Unequal Blood Research Articles

Management of Complete Aortic Dissection in a 65-Year-Old Male: A Case Report

Background: Aortic dissection is a life-threatening condition characterized by a tear in the aortic wall that separates its layers. Complete aortic dissection involves both the ascending and descending aorta, necessitating prompt diagnosis and intervention. We present a case report of a 65-year-old male with a complete aortic dissection and discuss the challenges and management strategies employed in his treatment. Case Presentation: A 75-year-old male with a history of hypertension presented to the emergency department with sudden-onset severe chest and back pain. Physical examination revealed unequal blood pressure readings in both arms, suggesting aortic involvement. Urgent computed tomography angiography (CTA) and TTE confirmed the diagnosis of a complete aortic dissection extending from the aortic root to the iliac arteries. The patient was promptly transferred to the operating room for surgical intervention. Discussion: The management of complete aortic dissection requires a multidisciplinary approach involving cardiovascular surgeons, interventional radiologists, and anesthesiologists. In this case, emergency surgery was performed to address the life-threatening condition. Aortic root replacement and ascending aorta repair were performed, followed by stent graft placement in the descending aorta to exclude the false lumen. Postoperative care involved close monitoring for potential complications such as renal dysfunction, paraplegia, and cardiac ischemia. Conclusion: Prompt diagnosis and appropriate surgical intervention are crucial in the management of complete aortic dissection. Collaboration among healthcare professionals is essential for optimizing patient outcomes. Further studies are warranted to assess long-term outcomes and identify strategies for preventing complications in patients with complete aortic dissection.

Fetal metabolic adaptations to cardiovascular stress in twin-twin transfusion syndrome

Monochorionic-diamniotic twin pregnancies are susceptible to unique complications arising from a single placenta shared by two fetuses. Twin-twin transfusion syndrome (TTTS) is a constellation of disturbances caused by unequal blood flow within the shared placenta giving rise to a major hemodynamic imbalance between the twins. Here, we applied TTTS as a model to uncover fetal metabolic adaptations to cardiovascular stress. We compared untargeted metabolomic analyses of amniotic fluid samples from severe TTTS cases vs. singleton controls. Amniotic fluid metabolites demonstrated alterations in fatty acid, glucose, and steroid hormone metabolism in TTTS. Among TTTS cases, unsupervised principal component analysis revealed two distinct clusters of disease defined by levels of glucose metabolites, amino acids, urea, and redox status. Our results suggest that the human fetal heart can adapt to hemodynamic stress by modulating its glucose metabolism and identify potential differences in the ability of individual fetuses to respond to cardiovascular stress.

Abstract 10875: Metabolic Reprogramming of the Failing Fetal Heart in Twin-Twin Transfusion Syndrome

Adult heart failure is associated with reactivation of the fetal metabolic program, including impaired mitochondrial oxidative phosphorylation and a shift toward glycolysis. In the fetus, the metabolic response to cardiac stress is less clear. We used twin-twin transfusion syndrome (TTTS) as a model to uncover metabolic adaptations of the fetus to cardiovascular stress. TTTS is a unique complication that occurs in monochorionic-diamniotic twins (one placenta, two amniotic sacs) when unequal blood flow between twins within the shared placenta is the set up for donor-recipient physiology (Fig 1a). This circulatory imbalance is detected by sonographic signs of donor hypovolemia and recipient hypervolemia. We analyzed second trimester amniotic fluid to identify alterations in metabolism of TTTS recipient twins (n=22) vs. singleton controls (n=10) using untargeted metabolomics (LC/MS). All TTTS cases were severe (stage III; abnormal Dopplers indicating increased afterload and/or right heart failure). Due to dilution of amniotic fluid molecules in TTTS, data for each sample was normalized to protein concentration. Evaluation of differential metabolites in TTTS cases revealed two distinct clusters of disease (Fig. 1b). Compared with TTTS cluster 1 and controls, cluster 2 showed significantly increased lactate and alanine production, and evidence of redox stress (Fig. 1c). No differences in clinical characteristics or outcomes were observed between TTTS cluster 1 vs. 2 (maternal age, gestational age, fetal sex, disease severity, preterm birth, and perinatal death). Our findings reveal subclinical heterogeneity of stage III TTTS and suggest that some fetuses undergo metabolic reprogramming under conditions of cardiac stress, shifting even further toward energy-efficient glucose utilization. These differences in fetal response may represent different points along the same spectrum vs. inherent differences in the ability of fetuses to adapt to stress.

How Can Eastern/Southern Mediterranean Countries Resolve Quality and Safety Issues in Transfusion Medicine?

Unlike their Western counterparts, some of the Eastern/Southern Mediterranean countries lack centralized coordinated blood transfusion services leading to an unequal blood safety level. This was recently highlighted by a recent World Health Organization (WHO) regional committee report in which WHO urges these countries to establish and implement a national blood system with well-coordinated blood transfusion activities and to make attempts to reach 100% voluntary non-remunerated blood donation. The objective is thus to meet the same levels or standards as Western countries in term of self-sufficiency and blood safety. This raises the question whether these countries can either comply with Western countries’ guidelines and experiences or develop their own safety scheme based on proper sociopolitical and economic features. Another option is to identify efficient and cost-effective strategies setup successfully in neighbor countries sharing cultural and economic features. To address this issue—and make an attempt to achieve this goal—we designed a number of surveys specifically addressed to Mediterranean countries, which were sent out to the national authorities; so far, five surveys aim at covering all aspects in blood collection, processing, testing, inventory and distribution, as well as patient immune-hematological testing and follow-up (including surveillance and vigilances). It is anticipated that such practice can help identifying and then sharing the more successful and cost-effective experiences, and be really focused on Mediterranean areas while not necessarily copying and pasting experiences designed for Western/Northern areas with significantly distinct situations.

Physiological role of erythrocyte nitric oxide.

Nitric oxide (NO) produced by endothelial cells interacts with erythrocyte through band 3 protein, being scavenged by haemoglobin. A signal transduction mechanism involving protein Gi and protein band 3 stimulates erythrocyte NO efflux when acetylcholine (ACh) binds to erythrocyte membrane acetylcholinesterase. Binding of normal plasma fibrinogen (Fib) levels, to erythrocyte membrane CD47 decreases the NO efflux. When high Fib concentration and ACh were present the efflux of NO from erythrocytes was normalized. The increased NO efflux from erythrocytes in presence of high Fib concentration and band 3 phosphorylation is reinforced in the presence of 4N1K an agonist peptide of CD47. When both Fib and 4N1K are present the NO efflux from erythrocytes is higher or not affected according lower or high levels of cAMP. Erythrocyte NO efflux in patients with systemic lupus erythematous and rheumatoid attrite was significantly negative associated with carotid intima-media thickness. In patients with amyotrophic lateral sclerosis erythrocyte NO content is preserved and an inverse association between respiratory function and NO efflux from the erythrocyte was verified. Sepsis patients before dead at 24 h showed higher efflux of NO from erythrocytes that worsening the blood sub lingual microcirculation observed by high unequal blood flow and high microvascular flow index. The in vivo animal models either of inflammation or of hypertension evidenced that the NO efflux from erythrocyte decrease as a compensatory mechanism. All studies conducted since 2000 where we demonstrated the existence NO inside the erythrocyte by fluorescence microscopy, and after their signaling pathway needs more development translational research for news therapeutics and further application in not invasive therapy to vascular inflammatory diseases.

Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases.

PurposeTo study the therapeutic effects of uterine artery embolization (UAE) on adenomyosis and to investigate the association between uterine blood supply and artery embolization treatment outcomes.MethodsUsing digital subtraction angiography (DSA) imaging data, we retrospectively evaluated the vascular features of 252 adenomyosis patients treated with UAE. The cases were classified based on the equality of uterine blood supply (equal and unequal subgroups) and the degree of vascularity at the adenomyosis lesion site (hypervascular, isovascular and hypovascular subgroups). Patients were followed-up for 5 years after UAE. Improvements in dysmenorrhea and menorrhagia were evaluated based on the relief of the patients’ symptoms. The improvement rates among the different subgroups were analyzed and compared.ResultsThe improvement rates of dysmenorrhea and menorrhagia were 74.0% and 70.9%, respectively, at the short-term (12-month) follow-up and 70.4% and 68.8%, respectively, at the long-term (5-year) follow-up. No statistically significant differences were observed in the improvement rates for dysmenorrhea or menorrhagia between the equal and unequal blood supply subgroups at either the short- or long-term follow-up. The improvement rates for dysmenorrhea among the hypervascular, isovascular and hypovascular subgroups were 86.5%, 71.8% and 58.8%, respectively, at the short-term follow-up (p = 0.002) and 83.6%, 67.3% and 52.8%, respectively, at the long-term follow-up (p = 0.005). The improvement rates for menorrhagia in the hypervascular, isovascular and hypovascular subgroups were 81.0%, 68.3% and 60.7%, respectively, at the short-term follow-up (p = 0.024) and 79.4%, 61.4% and 62.2%, respectively, at the long-term follow-up (p = 0.052).ConclusionUAE is effective in treating patients with adenomyosis in both the short and long term. The outcomes of patients with adenomyosis were significantly correlated with lesion vascularity.

The analysis of the clinical records diagnosed as Takayasu's arteritis with pulmonary vascular involvement

To enhance the understanding of Takayasu's arteritis with pulmonary vascular involvement through the analyses on clinical features, imaging findings, misdiagnoses and treatments. A retrospective study was conducted to analyze the clinical records of patients diagnosed as Takayasu's arteritis with pulmonary vascular involvement admitted to Beijing Chaoyang Hospital from January 2004 to December 2014. In recent 10 years, there were 90 patients diagnosed as Takayasu's arteritis in Beijing Chaoyang Hospital, 33 of them were involved with pulmonary arterial, which account for 36.7%, while 12 cases were involved with pulmonary arteries alone, which account for 13.3% of all. Among the 33 patients, dyspnea (23 cases, 69.7%) was the most common symptom, followed by hemoptysis (19 cases, 57.6%) and Vascular murmur (23 cases, 69.7%), pleural effusion (8 cases, 24.2%), unequal blood pressure of upper limbs (4 cases, 12.1%) were the main signs. The diagnostic time varied significantly, from 1 month to 10 years. 21 patients were misdiagnosed and the misdiagnosis rate was 63.6%. Takayasu's arteritis with pulmonary vascular involvement is not rare. The clinical manifestation of Takayasu's arteritis is unspecific and misdiagnosis rate is relatively high. Therefore, we should raise awareness of Takayasu's arteritis and detailed clinical examination will be helpful to reduce the misdiagnosis rate.

Donor-variation effect on red blood cell storage lesion: A close relationship emerges.

Although the molecular pathways leading to the progressive deterioration of stored red blood cells (RBC storage lesion) and the clinical relevance of storage-induced changes remain uncertain, substantial donor-specific variability in RBC performance during storage, and posttransfusion has been established ("donor-variation effect"). In-bag hemolysis and numerous properties of the RBC units that may affect transfusion efficacy have proved to be strongly donor-specific. Donor-variation effect may lead to the production of highly unequal blood labile products even when similar storage strategy and duration are applied. Genetic, undiagnosed/subclinical medical conditions and lifestyle factors that affect RBC characteristics at baseline, including RBC lifespan, energy metabolism, and sensitivity to oxidative stress, are all likely to influence the storage capacity of individual donors' cells, although not evident by the donor's health or hematological status at blood donation. Consequently, baseline characteristics of the donors, such as membrane peroxiredoxin-2 and serum uric acid concentration, have been proposed as candidate biomarkers of storage quality. This review article focuses on specific factors that might contribute to the donor-variation effect and emphasizes the emerging need for using omics-based technologies in association with in vitro and in vivo transfusion models and clinical trials to discover biomarkers of storage quality and posttransfusion recovery in donor blood.

Seizures and lost pulses: an atypical case of Takayasu’s arteritis

Seizure is a rare neurological manifestation of Takayasu's arteritis (TA). This report is about a 15 year old female patient, admitted with loss of consciousness, generalised seizures and hypertension. The patient had asymmetric peripheral pulses and unequal blood pressure in the arms. Doppler study showed diminished blood flow predominantly in left upper limb, while fluorescent aortogram revealed left subclavian artery stenosis. MRI was suggestive of posterior reversible encephalopathy syndrome (PRES). Electroencephalogram (EEG) report was consistent with cerebral dysrhythmia. The patient had coexistent ostium secundum atrial septal defect. Previous case reports attribute seizures to ischemia (caused by involvement of the carotid and vertebral arteries) and PRES in patients of TA. The presence of cerebral dysrhythmia after clinical improvement made the cause of seizure difficult to ascertain in our patient. The presence of atrial septal defect (ASD) was possibly coincidental.

Comments on: Chari, R.; Burke, T.A.; White, R.H.; Fox, M.A. Integrating Susceptibility into Environmental Policy: An Analysis of the National Ambient Air Quality Standard for Lead. Int. J. Environ. Res. Public Health 2012, 9, 1077–1096

A recent publication in International Journal of Environmental Research and Public Health by Chari et al. [1] provides no basis for changing the National Ambient Air Quality Standard (NAAQS) for lead in the U.S. to protect children in low socio-economic (SES) populations. The studies selected by Chari et al. for analysis do not provide comparable information on regression coefficients for the blood lead level-IQ relationship. The coefficients differ from one another more on the basis of unequal blood lead metrics, ages of blood lead measurement, and differences in covariate adjustments and standardization, than the difference postulated by Chari et al. to correspond to low vs. high SES populations.

Diagnosis and Management of Twin-Twin Transfusion Syndrome

ABSTRACT Twin-twin transfusion syndrome (TTTS) is a complication unique to monochorionic twin pregnancies, in which the two twins share a common placenta and unequal blood exchange from one twin (donor) to the cotwin occurs through placental arterovenous anastomoses. The diagnosis is posed with the sonographic detection of oligohydramnios in the donor's sac, as a consequence of hypovolemia, and polyhydramnios in the recipient's sac, resulting from hypervolemia. The severity of TTTS is assessed according to Quintero staging system, which is based on five stages that range from visualization of the donor's bladder to intrauterine demise of one or both twins. Because laser therapy has revealed the optimal treatment for TTTS, management of twins affected with TTTS consists in preoperative and postoperative assessment of the twins by ultrasound examination. The aim of this review was to describe the diagnosis and management of TTTS and discuss controversies and limitations of current literature. How to cite this article Rossi AC, D'Addario V. Diagnosis and Management of Twin-Twin Transfusion Syndrome. Donald School J Ultrasound Obstet Gynecol 2012;6(3):286-289.

Treatment of twin–twin transfusion syndrome

Twin–twin transfusion syndrome is characterized by unequal blood exchange from the donor twin to the recipient co-twin through placental vascular anastomoses. Treatment of twin–twin transfusion syndrome consists of serial amnioreduction, septostomy, laser photocoagulation of placental vessels and umbilical cord occlusion of the apparently sick twin. Amnioreduction reduces maternal discomfort due to polyhydramnios and improves fetal circulation by reducing amniotic fluid pressure on the placenta. Septostomy equalizes amniotic fluid pressure between the two gestational sacs. Laser therapy interrupts intertwin blood shunting and restores two independent circulations. Umbilical cord occlusion is offered when signs of imminent death are present, such as hydrops and cardiac failure. Laser therapy is associated with increased neonatal survival rates and lower risk of adverse outcomes compared with other treatments.

3D network model of NO transport in tissue

We developed a mathematical model to simulate shear stress-dependent nitric oxide (NO) production and transport in a 3D microcirculatory network based on published data. The model consists of a 100 μm × 500 μm × 75 μm rectangular volume of tissue containing two arteriole-branching trees, and nine capillaries surrounding the vessels. Computed distributions for NO in blood, vascular walls, and surrounding tissue were affected by hematocrit (Hct) and wall shear stress (WSS) in the network. The model demonstrates that variations in the red blood cell (RBC) distribution and WSS in a branching network can have differential effects on computed NO concentrations due to NO consumption by RBCs and WSS-dependent changes in NO production. The model predicts heterogeneous distributions of WSS in the network. Vessel branches with unequal blood flow rates gave rise to a range of WSS values and therefore NO production rates. Despite increased NO production in a branch with higher blood flow and WSS, vascular wall NO was predicted to be lower due to greater NO consumption in blood, since the microvascular Hct increased with redistribution of RBCs at the vessel bifurcation. Within other regions, low WSS was combined with decreased NO consumption to enhance the NO concentration.

Circulating Cell-Free Placental mRNA in the Maternal Plasma as a Predictive Marker for Twin-Twin Transfusion Syndrome

Twin-twin transfusion syndrome (TTTS), which is a serious complication in monochorionic diamniotic twins (MCDA-T), involves unequal blood flow via the placental vascular anastomoses from the donor to the recipient twin. Although the placental anastomoses are present in all MCDA-T and both fetuses are genetically identical, TTTS occurs in only 15% of MCDA-T, and much of the pathophysiological basis of TTTS remains poorly understood. Clinically, a staging system based on the ultrasound features of TTTS is widely used for the management (1) but not for the prediction of TTTS. In addition, the known predictive findings observable by ultrasonographic examination are detectable only in a small portion of TTTS cases (2). New predictive markers are therefore desirable for the early detection and prevention of TTTS. Recently, placental mRNAs, such as human placental lactogen (PL) and some other hormones were detected in maternal plasma, and concentrations of each marker were measured with quantitative real-time reverse transcription (RT)-PCR (3)(4). Thus, circulating cell-free mRNA (cf-mRNA) in maternal plasma has become an attractive target for the noninvasive …

Numb fingers and unequal blood pressures in a 58-year-old man

Numb fingers and unequal blood pressures in a 58-year-old man

Aortic arch angiography prior to carotid endarterectomy. Is its continued use justified?

Patients with significant stenosis at the carotid bifurcation are traditionally subjected to four vessel aortic arch angiography prior to consideration for carotid endarterectomy. The advent of the non-invasive vascular laboratory has necessitated a reappraisal of this approach. 1. Determine the yield from aortic arch angiography and its influence on surgical management. 2. Evaluate the accuracy of clinical examination and the non-invasive vascular laboratory in the detection of aortic arch branch lesions. One hundred and twenty-nine consecutive patients undergoing evaluation for carotid endarterectomy were prospectively enrolled into the study. The protocol entailed: 1. Clinical recording of upper limb pulses, blood pressure and supraclavicular bruits. 2. Duplex scan examination to evaluate proximal inflow into the carotid arteries. 3. Four vessel aortic arch angiography to detect aortic branch lesions. Data from the non-invasive tests were compared to angiography. Patients with aortic arch branch lesions were further evaluated to determine the proportion requiring additional surgery. Nineteen patients had angiographic evidence of aortic branch disease (14.7%); six involved the common carotid artery, three the innominate artery and 10 the subclavian artery. All of these lesions were detected by the combination of unequal blood pressure, pulse deficit, bruit or duplex scan. Seven patients underwent additional surgery (5.4%) which included carotid-subclavian bypass (five), aortoinnominate bypass (one) and innominate endarterectomy (one). In patients with significant stenosis at the carotid bifurcation undergoing evaluation for carotid endarterectomy, aortic arch angiography is unnecessary except in a small percentage of patients with abnormal clinical and non-invasive findings.

Oxygen supply and uptake in tissue models with unequal distribution of blood flow and shunt

The effects of unequal distribution of blood flow on O 2 uptake are studied on a model composed of 3 tissue compartments with blood flow/O 2 requirement ratios in the relation 9:3:1 (unequal blood flow model), a model with 33% shunt blood flow (shunt model), and a single compartment model without shunt (reference model). Diffusion limitation is assumed to be absent. Total blood flow (Q̇), arterial O 2 content (Ca O 2 ) and O 2 requirement of tissue are varied singly, and the resulting (mixed) venous O 2 content (Cv O 2 ) and O 2 uptake are calculated. In the reference model, Cv O 2 become zero, and O 2 uptake starts falling below the O 2 requirement, as soon as the O 2 delivery (Q̇·Ca O 2 ) becomes smaller than the O 2 requirement. In contrast, in the unequal blood flow model, decrease in the ratio O 2 uptake/O 2 requirement and in Cv O 2 sets in earlier, and proceeds more gradually, with decreasing Q̇ or Ca O 2 or increasing O 2 requirement; this is, because O 2 delivery limitation sets in sequentially in the compartments, starting with the least perfused compartment. The shunt model behaves similarly to the reference model if Q̇ or O 2 requirement is varied, and to the unequal blood flow model if Ca O 2 is varied. Some features such as the parallel fall of O 2 uptake and of Cv O 2 with decreasing Ca O 2 , common to the unequal blood flow and shunt models, are similar to expected effects of diffusion limitation. Therefore, when the influence of diffusion limitation on tissue O 2 supply is to be investigated quantitatively, the effects of a possible unequal distribution of blood flow must be taken into account.

Obtaining a Representative Blood Sample in Lactate Tracer Studies

Reasons why venous tracer infusion with arterial sampling [(v-a) mode] has advantages compared to arterial infusion and venous sampling [(a-v) mode] for studies of blood lactate kinetics are presented. Arterial tracer infusion can result in biased tracer input due to streaming and unequal blood flow distribution. The procedure is impractical for human studies. Venous sampling from the jugular, or any other peripheral or great vein, provides a sample which may, or may not represent mixed venous systemic blood, which exists only in the pulmonary artery. Venous sampling will not represent cardiac lactate metabolism because the coronary arteries drain into the coronary sinus. Venous sampling, as well as pulmonary artery sampling, will also ignore lactate metabolism in the lungs which drain into the left atrium from bronchial and pulmonary circulations. Turnover rates calculated from either venous or arterial specific activities underestimate true tissue turnover. Correction for either measurement depends on good estimates of blood flows to lactate exchanging and non-exchanging tissue. Equilibration between lactate and pyruvate pools does not invalidate the use of tracers to measure lactate turnover. The (v-a) mode with venous infusion and arterial sampling has advantages for lactate tracer studies.

Pulmonary vascularity in pediatric heart disease.

In children, analysis of pulmonary vascularity can provide useful information about cardiac and noncardiac abnormalities. The abnormal vascular patterns encountered in children with heart disease include (1) active engorgement, (2) passive congestion, (3) diminished pulmonary blood flow, (4) cephalad redistribution, and (5) unequal blood flow. Familiarity with these various patterns enables the clinician to produce relevant differential diagnoses for each. With additional study of the cardiac chambers, great vessels, and other radiographic findings, a specific diagnosis may often be suggested.

Intrauterine growth of chronically instrumented rhesus monkey fetuses

The effect of surgical and experimental manipulations on intrauterine growth of the fetus was investigated in 61 rhesus monkey fetuses in which chronic preparations were attempted. The surgical procedure consisted of hysterotomy and insertion of vascular catheters and included unilateral ligation of the fetal carotid artery. The mother was kept in a restraining chair after the operation for the duration of the preparation (0 to 39 days). Thirty-four fetuses who died within 48 hours after operation served as the control group for the growth parameters. The remaining fetuses that survived 7 days or more after the operation were included in the experimental group. Body weight, crown-rump length, crown-heel length, and foot length of the fetus and placental weight were measured at the termination of the preparation. There were significant linear correlations between all parameters and gestational age. Comparison between the control and experimental groups revealed that none of the parameters from the experimental group differed significantly from those of the control group. No relationships were found between the duration of the preparation and any of the parameters. Total brain weights from 19 fetuses exhibited a significant increase with gestational age and these values were within the normal range reported previously. There were no significant differences in weight between right and left cerebral hemispheres. No evidence of unequal blood flow to the cerebral hemispheres was found with the radioactive microsphere technique. The data suggest that the surgery performed on both the mother and the fetus and prolonged maternal restraint did not alter intrauterine fetal development.