vs. Stage B, 0.337±0.016, P<0.05). There was a tendency for a positive correlation between increased LVEDV and grey matter reduction in the right hippocampus (Stage C, r=0.37, P=0.20; Stage B, r=0.28, P=0.34). Conclusion: These results indicate that HF is associated with cardiac remodeling along with grey matter reduction in the hippocampus and the primary motor cortex, which may be involved in depressive symptoms and reduced daily activity in HF patients.