Severe Circulatory Disturbance Research Articles

Intrapericardial Teratoma and Associated 3q29 Deletion in a Fetus: Case Report.

Depending on its location, size, and proximity to the cardiac structures, an intrapericardial teratoma may lead to severe circulatory disturbances and even fetal demise. A 34-year-old G2P1 presented at 20w5d with a solid cystic mass in the right thorax of the fetus, originating from the right atrium or lung, with signs of non-immune fetal hydrops, soon resulting in intrauterine fetal death. Detailed post-mortem autopsy revealed signs of hydrops fetalis universalis due to a spherical tumor mass originating from the aortic root. Histologic examination of the tumor showed the characteristic morphology of a teratoma. A 1.6-Mb microdeletion at 3q29 was identified by single nucleotide polymorphism array. This is the first report presenting the diagnosis of an intrapericardial teratoma in a fetus with a microdeletion of 3q29. Intrapericardial teratoma has a poor prognosis and the fetal outcome relies on the development of hydrops. A post-mortem examination is essential in order to make a definitive diagnosis, which underlines the status of the fetal pathologist and the need for interdisciplinary cooperation.

Severe Circulatory Disturbance in Optic Disc, Retina, and Choroid Following Sub-Tenon Triamcinolone Acetonide Injection for Posterior Scleritis.

To report a rare case of optic disc and chorioretinal vascular occlusions in the right eye following sub-Tenon injection of triamcinolone acetonide (STTA) in an older male patient with scleritis and to discuss the associated risk factors and potential alternative therapies. The medical history and clinical examination, including fundoscopy, fluorescein angiography (FA), and indocyanine green angiography (ICGA), were conducted to diagnose and evaluate the extent of vascular occlusion after STTA. An extensive literature review was undertaken to ascertain the associated risks and consider other treatment options for scleritis. Severe circulatory disturbances in the optic disc and chorioretinal regions of the right eye developed after STTA for exacerbated scleritis, as confirmed by FA and ICGA, resulting in a significant decrease in visual acuity. A complex medical history encompassing ophthalmic and systemic health issues may have contributed to this negative outcome. A literature review pointed out the potential complications of STTA and highlighted alternative approaches to scleritis management. Cautious application of STTA in treating scleritis is crucial, especially in patients with pre-existing vascular or ocular conditions. Thus, a multidisciplinary approach and a careful assessment of various treatment options are vital to minimize the risk of severe complications and improve patient outcomes.

A randomised-controlled trial (TARGET-C) of high vs. low target mean arterial pressure in patients with cirrhosis and septic shock

A high mean arterial pressure (MAP) target has been associated with improved renal outcomes in patients with cirrhosis, though it has not been studied in critically ill patients with cirrhosis and septic shock (CICs). We compared the efficacy of a high (80-85mmHg; H-MAP) vs. low (60-65; L-MAP) target MAP strategy in improving 28-day mortality in CICs. We performed open-label 1:1 randomisation of 150 CICs (H-MAP 75; L-MAP 75). The primary endpoint was 28-day mortality and secondary endpoints included reversal of shock, acute kidney injury (AKI) at day 5, the incidence of intradialytic hypotension (IDH), and adverse events. Endothelial markers were analysed in a subset of patients. The baseline characteristics were comparable. On intention-to-treat analysis, 28-day mortality (65% vs. 56%; p= 0.54), reversal of shock (47% vs. 53%; p= 0.41) and AKI development (45% vs. 31%;p= 0.06) were not different between the H-MAP and L-MAP groups, respectively. A lower incidence of IDH (12% vs. 48%; p <0.001) and higher adverse events necessitating protocol discontinuation (24% vs. 11%; p= 0.031) were noted in the H-MAP group. On per-protocol analysis (L-MAP 67; H-MAP 57), a significantly higher reversal of AKI (53% vs. 31%; p= 0.02) and a lower incidence of IDH (4% vs. 53%; p <0.001) were observed in the H-MAP group. Endothelial repair markers such as ADAMTS (2.11 ± 1.13 vs. 1.15 ± 0.48; p= 0.002) and angiopoietin-2 (74.08 ± 53.00 vs. 41.80 ± 15.95; p= 0.016) were higher in the H-MAP group. A higher MAP strategy does not confer a survival benefit in CICs, but improves tolerance to dialysis, lactate clearance and renal recovery. Higher adverse events indicate the need for better tools to evaluate target microcirculation pressures in CICs. Maintaining an appropriate organ perfusion pressure during sepsis is the ultimate goal of haemodynamic management. A higher mean arterial pressure (MAP) improves renal outcomes in patients with hepatorenal syndrome. Patients with cirrhosis and septic shock have severe circulatory disturbances, low MAP, and poor tissue perfusion. In these patients, targeting higher MAP vs. lower MAP does not confer any survival benefit but is associated with more adverse events. A higher target strategy was associated with better tolerance and lesser episodes of hypotension on dialysis. Patients who could achieve the higher target MAP, without the development of adverse events, had improved renal outcomes and better lactate clearance. Higher MAP was also associated with improvements in markers of endothelial function. A higher target MAP strategy, with close monitoring of adverse events, may be recommended for patients with cirrhosis and septic shock. NCT03145168.

Hemophagocytic lymphohistiocytosis in a newborn infant born to a mother with Sjögren syndrome antibodies

We encountered a neonatal patient with hemophagocytic lymphohistiocytosis (HLH) whose mother was positive for anti-Ro/SSA and anti-La/SSB antibodies. Complete atrioventricular block was found in a male patient at 29 weeks of gestation. The patient was born at 40 weeks of gestation. He showed severe circulatory disturbance at 22 h after the birth, and he also had elevated serum levels of aspartate aminotransferase (1027 IU l(-1)), alanine aminotransferase (121 IU l(-1)), lactic dehydrogenase (3490 IU l(-1)), ferritin (9769.7 ng ml(-1)) and soluble interleukin-2 (IL-2) receptor (3230 U ml(-1)). We could not find any known HLH genetic abnormality in the patient, but he fulfilled seven of the eight criteria for HLH. Serum levels of IL-6 and IL-8 had been already elevated in his cord blood, and serum levels of granulocyte-macrophage colony-stimulating factor and IL-8 were significantly increased on the second day of life. His symptoms regressed with the administration of hydrocortisone. We presumed that transplacental transfer of maternal antibodies could be related to the occurrence of HLH.

Hydranencephaly with extensive periventricular necrosis and numerous ectopic glioneuronal nests

The case reported here relates to a male infant with hydranencephaly who was born at 37 weeks of gestation and died immediately after birth. Post-mortem examination revealed that the cerebral hemispheres had been replaced by fluid-filled cavities within a normal-sized cranium. The membranous hemispheric wall was composed of gliosed tissue with multiple foci of necrosis and hemosiderin-laden macrophages. The ependyma was absent. Many necrotic foci containing hemosiderin were also found around the aqueduct and fourth ventricle. These findings suggest that hemorrhagic necrosis had occurred throughout the periventricular region, and more severely in the cerebral hemispheres. Moreover, numerous glioneuronal nests were found throughout the subarachnoid space and ventricles. Glioneuronal nests, if present, are usually minimal in hydranencephaly, whereas it is one of the pathological features of multicystic encephalopathy. The transition of multicystic encephalopathy to hydranencephaly has been demonstrated repeatedly. The former is a condition resulting from a severe circulatory disturbance, most often at the end of gestation or in the perinatal period. These lesions date later than hydranencephaly. Considering that numerous glioneuronal nests were found in the present case, it is likely that the encephaloclastic process developed toward the end of gestation.

Enhanced neuropathogenicity of avian influenza A virus by passages through air sac and brain of chicks.

Three-day-old, specific-pathogen-free (SPF) chicks were inoculated with the strains of influenza A/whistling swan/Shimane/ 499/83 (H5N3) via the air sac route. The strains had been passaged through air sacs or air sacs and brains of SPF chicks. Two experiments were undertaken to examine the pathogenicity of these strains and the development of brain lesions based on time-interval changes. In experiment 1, original strain (4e) showed low pathogenicity with mild respiratory signs and zero mortality. Air sac passaged strains (18a and 24a) of 4e demonstrated mortalities of 50% and 67%, respectively, and inoculated chicks showed hemorrhages and necrotic lesions in major organs. Air sac-brain passaged strain (24a5b) of 4e produced 100% mortality and severe nervous signs. Severe circulatory disturbance with multiple foci of necrosis in major organs including the brain was found in chicks inoculated with 24a5b. The 24a5b was analogous to highly pathogenic avian influenza virus in regard to its pathogenicity to chicks. Hence, low pathogenic influenza virus (4e) gradually aggravated its pathogenicity to highly pathogenic virus (24a5b) by air sac and brain passages. In experiment 2, chicks were inoculated with 24a5b, and the earliest histological lesion was the enlargement of the vascular endothelial cells at 18 hr post-inoculation (PI) followed by necrotizing encephalitis at 24 to 48 hr PI. Immunohistological staining revealed avian influenza virus antigen initially in the vascular endothelial cells and then in the astrocytes, neurons and ependyma.

Controlled trial of antithrombin III supplementation in fulminant hepatic failure

Patients with fulminant hepatic failure have severe circulatory disturbances which may be due to fibrin and cellular plugs in micro-vessels which are a consequence of intravascular coagulation and which can lead to multiorgan failure. Since antithrombin III supplementation has been shown to be beneficial in animal models of septic shock with disseminated intravascular coagulation, a controlled study was performed to investigate the effect of antithrombin III supplementation in fulminant hepatic failure. Twenty-five patients in grade III or IV coma were selected on the basis of evidence of sepsis, intravascular coagulation and a high risk of developing multiorgan failure. Thirteen patients received 3000 units of antithrombin III (Kybernin P; Behringwerke), followed by a further 1000 units every 6 h. Antithrombin III activity increased from 0.26 +/- 0.04 SE U/ml to 0.82 +/- 0.07 U/ml at 3 h post infusion (normal range 0.80-1.20 U/ml) and remained greater than 0.80 U/ml throughout the study without any apparent increase in the frequency of bleeding. However, survival was not improved and markers of intravascular coagulation remained similar between the two groups. Thus, although the antithrombin III deficiency in fulminant hepatic failure can be corrected by supplementation with antithrombin III concentrate, its use in the prevention of intravascular coagulation and to avoid microvessel plugging needs to be studied at an earlier stage in the disease.

A New Method for Repairing Skin Defects of the Lower Leg under Unsatisfactory Conditions

As a new procedure for the repair of tissue defects in the lower leg under unsatisfactory conditions, we have devised a surgical procedure for peroneal island flap transfer from the opposite sound leg. This report presents three patients treated by cross-leg island flaps with reversed blood flow. This procedure can be applied for reconstruction of the leg with severe circulatory disturbance caused by arterial damage due to trauma and arterial disease such as Buerger's disease. Furthermore, joint exercise is possible because the pedicle is long and no rigid immobilization is required.

振動障害患者の上下肢の冷え，しびれの自覚症状の解析

Coldness and numbness of the lower limbs in patients with vibration syndrome were studied in correlation with the frequency of attacks of vibration-induced white finger (VWF), coldness and numbness of the upper limbs, and awakening at night due to numbness of the arm. Subjects were 229 patients aged 50-69 years without disease other than vibration syndrome who had mainly operated chain saws. The present study showed that patients with more frequent VWF attacks had a higher prevalence and frequency of coldness in the fingers, awakening at night due to numbness of the arm, and coldness and numbness in the legs. Particularly patients having almost daily attacks of VWF had a high prevalence of these symptoms. Positive correlation was observed in prevalence and frequency between coldness of the fingers and that of the legs, and between coldness and numbness in the legs. The prevalence of VWF, numbness and coldness of the fingers, and coldness of the legs was higher the longer the total chain saw operating period. The present findings suggest that patients with severe circulatory disturbances in the upper limbs have severe circulatory disturbance in the lower limbs. Further studies on circulatory disturbances in the lower limbs are indicated, and their mechanism involved should be also pursued from the pathogenetic point of view.

Response of exposed pulp to composite resin in germ-free rat molars

The response of the pulp to the composite resin (Clearfil F) was histopathologically investigated in 23 germ-free rats. The upper first molar pulp was exposed with a #1/2 round bur through the mesial surface of the tooth and the cavity was arranged with a #33 1/2 inverted cone bur, and the composite resin was applied to the surface of the exposed pulp. The observation period was 2, 4, 7, 10 and 14 days postoperatively. The results indicated that the pulpal response to the composite resin was characterized by the initial weak inflammatory cell infiltration at 2, 4 and 7 days, followed by the reduced responses with evidence of newly formed calcified tissues at 10 and 14 days. However, moderate to severe circulatory disturbance was observed throughout the experimental period. From these findings, the composite resin proved to have an irritating potential on the rat molar pulp. The germ-free rats could be used as an excellent model to investigate the exposed pulp responses to the composite resin.

Comparative study on pathogenesis of selective cerebral lesions in carbon monoxide poisoning and nitrogen hypoxia in cats.

Since in a previous study hypoxia and subsequent hypotension were considered to be essential for the pathogenesis of carbon monoxide encephalopathy (CO-encephalopathy), experiments were conducted to see whether a combination of nitrogen hypoxia and subsequent systemic hypotension of similar degree and duration as in the previous experimental CO poisoning could induce the same lesion in the CNS of cats. The partial pressure of blood oxygen was reduced to less then 26 mm Hg by increasing the concentration of nitrogen in N2/O2 gas to be inhaled in 1.5h and then the aortic blood pressure (BP) was reduced to 60-80 mm Hg by blood depletion and ganglion-blockage for 1h. In 11 of the 15 cats, lesions were produced in the CNS which were similar by light and electron microscopy to those in CO-encephalopathy. In control groups which were treated by hypoxemia only, hypotension only or a combination CO2-gas inhalation and hypotension without hypoxemia, such lesions were not found in the cerebral white matter. Considering the pathogenesis of lesions in the cerebral white matter in both nitrogen hypoxia and CO-poisoning, two factors i.e., hypoxemia and subsequent systemic hypotension, are common and essential. Further, the enormous vasodilatation in the cerebral white matter induced by hypoxemia and subsequent drop in BP seem to cause a more severe circulatory disturbance in the cerebral white matter than in the cortex.

ACUTE DECOMPRESSION SICKNESS

A case of acute decompression sickness presenting severe clinical features was reported. At the time of autopsy, intra‐and extravascular air bubbles were found in various organs. Pulmonary fat embolism was also prominent in association with severe circulatory disturbances of the lungs. The spinal cord showed edematous and congestive swelling which was intimately related to the coagulation of blood within the epidural veins that contained innumerable fat droplets. Intravascular fat seemed to be created in and released from the injured adipose tissue, especially that of the bone marrow during decompression and to have acted as an accelerator of intravascular coagulation. The pathophysiological significance of the fat embolism for the development and the progression of decompression sickness is discussed.

Branchiomycosis of the Reared Japanese Eel in Taiwan

Branchiomycosis broke out among the reared Japanese eel (Anguilla japonica) in summer, 1977, in Taiwan. The causative fungus had characteristics similar to B. sanguinis.Fungal hyphae grew in the filamental arteries and lamella capillaries in the gills. Intrahyphal spore-formation was observed in the well grown hyphae. The affected lamellae showed severe circulatory disturbance as dilatation of capillaries, hemorrhages and fibrin deposition. Metastatic lesions with hyphae and spores were observed in the epicardium, but the spleen only spores.

Plasma volume estimation in severely ill infants and children using a simplified Evans blue method.

Plasma volume was measured using Evans blue dye and 125iodinated human serum albumin (RIHSA) simultaneously in order to evaluate the accuracy of a simplified Evans blue method recommended by Nielsen and Nielsen (1962). 9 studies were performed in 8 newborn infants weighing 1.07 to 2.85 kg and 16 studies in 14 patients aged 6 months to 14 years suffering from severe circulatory disturbances. In 20 studies, plasma volumes measured by Evans blue and by RIHSA agreed within +/-5%, and in all the studies within +/-10%. The Evans blue method yielded higher plasma volumes than the RIHSA method in 19 instances. The mean difference (paired t-test) was only significant in newborn infants (+4.0+/-3.6%; P less than 0.05). The disappearance rates of Evans blue exceeded that of RIHSA in 16 studies, but this was only significant in the patients older than 6 months (+2.3+/-4.2%/h; P less than 0.05).

A histopathological study on diabetic nephropathy -- light and electron microscopic observations.

A historical review and the present author's study on diabetic nephropathy have been presented. Three characteristic lesions in KW-lesion, namely nodular, exudative and doughnut lesion may all be regarded as to be caused by severe circulatory disturbance occurring in intraglomerular branches of the afferent artery. This circulatory disturbance is considered to be brought about by sudden spasm of the peripheral portion of the afferent branches. The diffuse form of Bell may be regarded as to be a slighter type without severe mesangiolysis. Arteriolar hyalinosis and arteriosclerosis and/or atherosclerosis may be caused by intraglomerular circulatory disturbances. The most important problem in diabetic nephropathy, including KW-lesion and Bell's diffuse form, is to elucidate the mechanism leading to the occurrence of spasm of the peripheral portion of intraglomerular afferent branches. Becker found fixation of antiactomyosin-antibody in the mesangial tissue by the immunofluorescent method. Many studies along this line have been made, but none are adequate in fully explaining the mechanism involved.

Two-stage occulsion of the protal vein in the rat:survival related to weight variation and the interval between partial and total occulusion.

A portal vein stenosis with a diameter of 1.1 mm was performed in female Wistar rats of four different weight groups. The mortality rate was found to increase with increasing weight of the animals, a near linear correlation between mortality rate and body weight being found. Severe circulatory disturbances of the small intestine with haemorrhage and necrosis of the bowel wall were a prominent finding at death. In the survivors total occulsion was carried out at varying times, from 48 h after the first operation, and the mortality rates were recorded. A major contributing cause of death appeared to be ischaemic infarction of the liver. Only a slight congestion of the duodenum was found and no circulatory disturbance of the small intestine. Thus by 48 h the porto-systemic collaterals are sifficiently developed to prevent subsequent venous congestion. The survival rates showed a significant increase when the time interval between partial and total occlusion was extended from 48 to 72 h. This may be due to an increased blood flow through the hepatic artery and collateral arteries to the liver.

Ischemic Forms of Venous Thrombosis: Phlegamasia Cerulea Dolens Venoys Gangrene.

This small text is devoted to the severe circulatory disturbances of the extremities secondary to venous thrombosis which are covered by a variety of terms, including phlegmasia cerulea dolens. Of the 230 pages, 73 are taken up with extensive tables listing individual cases of venous occlusion and adding little if anything to the substance of the text. Such space would more profitably have been used for more of the excellent photographs which are already present in the text but in small number. Although the author distinguishes between the various types of venous thrombosis and between venous thrombosis and arterial embolism in the chapter on diagnosis, the earlier discussions shift too rapidly back and forth between the different types of venous thrombosis, which are not clearly separated. The reader has difficulty in being certain which condition is being discussed without considerable rereading. The section on pathologic physiology reviews the pertinent literature

Ischemic Forms of Venous Thrombosis—Phlegmasia Cerulea Dolens; Venous Gangrene.

severe circulatory disturbances of the extremities secondary to venous thrombosis which are covered by a variety of terms, including phlegmasia cerulea dolens. Of the 230 pages, 73 are taken up with extensive tables listing individual cases of venous occlusion and adding little if anything to the substance of the text. Such space would more profitably have been used for more of the excellent photographs which are already present in the text but in small number. Although the author distinguishes between the various types of venous thrombosis and between venous thrombosis and arterial embolism in the chapter on diagnosis, the earlier discussions shift too rapidly back and forth between the different types of

Anomalous drainage of entire pulmonary venous system into left innominate vein: clinical and surgical considerations.

Total anomalous drainage of pulmonary venous blood produces a severe circulatory disturbance. In the most common type of this category of lesions, the entire venous return from the lungs enters a common venous channel ascending in the left superior mediastinum where it connects with the innominate vein. Seven cases of this type are described. Successful total correction was possible in 4 of these patients in whom a special technic was used, which incorporated the pump oxygenator for temporary cardiopulmonary bypass. This technic provides optimum conditions for complete correction of this complicated anomaly.