Severe Complications Research Articles

Abstract 4129195: Mechanisms of Healthy Aging in the Prevention of Atrial Fibrillation

Introduction: Atrial Fibrillation (AF) is the most frequent cardiac arrhythmia. AF can lead to severe complications such as myocardial infarction, strokes, and sudden death. With 70% of AF patients aged 65 and older, aging stands as the major risk factor for AF. Our group have recently contributed to reveal that old Wistar rats (20 months) are more susceptible to AF than younger rats (5 months). Interestingly, Lou/c/jall (LOU) rats, a model of healthy aging derived from Wistar rats, can live up to ~35 months old (equivalent to 100 human years). LOU rats have been identified as resistant to age-related diseases such as obesity, hypertension, and neurodegenerative disorders, which are major risk factors for AF. However, the susceptibility of LOU rats to AF have never been reported. Hypothesis: LOU rats may carry specific molecular adaptations conferring resistance to age-related cardiac remodeling and low AF vulnerability. Objectives: Characterize the vulnerability of very old LOU rats (32 months) to AF compared to old Wistar rats (22 months). Determine the atrial inflammatory profile of LOU rats and identify the molecular adaptations that may explain their resistance to AF Methods: Male and Female rats were divided into five groups: LOU and Wistar rats of 5 months (young), 20 months (old), and 32 months (very old: LOU/c rats only). AF inducibility was assessed in vivo using transesophageal electrophysiological study and cardiac structure and function were analyzed by in vivo echocardiography. Atrial electrical conduction was examined using ex vivo optical mapping. Histological analyses were performed to assess atrial fibrosis. Additionally, immunoblot analysis, qPCR, and RNA sequencing were employed to investigate the levels of biomarkers involved in atrial inflammation and fibrosis. Result: Old Wistar rats were more vulnerable to AF than young rats. Old and very old LOU were significantly more resistant to AF than old Wistar animals. LOU rats’ low susceptibility to AF was accompanied with absence of cardiac structural and functional remodeling and low levels of atrial fibrosis compared to old Wistar. Additionally, advanced age did not affect LOU rats’ atrial electrical conduction properties as compared to old Wistar rats. Conclusion: Promotion of healthy aging conditions mimicking LOU rats’ resistance to cardiac remodeling and reduction of atrial fibrosis may contribute to prevent AF in subjects with pathological aging.

Can Radiological Renal Artery Parameters Predict Acute Kidney Injury in Infective Endocarditis Surgery?—From Imaging to Outcomes

Background: Infective endocarditis (IE) poses significant challenges in cardiovascular medicine, often necessitating valvular surgery to manage severe complications. Postoperative acute kidney injury (AKI) is a notable complication affecting patient outcomes. While clinical and procedural factors have been well studied, the role of radiological renal artery parameters in AKI risk remains underexplored. Methods: This retrospective study analyzed 80 patients with IE who underwent valvular surgery from 2013 to 2021, focusing on postoperative AKI as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Radiological parameters, including renal artery calcification, renal ostial calcification, the presence of renal infarctions, and additional arteries, were assessed using preoperative computed tomography (CT). Statistical analyses included binary logistic and linear regression models, Kaplan–Meier survival curves, and Cox proportional hazard regression to explore associations between these parameters and AKI incidence, creatinine levels, and mortality. Results: Out of 80 patients, 31 (38.8%) developed AKI. No significant differences were found in baseline characteristics or radiological parameters between the AKI+ and AKI− groups. Binary logistic and linear regression analyses revealed no substantial relationship between anatomical factors and AKI risk or creatinine levels. However, Cox regression identified “additional renal artery” as a significant predictor of 1-month mortality (HR: 1.747, 95% CI: 1.024–2.979, p = 0.041) but not for 6- or 12-month mortality. Conclusions: Radiological anatomical factors, including calcifications and additional arteries, did not significantly impact AKI risk in IE patients undergoing valvular surgery. However, the presence of additional arteries was associated with increased short-term mortality. These findings suggest the need for further research to elucidate factors contributing to AKI and mortality in this context.

Abstract 4121816: Viral Venture: A Case of Myocarditis and IgA Vasculitis from Adenovirus Infection

Case Description: A 19-year-old man presented to the emergency department for 3 days of shortness of breath, progressive bilateral lower extremity rash, generalized fatigue, and diffuse joint following an earlier visit to urgent care for pharyngitis symptoms. Physical exam was notable for tachycardia, pain with active wrist and ankle range of motion, pharyngeal erythema, cervical adenopathy, and confluent erythematous palpable purpura and petechiae noted on bilateral lower extremities with scattered lesions on his thighs, arms, and back. Laboratory workup notable for markedly elevated high-sensitivity troponin to 3398 ng/L, and elevated CRP. Further workup was notable for normal urinalysis, negative streptococcus antigen, negative ANCA antibodies, ANA, Hepatitis B and C, and cryoglobulins. Imaging and cardiac workup were notable for normal left ventricular function and cardiac MRI notable for late gadolinium enhancement in the anteroapical mid-myocardial region suggestive of myocarditis. Skin biopsy ultimately revealed immunodeposition of IgA on superficial capillaries compatible with a diagnosis of IgA vasculitis. The patient was started on steroids for IgA vasculitis with rapid improvement in his symptoms and he was discharged home in good condition. Discussion: Recognizing the severe complications of viral infection can lead to prompt treatment and prevention of progression to severe end organ damage. Our case highlights rarely reported cardiac involvement of IgA vasculitis secondary to adenovirus infection based on laboratory and imaging diagnosis with cardiac MRI. To date, only 16 cases of cardiac involvement in IgA vasculitis have been reported. This case adds to the limited body of published cases describing this presentation of IgA vasculitis and is also consistent with the results of prior cases suggesting that an immunosuppressive regimen including glucocorticoids may help to prevent disease progression and induce remission in cases with cardiac involvement without the need for endomyocardial biopsy.

Abstract 4135212: An Overlap Between Takotsubo Cardiomyopathy and Hypertrophic Obstructive Cardiomyopathy Causing Dynamic Left Ventricular Outflow Tract Obstruction: A Unique Case Report

Background: Takotsubo cardiomyopathy (TC) can cause dynamic left ventricular outflow tract (LVOT) obstruction leading to cardiogenic shock. Due to differential wall-motion abnormalities, flow acceleration in the LVOT can lead to systolic anterior motion (SAM) of the mitral valve which worsens LVOT obstruction and leads to hemodynamic compromise. We present a case of overlap between TC and hypertrophic obstructive cardiomyopathy (HOCM) with worsening LVOT obstruction leading to cardiogenic shock. Case: A 76-year-old female presented with typical chest pain, nausea, and worsening shortness of breath. On examination, she was hypotensive and cold to touch. EKG showed T-wave inversions in lateral leads with elevated cardiac troponins. Coronary angiogram showed non-obstructive coronary artery disease, and right heart catheterization revealed elevated filling pressures. Transthoracic echocardiogram (TTE) showed septal hypertrophy and SAM of the mitral valve causing dynamic LVOT obstruction (Figure 1) and ejection fraction (EF) of 20%. TTE with contrast showed apical ballooning consistent with TC (Figure 2). Decision Making: Initially with diuresis, she became hypotensive so it was stopped and she received controlled intravenous fluids along with phenylephrine to reduce LVOT obstruction. Her blood pressure improved and she was started on low-dose metoprolol succinate along with ivabradine to reduce heart rate. She tolerated this therapy and hemodynamics stabilized. Conclusion: Cardiogenic shock can be a severe complication of TC. Early detection of LVOT obstruction in cardiogenic shock is important as traditional management strategies of increased inotropy and reduction of afterload can be fatal in these cases. The treatment strategy focuses on reducing the LVOT gradient and includes fluid administration to increase preload, beta-blockers to increase diastolic filling time, and vasopressors to raise afterload.

Abstract 4137833: The plasma cell-free transcriptome non-invasively profiles the immune response and myocardial damage in immune checkpoint inhibitor-induced myocarditis.

Introduction: Immune checkpoint inhibitor-induced myocarditis (ICI-m) is a severe complication of cancer immunotherapy, marked by cardiac inflammation. Despite its high mortality rate, diagnosing ICI-m remains challenging due to the lack of sensitive and non-invasive diagnostic modalities. Plasma cell-free mRNA (cf-mRNA) has recently been highlighted as a promising tool for non-invasive tissue profiling. Hypothesis: The plasma cf-mRNA profile contains disease-specific immune and tissue transcriptomic signatures of ICI-m that can be leveraged for disease-specific precision diagnostics. Aims: To establish and validate a novel cf-mRNA bench and bioinformatic pipeline for noninvasive profiling of the immune and tissue landscape of patients with ICI-m. Methods: We isolated, DNase-treated, and sequenced bulk cfRNA from frozen plasma of patients with ICI-treated cancer patients with no autoimmunity (group A, n=5), extracardiac autoimmunity (group B, n=7), and ICI-m with or without extracardiac autoimmunity (group C, n=10). Publicly available healthy control cfRNA was downloaded (n=30) as external controls. We used cell type-specific gene panels curated from single-cell RNA-sequencing datasets of circulating immune cells and cardiac cells for cellular deconvolution of the cf-mRNA. Signature scores of the sum of the counts of each cell type-specific gene were used to compare cell type contributions between patient groups. Results: Cancer and inflammatory gene pathways were significantly enriched in the cf-mRNA of all ICI-treated cancer patients. Cardiac pathways and conduction genes were significantly enriched in group C vs. A and B patients. Signature scores of Temra CD8+ T cells and cardiomyocytes, and gene expression of CCL5 and MYH6 were elevated in group C patients. Our custom ICI-m classifier containing 3 cardiac- and 3 immune cell-specific genes differentiated group C from A (AUC 0.903, 95% CI 0.858-0.903) and B patients (AUC 0.983, 95% CI 0.970-0.983) effectively, outperforming a diagnostic classifier obtained from unsupervised feature selection from all differentially expressed genes. Conclusions: Using our novel plasma cf-mRNA platform, we developed a diagnostic classifier that captures the disease-specific immune and tissue transcriptomic signatures of ICI-m, highlighting the advantages of this disease-specific approach over conventional biomarker discovery, and demonstrating the broader implications of the platform for the field of precision diagnostics.

Abstract 4117690: Cardiac Rupture as a Life-Threatening Outcome of Takotsubo Syndrome: A Systematic Review.

Background: Takotsubo syndrome is a reversible cause of heart failure; however, a low percentage of patients can develop serious complications, including cardiac rupture. Aims: Analyze case reports or case series of cardiac rupture in patients with Takotsubo syndrome, detailing patient characteristics to uncover risk factors and prognosis for this severe complication. Methods: We conducted a systematic search of MEDLINE and Embase databases to identify case reports or case series of patients with Takotsubo syndrome complicated by cardiac rupture, from inception to October 2023. Results: We identified 39 reported cases, including 44 subjects (40 females; 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity. An emotional trigger was present in 15 (34%) subjects and common admission symptoms were chest pain (35 [80%]) and dyspnea (14 [32%]). ST-segment elevation was present in 39 (93%) of 42 cases, with the anterior myocardial segments (37 [88%]) being the most compromised, followed by lateral (26 [62%]) and inferior (14 [33%]) segments. The mean left ventricular ejection fraction was 40±13% and an apical ballooning pattern was observed in all (100%) ventriculographies. The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery treatment was attempted in 16 (36%) cases, and 28 (64%) patients did not survive (Figure). Conclusions: Cardiac rupture as a complication of Takotsubo syndrome is a rare clinical condition associated with high mortality. Elderly females, especially from White/Caucasian or East Asian/Japanese descent, presenting with ST-segment elevation in the anterior or lateral leads, and an apical ballooning pattern, are disproportionally affected. Additional studies with prospective collection of patient-level data are needed to better identify those at increased risk for cardiac rupture associated with Takotsubo syndrome and to address ways to improve mortality rates in this population.

Updated risk prediction model for pancreaticoduodenectomy using data from the National Clinical Database in Japan

AbstractAimRisk prediction models for mortality, severe postoperative complications, and postoperative pancreatic fistula in patients undergoing pancreaticoduodenectomy were established using data from the National Clinical Database more than a decade ago, and the surgical outcomes of pancreaticoduodenectomy have improved over the years. The aim of this study is to update the risk prediction model for pancreaticoduodenectomy using National Clinical Database data.MethodsBetween 2019 and 2021, the data of 35 365 patients who underwent pancreaticoduodenectomy and who were registered in the National Clinical Database were retrospectively analyzed. According to the registration year, the patients were divided into two cohorts: the development cohort (2019–2020; n = 23 654) and the validation cohort (2021; n = 11 711). Logistic regression analyses were performed to create risk models for surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula.ResultsOverall, the rates of surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula were 1.8%, 2.2%, and 1.3%, respectively. Logistic regression analyses revealed 28, 28, and 14 risk factors for surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula, respectively. The area under the receiver operating characteristic curve of the risk model in the development cohort was 0.759 for surgical mortality, 0.712 for severe complications, and 0.699 for postoperative pancreatic fistula, comparable to the validation cohort. The calibration plots were favorable in both cohorts.ConclusionThe updated risk model for pancreaticoduodenectomy will be useful to predict surgical mortality, severe postoperative complications, and grade C postoperative pancreatic fistula.

Role of DDR1 in Regulating MMPs in External Root Resorption

Human periodontal ligament cells (hPDLCs) express matrix metalloproteinases (MMPs), a group of enzymes responsible for the destruction of most extracellular matrix proteins in dental tissues, especially MMP-1, MMP-2, and MMP-13. Exploring the regulatory mechanism of MMPs is crucial for understanding external root resorption (ERR), one of the most severe complications, along with substantial loss of dental tissue, induced by trauma, pulpal infection, tooth bleaching, and orthodontic treatment, etc. Discoidin domain receptor 1 (DDR1), a cell surface receptor binding to collagen, has the potential to regulate the expression of MMP-1, MMP-2, and MMP-13, but the mechanism remains unclear. Thus, the present study aimed to investigate the connection and underlying mechanism between MMP-1, MMP-2, MMP-13, and DDR1 in hPDLCs. Our post-replantation ERR model revealed that Mmp-1, Mmp-2, Mmp-13, and Ddr1 all increased in the sites of ERR. hPDLCs with DDR1 knockdown exhibited a substantial reduction in MMP-1, MMP-2, and MMP-13 expression. To further confirm the underlying mechanism, we conducted further in vitro experiments, including RNA sequencing, RNA interference, RT-qPCR, Western blotting, and ELISA. Based on our results, MMP-1 was positively regulated by the Smad2/3 and MEK-ERK1/2 pathways and negatively regulated by the PI3K-Akt pathway through CCN2. MMP-2 and MMP-13 were positively regulated by the Smad2/3 pathway. MMP-13 was positively regulated by the MEK-ERK1/2 and PI3K/Akt signaling pathways. Collectively, DDR1 is a potent regulator of MMP-1, MMP-2, and MMP-13 expression through the Smad2/3, MEK-ERK1/2, and PI3K/Akt signaling pathways. Clarifying the significance and underlying mechanism by which DDR1 is involved in ERR might bring the chances to hinder the pathogenic process of ERR, hence reducing its incidence rate.

Clinical characteristics and associated factors of pediatric acute necrotizing encephalopathy: a retrospective study.

In the clinic, pediatric acute necrotizing encephalopathy (ANE) primarily affects children under five years of age and is characterized by severe brain damage and high mortality. However, some challenges remain regarding the diagnosis and treatment of ANE. In the present study, we analyzed the clinical characteristics and related factors of ANE with the aim of providing improved diagnostic and treatment strategies. Thirty-four pediatric ANE patients admitted to Zhejiang University School of Medicine Hospital between February 2019 and December 2023 were included in this study. To identify the factors associated with mortality, clinical, laboratory and imaging data were analyzed with independent-sample t tests, Mann‒Whitney U tests, Fisher's exact probability tests and receiver operating characteristic (ROC) curve analyses. In this cohort of 34 patients, the most common symptoms were fever, seizures, altered consciousness, vomiting, diarrhea and shock. The mortality rate was 55.9%. Laboratory tests revealed that patients who died had higher creatinine, lactate, activated partial thromboplastin time (APTT), thrombin time (TT), interleukin-6 (IL-6), interleukin-10 (IL-10), creatine kinase (CK), and D-dimer than survivors. Imaging examinations predominantly revealed symmetrical lesions in the thalamus. The fatal group displayed lower Glasgow Coma Scale (GCS) scores and severe complications. Other factors related to mortality included the arterial pH, GCS score and hospitalization duration. The most common symptoms of ANE are fever, seizures, altered consciousness, vomiting, diarrhea and shock, and ANE has a high mortality rate. The GCS score and arterial pH are critical biomarkers for assessing the severity of ANE.

Prognostic impact of a 3-week multimodal prehabilitation program on frail elderly patients undergoing elective gastric cancer surgery: a randomized trial.

Research indicates that prehabilitation is effective in optimizing physical status before surgery, although this method may be considered "aggressive" for frail elderly patients. This study aimed to evaluate whether multimodal prehabilitation decreases postoperative complications and improves functional recovery in frail elderly patients undergoing gastric cancer surgery, in comparison to usual clinical care. This study was a single-center, single-blind, randomized controlled trial. Patients over 65 years old with a Fried Frailty Index of 2 or higher, scheduled for gastric cancer surgery, were considered for inclusion. Eligible participants were randomized in a 1:1 ratio to either the intervention or control group. The intervention group underwent a 3-week multimodal prehabilitation program prior to surgery, in addition to perioperative care guided by ERAS protocols. The control group received only the latter. The primary outcome was the comprehensive complications index (CCI) measured at 30 days after surgery. Secondary outcomes included 30-day overall complications, functional walking capacity as assessed by 6-minute walking distance (6MWD) at 4 weeks postoperatively, and 3-month postoperative quality of life. This study was registered at ClinicalTrials.gov (No. NCT06510088). Among the 112 eligible patients, the median age was 74 years, with 58 (52.7%) being female.No between-group difference was found in the primary outcome measure, 30-day CCI. The Median (Q1-Q3) CCI for the intervention and control groups was 0 (0-12.2) and 0 (0-22.6) (P = 0.082), while the mean (SD) CCI was 6.1 (15.8) and 9.8 (12.7), respectively (P = 0.291). Notably, the incidence of severe complications (CCI > 20) was significantly lower in the intervention group compared to the control group (11.1% vs. 25.9%, P = 0.046), particularly in terms of medical complications (12.3% vs. 29.3%, P = 0.025). Preoperatively, 27 patients (47.4%) in the intervention group exhibited an increase in the 6MWD of at least 20m, compared to 16 patients (27.6%) in the control group (P = 0.028). At 4 weeks postoperatively, more patients in the intervention group returned to their baseline 6MWD levels (63.2% vs. 43.1%, P = 0.031). Secondary parameters of functional capacity in the postoperative period generally favored the multimodal prehabilitation approach. In frail elderly patients undergoing elective gastric cancer surgery, a prehabilitation program did not affect the 30-day postoperative complication rate or CCI but reduced severe complications and improved perioperative functional capacity. [ClinicalTrials.gov], [NCT06510088], [07/15/2024], [Retrospectively registered].

Using Extracorporeal Shockwave Therapy in Patients with Orthopedic Conditions

Background: Among other non-invasive procedures, Extracorporeal Shockwave Treatment (ESWT) has been used to resolve many musculoskeletal ailments. The authors completed a systematic review to study articles that reported the effectiveness of focused shockwave therapy in patients with orthopedic conditions. Methods: A comprehensive search was conducted across reputable databases including Pub Med, The Cochrane Library, Science Direct, PEDro, Clinicaltrials.gov, and Google Scholar, ensuring a thorough review of the literature until October 10, 2022. Original articles of any design reporting on the use of ESWT in orthopedic patients were meticulously selected. Information related to study design, sample size, participants, intervention, and key findings of the study were extracted. The PEDro classification scale, a recognized tool, was used to evaluate the quality of the studies, further enhancing the credibility of findings. Results: Nineteen research articles (including 1157 participants) were retrieved and included for qualitative analysis. The sample size ranged from twenty-one to one hundred fifteen subjects, and the articles were published between 2001 and 2022. Out of 19 studies published, five were conducted in China, three in Germany, two in Iran and Turkey, and one in the United States, Canada, Italy, Denmark, Spain, Taiwan, and Saudi Arabia. The risk of bias was either moderate or low among the included studies. In patients with various orthopedic conditions, considerable moderate evidence of ESWT’s effectiveness and success in lowering pain levels, increasing treatment success rates, promoting patient-reported functional recovery, and raising performance-based functional outcomes was seen in the results. Conclusion: The systematic literature review provided compelling evidence of the successful application of ESWT in treating a wide range of musculoskeletal problems. These positive outcomes were achieved without severe complications and morbidities, offering a promising outlook for the future of orthopedic treatment.

ETIOPATHOGENETIC MECHANISMS OF IMMUNE DYSFUNCTION IN COMBATANTS WITH LOWER LIMB SOFT TISSUE INJURIES UNDER CHRONIC STRESS

Introduction. Combat injuries, including gunshot, shrapnel, and mine-explosive wounds, affect a significant number of soldiers in modern warfare. Notably, most of these injuries involve damage to the soft tissues of the extremities. Surgeons have expressed concerns regarding the unsatisfactory treatment outcomes in this group of combatants, attributing one of the primary challenges to the limited understanding of immune dysfunction pathogenesis in military trauma cases. This study aims to address this gap by examining immune system dysfunctions in combat-related injuries. The objective of this study is to thoroughly analyze and synthesize the key stages of immune dysfunction occurring over extended periods post-combat trauma, including the subsequent development of traumatic disease and various wound complications. Materials and Methods. The rising prevalence of combat trauma among soldiers has intensified interest in studying this issue, prompting surgeons and traumatologists to address its various medical aspects comprehensively. The literature search focused on recent publications, allowing for a targeted analysis of the immunological aspects relevant to military medical traumatology. Results. In the initial stages of severe or combined injuries affecting various tissues—such as tubular bones, joints, blood vessels, and peripheral nerves—systemic inflammatory response syndrome (SIRS) commonly occurs. This stage is marked by an intense activation of innate antibacterial and immune-protective responses, leading to a significant increase in inflammation. This initial response is soon replaced by a prolonged phase known as compensatory anti-inflammatory response syndrome. During this period, immune-protective responses sharply decrease, certain immunocompetent cells become inhibited, and lymphopenia develops. This phase is often accompanied by infectious contamination of wounds with pathogenic and opportunistic microorganisms, resulting in both local purulent-necrotic processes and potentially severe systemic complications, such as septic shock, sepsis, multiple organ failure, and others. The final stage, known as persistent inflammatory, immunosuppressive, catabolic syndrome, is characterized by the chronic progression of traumatic disease, accompanied by ongoing immune system dysfunction in combatants. Conclusion. In the early period of traumatic injury, the wounded experience sharp inflammatory processes and activation of immune defense mechanisms. At subsequent stages, severe disruptions in the functioning of the immune system, damage to internal organs, and the development of catabolic syndrome are recorded. These changes, especially those resulted from exposure to chronic combat stress preceding the injury, aggravate the processes of infectious decontamination of wounds, regeneration of damaged tissues, and the general process of combatant rehabilitation.

An unusual late complication of peridural anesthesia: The case of a subdural spinal epidermoid cyst: A case report and literature review

The peridural approach is primarily used today to provide analgesia in obstetrics and postoperative care. Peridural analgesia is not only more effective than systemic analgesia, but it also has benefits in terms of morbidity, particularly regarding postoperative respiratory complications and the shortened duration of postoperative ileus. Unlike dural tears, immediate and severe neurological complications such as hematomas or abscesses are very rare. Long-term sequelae are less well known because the relationship with epidural analgesia performed several months or years earlier is not always well established. We report a rare case of a 35-year-old patient with a history of epidural anesthesia five years ago during childbirth, who was admitted with cauda equina syndrome. MRI (magnetic resonance imaging) of the lumbar spine showed a subdural lesion at the level of L3. The patient underwent resection of the lesion, and the pathological examination of the surgical specimen concluded it was an epidermoid cyst.

Critical role of Babesia bovis spherical body protein 3 in ridge formation on infected red blood cells.

Babesia bovis, an apicomplexan intraerythrocytic protozoan parasite, causes serious economic loss to cattle industries around the world. Infection with this parasite leads to accumulation of infected red blood cells (iRBCs) in the brain microvasculature that results in severe clinical complications known as cerebral babesiosis. Throughout its growth within iRBCs, the parasite exports various proteins to the iRBCs that lead to the formation of protrusions known as "ridges" on the surface of iRBCs, which serve as sites for cytoadhesion to endothelial cells. Spherical body proteins (SBPs; proteins secreted from spherical bodies, which are organelles specific to Piroplasmida) are exported into iRBCs, and four proteins (SBP1-4) have been reported to date. In this study, we elucidated the function of SBP3 using an inducible gene knockdown (KD) system. Localization of SBP3 was assessed by immunofluorescence assay, and only partial colocalization was detected between SBP3 and SBP4 inside the iRBCs. In contrast, colocalization was observed with VESA-1, which is a major parasite ligand responsible for the cytoadhesion. Immunoelectron microscopy confirmed localization of SBP3 at the ridges. SBP3 KD was performed using the glmS system, and effective KD was confirmed by Western blotting, immunofluorescence assay, and RNA-seq analysis. The SBP3 KD parasites showed severe growth defect suggesting its importance for parasite survival in the iRBCs. VESA-1 on the surface of iRBCs was scarcely detected in SBP3 KD parasites, whereas SBP4 was still detected in the iRBCs. Moreover, abolition of ridges on the iRBCs and reduction of iRBCs cytoadhesion to the bovine brain endothelial cells were observed in SBP3 KD parasites. Immunoprecipitation followed by mass spectrometry analysis detected the host Band 3 multiprotein complex, suggesting an association of SBP3 with iRBC cytoskeleton proteins. Taken together, this study revealed the vital role of SBP3 in ridge formation and its significance in the pathogenesis of cerebral babesiosis.

Diagnostics and Surgical Treatment of Deep Endometriosis—Real-World Data from a Large Endometriosis Center

Background: Deep endometriosis (DE) is a special form of endometriosis, one of the most common benign diseases in gynecology. In the specific case of DE, ectopic endometrium can be found not only in peritoneal but also in deeper tissue layers or even as parenchymal organ infiltration. Symptoms include dysmenorrhea, dyspareunia, dyschezia, and dysuria, as well as asymptomatic hydronephrosis or other organ dysfunctions. Due to a pathogenesis of the disease that has not been conclusively clarified to date, no causal therapy exists, which is why surgical resection of DE is still the gold standard for symptomatic cases. Methods: This article retrospectively describes the challenges in diagnosis and surgical treatment of DE at a German Level III Endometriosis Center, with a focus on diagnosis and surgical treatment, as well as the analysis of perioperative and postoperative complications. Results: The surgical treatment of DE is performed in most cases by minimally invasive laparoscopy (94.1%), whereas complex procedures such as ureterolysis, adhesiolysis, or preparation of the rectovaginal septum are considered standard procedures as well. The complexity of the procedures is further underlined by a high need for interdisciplinary operations (28%). Despite high complexity, severe postoperative complications occurred in only 3.1% of surgeries, with the complication rate being significantly higher whenever bowel surgery was necessary for DE resection. Conclusions: Our results emphasize the complexity and interdisciplinary nature of the disease. Therefore, treatment should preferably take place at an endometriosis center of the highest level with experienced, well-coordinated teams.

Postoperative groin lymphocele: an overview of old and new therapeutical strategies

Lymphatic complications (lymphoma and lymphorrae) following vascular access or interventions in the groin are frequently benign but may increase the risk of wound infection, need for reintervention, and prolong the length of the hospital stay. Several management strategies have been developed so far, including percutaneous drainage, chemical sclerotherapy, and surgery, but a validated treatment algorithm has yet to be established in the current literature. In this paper, the authors investigated the indications and outcomes of currently available strategies for treating groin lymphocele following surgical dissection of the femoral vessels and suggested an algorithm for treating this potentially severe complication.

Tolerability of perioperative chemotherapy for gastric cancer in real clinical practice

Background. The choice of the optimal scheme of perioperative chemotherapy of locally advanced gastric cancer is an urgent problem in real clinical practice. Aim. To analyze therapy tolerability in this cohort of patients. Materials and methods. Perioperative chemotherapy of gastric cancer was performed in 90 patients in the Chemotherapy Department of the Oncology Center №1 of the Yudin City Clinical Hospital from January 2021 to February 2024. Results. The incidence of severe complications at the preoperative stage was 41.9% for the FOLFOX regimen and 40.7% for the FLOT regimen, at the adjuvant stage – 17.4 and 43.2%, respectively. Operative treatment was successfully performed in 79 (87.8%) patients, and the full scope of combined treatment of locally advanced gastric cancer was completed in 59 (65%) patients. 80.8% of pathomorphologic responses in the FOLFOX group and 67.9% in the FLOT group were TRG3-4, with complete response noted in only one patient. Conclusion. High toxicity rates in elderly and comorbid patients on the FOLFOX regimen require the development of an individualized approach to the treatment of this group of patients.

Comprehensive Management of Cholesteatoma in Otitis Media: Diagnostic Challenges, Imaging Advances, and Surgical Outcome

Background: This study presents a comprehensive analysis of cholesteatoma of the middle ear, focusing on its clinical presentation, diagnostic imaging, and treatment outcomes. Cholesteatomas are defined by the keratinized squamous epithelium within the middle ear, leading to significant bone erosion, often affecting the ossicular chain and surrounding structures. Methods: The study explores various mechanisms involved in cholesteatoma progression, including enzymatic lysis, inflammatory responses, and neurotrophic disturbances. The study conducted a retrospective clinical and statistical review of 580 patients over a 20-year period (2003–2023), highlighting the role of advanced imaging, including computed tomography (CT) and diffusion-weighted magnetic resonance imaging (DWI), in preoperative planning and postoperative follow-up. Results: Findings revealed that early detection and intervention are crucial in preventing severe complications such as intracranial infection and hearing loss. Surgical treatment primarily involved tympanoplasty and mastoidectomy, with a recurrence rate of 1.55% within two years. The study underscores the importance of integrating imaging advancements into clinical decision-making to enhance patient outcomes and suggests further investigation into molecular mechanisms underlying cholesteatoma progression and recurrence. Histopathological and microbiological analysis was performed to identify pathological patterns and microbial agents. Conclusions: The study highlights the importance of early diagnosis and intervention to prevent complications such as intracranial infections and permanent hearing loss, while also emphasizing the role of advanced imaging techniques in the management and long-term monitoring of cholesteatoma patients.

Respiratory variation of velocity time integral and peak velocity of left ventricular outflow tract for predicting hypotension after induction of general anesthesia in elderly patients.

Hypotension after induction of general anesthesia may lead to severe complications in elderly patients. This study investigated whether the respiratory variation of velocity time integral (ΔVTI) and peak velocity (ΔVpeak) of left ventricular outflow tract (LVOT) could predict hypotension after induction of general anesthesia in elderly patients. 120 elderly patients undergoing selective operation under general anesthesia were enrolled in this study. ΔVTI and ΔVpeak of LVOT were measured by transthoracic echocardiography before induction of general anesthesia. After induction, mean arterial pressure (MAP) was recorded every 1 minute for 15 min. Hypotension was defined as a decrease of more than 30% in MAP at baseline or MAP below 65 mmHg from the start of induction. Receiver operating characteristic curves with gray zone and multivariate logistic regression analysis were used to assess the ability of ΔVTI and ΔVpeak of LVOT to predict hypotension after induction of general anesthesia. Hypotension occurred in 64 (53.3%) patients after induction of general anesthesia. The area under receiver operating characteristic curves (AUC) for ΔVpeak of LVOT to predict hypotension after induction of general anesthesia was 0.811, and the optimal cutoff value was 13.1% with a gray zone of 9.9% to 13.8%, including 45.0% of patients. The AUC for ΔVTI of LVOT was 0.890, and the optimal cutoff value was 13.8% with a gray zone of 11.1% to 13.9%, including 25.8% of patients. After adjusting for confounders, ΔVTI (Odds ratio = 2.24) and ΔVpeak (Odds ratio = 2.09) of LVOT were two significant independent predictors of hypotension after induction of general anesthesia. ΔVTI of LVOT was a reliable predictor of hypotension after the induction of general anesthesia in elderly patients. ΔVpeak of LVOT should be used cautiously to predict hypotension after induction of general anesthesia due to nearly half of elderly patients in the gray zone.Trial registrationThis study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR2300077117).

Colostomy formation in a peritoneal dialysis patient.

This case report discusses the complex management of a 46-year-old man with poorly controlled type 1 diabetes mellitus, stage 5 chronic kidney disease, and severe neuropathic complications, which led to bilateral leg amputations. The patient experienced persistent diarrhea due to diabetic neuropathy, significantly impairing his daily functioning. Despite transitioning from hemodialysis to peritoneal dialysis, the diarrhea persisted. A colostomy was subsequently performed, which, although it did not completely resolve the diarrhea, allowed for better control, improving the patient's self-care and independence. Notably, the catheter exit site was maintained on the opposite side of the abdomen. Despite initial concerns about the feasibility of peritoneal dialysis (PD) in patients with stomas, including the challenges of creating a stoma in patients with an existing PD catheter, this case demonstrates the successful continuation of PD following a colostomy. Traditionally, intestinal stomas have been viewed as a relative contraindication to PD due to risks such as leakage and infection. However, current guidelines recommend using extended catheters with a presternal exit site to minimize these risks. The patient's quality of life improved significantly after the colostomy, with no major complications observed during follow-up. This report underscores the importance of tailoring treatment to individual patient needs, balancing risks with potential well-being benefits, and highlights the necessity of interdisciplinary collaboration and adherence to best practices. Given the limited literature on PD in patients with intestinal stomas, this case contributes valuable clinical insights for future management.