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Cardiorenal Medicine May 2024Congestion, marked by elevated cardiac filling pressures and their repercussions, is a contributing factor to morbidity and mortality in heart failure and critical... (Review)
Review
Congestion, marked by elevated cardiac filling pressures and their repercussions, is a contributing factor to morbidity and mortality in heart failure and critical illness. Relying on traditional methods for bedside evaluation often leads to inadequate decongestion and increased hospital readmissions. Point-of-care ultrasound (POCUS), particularly multi-organ POCUS, including the Venous Excess Ultrasound (VExUS), offers a promising approach in this scenario. VExUS enables the quantification of systemic venous congestion, aiding in fluid overload states by assessing inferior vena cava and venous Doppler waveforms. This comprehensive review delves into the latest developments in comprehending and evaluating congestion, shedding light on technical intricacies to enhance the effective application of VExUS. Recent studies emphasize the importance of evaluating signs of hemodynamic congestion before administering intravenous fluids, highlighting the concept of 'fluid tolerance'. Moreover, VExUS-guided decongestion significantly improves decongestion rates in acute decompensated heart failure patients with acute kidney injury. Newer studies also highlight the prognostic implications of VExUS in the general ICU cohorts not confining to cardiac surgery patients. However, performing VExUS without understanding technical pitfalls may lead to clinical errors. Technical considerations in performing VExUS include nuances related to inferior vena cava and internal jugular vein ultrasound and familiarity with Doppler principles, optimal settings, and artifacts. Additionally, local structural alterations such as those seen in liver and kidney disease impact Doppler waveforms, emphasizing the need for careful interpretation. Overall, VExUS presents a valuable tool for assessing congestion and guiding management, provided clinicians are familiar with its technical complexities and interpret findings judiciously.
PubMed: 38815571
DOI: 10.1159/000539469 -
Research (Washington, D.C.) 2024Thrombosis can cause life-threatening disorders. Unfortunately, current therapeutic methods for thrombosis using injecting thrombolytic medicines systemically resulted...
Thrombosis can cause life-threatening disorders. Unfortunately, current therapeutic methods for thrombosis using injecting thrombolytic medicines systemically resulted in unexpected bleeding complications. Moreover, the absence of practical imaging tools for thrombi raised dangers of undertreatment and overtreatment. This study develops a theranostic drug carrier, Pkr(IR-Ca/Pda-uPA)-cRGD, that enables real-time monitoring of the targeted thrombolytic process of deep vein thrombosis (DVT). Pkr(IR-Ca/Pda-uPA)-cRGD, which is prepared from a Pickering-emulsion-like system, encapsulates both near-infrared-II (NIR-II) contrast agent (IR-1048 dye, loading capacity: 28%) and urokinase plasminogen activators (uPAs, encapsulation efficiency: 89%), pioneering the loading of multiple drugs with contrasting hydrophilicity into one single-drug carrier. Upon intravenous injection, Pkr(IR-Ca/Pda-uPA)-cRGD considerably targets to thrombi selectively (targeting rate: 91%) and disintegrates in response to acidic thrombi to release IR-1048 dye and uPA for imaging and thrombolysis, respectively. Investigations indicate that Pkr(IR-Ca/Pda-uPA)-cRGD enabled real-time visualization of targeted thrombolysis using NIR-II imaging in DVT models, in which thrombi were eliminated (120 min after drug injection) without bleeding complications. This may be the first study using convenient NIR-II imaging for real-time visualization of targeted thrombolysis. It represents the precision medicine that enables rapid response to acquire instantaneous medical images and make necessary real-time adjustments to diagnostic and therapeutic protocols during treatment.
PubMed: 38812529
DOI: 10.34133/research.0388 -
Arquivos de Neuro-psiquiatria May 2024Increasing evidence suggests that inflammatory biomarkers play a significant role in cerebral venous sinus thrombosis (CVST). The neutrophil-to-lymphocyte ratio...
BACKGROUND
Increasing evidence suggests that inflammatory biomarkers play a significant role in cerebral venous sinus thrombosis (CVST). The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) are related to thrombotic conditions and indicators of systemic inflammation.
OBJECTIVE
To analyze the correlation between inflammatory biomarkers and the extent of thrombus, determined by the CVST-Score.
METHODS
A total of 40 patients with CVST (24 female subjects; 60%) and 40 age- and sex-matched healthy controls were retrospectively evaluated. Inflammatory biomarkers, including C-reactive protein (CRP), PLR, NLR, MLR, and the CVST-Score, were recorded to assess the relationship between biomarkers and thrombus burden. The patients were grouped according to symptom duration (group 1: 0-3 days; group 2: 4-7 days; and group 3: 8-30 days) to compare biomarker levels.
RESULTS
The CRP, NLR, and PLR were significantly higher in the CVST group ( < 0.001; = 0.003; = 0.014 respectively). The NLR and PLR presented a significant positive correlation with the CVST-Score ( = 0.003, r = 0.464; = 0.040, r = 0.326 respectively). The NLR was significantly higher in group 1 compared with groups 2 and 3 ( = 0.016 and = 0.014 respectively). In group 1, there was a stronger positive correlation between the CVST-Score and the NLR ( = 0.026, r = 0.591) and the PLR ( = 0.012, r = 0.648). The multiple linear regression analysis revealed that the NLR is a key factor in predicting the CVST-Score ( = 0.019).
CONCLUSION
The NLR and PLR are associated with thrombus burden in CVST, especially in patients admitted to the hospital in the early stages. The NLR is an independent factor to predict the thrombus burden in CVST.
Topics: Humans; Female; Male; Sinus Thrombosis, Intracranial; Biomarkers; Adult; C-Reactive Protein; Retrospective Studies; Neutrophils; Middle Aged; Case-Control Studies; Lymphocytes; Inflammation; Platelet Count; Young Adult; Blood Platelets; Lymphocyte Count; Reference Values; Statistics, Nonparametric; Monocytes; Time Factors
PubMed: 38811022
DOI: 10.1055/s-0044-1787137 -
Frontiers in Immunology 2024L-carnitine, available as feed additive, is essential for the beta-oxidation of free fatty acids in the mitochondrial matrix. It provides energy to immune cells and may...
L-carnitine, available as feed additive, is essential for the beta-oxidation of free fatty acids in the mitochondrial matrix. It provides energy to immune cells and may positively impact the functionality of leukocytes during the acute phase response, a situation of high energy demand. To test this hypothesis, German Holstein cows were assigned to a control group (CON, n = 26) and an L-carnitine supplemented group (CAR, n = 27, rumen-protected L-carnitine product: 125 g/cow/d, corresponded to total L-carnitine intake: 25 g/cow/d, supplied with concentrate) and received an intravenous bolus injection of lipopolysaccharides (LPS, 0.5 µg/kg body weight, ) on day 111 as a model of standardized systemic inflammation. Blood samples were collected from day 1 until day 14 , with frequent sampling through an indwelling venous catheter from 0.5 h to 12 h . All parameters of the white blood cell count responded significantly to LPS, while only a few parameters were affected by L-carnitine supplementation. The mean eosinophil count, as well as the percentage of basophils were significantly higher in CAR than in CON over time, which may be due to an increased membrane stability. However, phagocytosis and production of reactive oxygen species by leukocytes remained unchanged following L-carnitine supplementation. In conclusion, although supplementation with 25 g L-carnitine per cow and day resulted in increased proportions of specific leukocyte populations, it had only minor effects on the functional parameters studied in mid-lactating dairy cows during LPS-induced inflammation, and there was no evidence of direct improvement of immune functionality.
Topics: Animals; Cattle; Lipopolysaccharides; Carnitine; Dietary Supplements; Female; Lactation; Inflammation; Leukocyte Count
PubMed: 38807585
DOI: 10.3389/fimmu.2024.1390137 -
Medical Ultrasonography May 2024VEXAS syndrome is a recently described condition characterized by systemic inflammation, predisposition to hematologic malignancy and a high rate of venous thrombosis....
VEXAS syndrome is a recently described condition characterized by systemic inflammation, predisposition to hematologic malignancy and a high rate of venous thrombosis. Here we report the case of an elderly male with erythema nodosumlike lesions, ankle arthralgia, and general symptoms. B-mode and Doppler ultrasound of the subcutis diagnosed superficial thrombophlebitis of the lower limbs, which turned out to be the manifestation of a paucisymptomatic VEXAS syndrome. VEXAS should be considered in any patient who presents with unexplained superficial thrombophlebitis, macrocytic anemia and unexplained systemic inflammation.
PubMed: 38805617
DOI: 10.11152/mu-4384 -
Andes Pediatrica : Revista Chilena de... Apr 2024Sepsis is one of the main causes of admission to Intensive Care Units (ICU). The hemodynamic objectives usually sought during the resuscitation of the patient in septic... (Review)
Review
Sepsis is one of the main causes of admission to Intensive Care Units (ICU). The hemodynamic objectives usually sought during the resuscitation of the patient in septic shock correspond to macrohemodynamic parameters (heart rate, blood pressure, central venous pressure). However, persistent alterations in microcirculation, despite the restoration of macrohemodynamic parameters, can cause organ failure. This dissociation between the macrocirculation and microcirculation originates the need to evaluate organ tissue perfusion, the most commonly used being urinary output, lactatemia, central venous oxygen saturation (ScvO2), and veno-arterial pCO2 gap. Because peripheral tissues, such as the skin, are sensitive to disturbances in perfusion, noninvasive monitoring of peripheral circulation, such as skin temperature gradient, capillary refill time, mottling score, and peripheral perfusion index may be helpful as early markers of the existence of systemic hemodynamic alterations. Peripheral circulation monitoring techniques are relatively easy to interpret and can be used directly at the patient's bedside. This approach can be quickly applied in the intra- or extra-ICU setting. The objective of this narrative review is to analyze the various existing tissue perfusion markers and to update the evidence that allows guiding hemodynamic support in a more individualized therapy for each patient.
Topics: Humans; Child; Microcirculation; Hemodynamics; Shock, Septic; Monitoring, Physiologic; Hemodynamic Monitoring; Acute Disease; Sepsis; Biomarkers
PubMed: 38801369
DOI: 10.32641/andespediatr.v95i2.4915 -
Narra J Apr 2024Stroke ranks among the prevalent factors contributing to child mortality. Cryptogenic stroke has been linked with patent foramen ovale (PFO), which has been suggested as...
Stroke ranks among the prevalent factors contributing to child mortality. Cryptogenic stroke has been linked with patent foramen ovale (PFO), which has been suggested as a possible route for thrombus, gas bubble, or another particulate that comes through systemic venous circulation to the brain artery. Yet, the most effective approach for managing cryptogenic stroke involving a PFO remains uncertain. This case aims to report a PFO patient with complications of stroke. A 5-year-old girl was admitted to the emergency department at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia, after experiencing numbness and weakness on her right side and a sudden onset of slurred speech three days before admission. Laboratory findings only showed leukocytosis, while coagulation tests were normal. Non-contrast brain CT revealed an occurrence of cerebral infarction in the left hemisphere. Transcranial Doppler showed no atherosclerosis in cerebral arteries, and carotid Doppler ultrasound results were reported normal. Transthoracic echocardiography showed a PFO with the right-to-left shunt. The patient was treated with an intravenous infusion of citicoline 250 mg twice daily, oral aspirin 80 mg daily, and oral mecobalamin 250 mg daily and was planned to undergo a PFO closure procedure. However, the patient's parents rejected the plan to perform a PFO closure procedure. PFO has the potential to be a contributing factor to cryptogenic stroke among children. PFO closure followed by antiplatelet therapy for a couple of months has been shown to outperform medical therapy alone. However, additional evaluation should be done to cautiously consider the PFO closure procedure in children.
Topics: Humans; Female; Foramen Ovale, Patent; Child, Preschool; Stroke; Indonesia; Ischemic Stroke
PubMed: 38798870
DOI: 10.52225/narra.v4i1.273 -
Thrombosis Research May 2024Hughes-Stovin syndrome (HSS) is a rare systemic vasculitis with widespread venous/arterial thrombosis and pulmonary vasculitis. Distinguishing between pulmonary embolism...
Pulmonary embolism versus pulmonary vasculitis in Hughes-Stovin syndrome: Characteristic computed tomography pulmonary angiographic findings and diagnostic and therapeutic implications. HSS International Study Group.
BACKGROUND AND AIM
Hughes-Stovin syndrome (HSS) is a rare systemic vasculitis with widespread venous/arterial thrombosis and pulmonary vasculitis. Distinguishing between pulmonary embolism (PE) and in-situ thrombosis in the early stages of HSS is challenging. The aim of the study is to compare clinical, laboratory, and computed tomography pulmonary angiography (CTPA) characteristics in patients diagnosed with PE versus those with HSS.
METHODS
This retrospective study included 40 HSS patients with complete CTPA studies available, previously published by the HSS study group, and 50 patients diagnosed with PE from a single center. Demographics, clinical and laboratory findings, vascular thrombotic events, were compared between both groups. The CTPA findings were reviewed, with emphasis on the distribution, adherence to the mural wall, pulmonary infarction, ground glass opacification, and intra-alveolar hemorrhage. Pulmonary artery aneurysms (PAAs) in HSS were assessed and classified.
RESULTS
The mean age of HSS patients was 35 ± 12.3 years, in PE 58.4 ± 17 (p < 0.0001). Among PE 39(78 %) had co-morbidities, among HSS none. In contrast to PE, in HSS both major venous and arterial thrombotic events are seen.. Various patterns of PAAs were observed in the HSS group, which were entirely absent in PE. Parenchymal hemorrhage was also more frequent in HSS compared to PE (P < 0.001).
CONCLUSION
Major vascular thrombosis with arterial aneurysms formation are characteristic of HSS. PE typically appear loosely-adherent and mobile whereas "in-situ thrombosis" seen in HSS is tightly-adherent to the mural wall. Mural wall enhancement and PAAs are distinctive pulmonary findings in HSS. The latter findings have significant therapeutic ramifications.
PubMed: 38795561
DOI: 10.1016/j.thromres.2024.109040 -
Journal of Clinical Medicine May 2024Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk...
Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], = 0.006). Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.
PubMed: 38792272
DOI: 10.3390/jcm13102730 -
International Journal of Molecular... May 2024Chronic venous disease (CVD) comprises a spectrum of morphofunctional disorders affecting the venous system, affecting approximately 1 in 3 women during gestation....
Chronic venous disease (CVD) comprises a spectrum of morphofunctional disorders affecting the venous system, affecting approximately 1 in 3 women during gestation. Emerging evidence highlights diverse maternofetal implications stemming from CVD, particularly impacting the placenta. While systemic inflammation has been associated with pregnancy-related CVD, preliminary findings suggest a potential link between this condition and exacerbated inflammation in the placental tissue. Inflammasomes are major orchestrators of immune responses and inflammation in different organs and systems. Notwithstanding the relevance of inflammasomes, specifically the NLRP3 (nucleotide-binding domain, leucine-rich-containing family, pyrin domain-containing-3)- which has been demonstrated in the placentas of women with different obstetric complications, the precise involvement of this component in the placentas of women with CVD remains to be explored. This study employs immunohistochemistry and real-time PCR (RT-qPCR) to examine the gene and protein expression of key components in both canonical and non-canonical pathways of the NLRP3 inflammasome (NLRP3, ASC-apoptosis-associated speck-like protein containing a C-terminal caspase recruitment domain-caspase 1, caspase 5, caspase 8, and interleukin 1β) within the placental tissue of women affected by CVD. Our findings reveal a substantial upregulation of these components in CVD-affected placentas, indicating a potential pathophysiological role of the NLRP3 inflammasome in the development of this condition. Subsequent investigations should focus on assessing translational interventions addressing this dysregulation in affected patient populations.
Topics: Humans; Female; NLR Family, Pyrin Domain-Containing 3 Protein; Pregnancy; Placenta; Inflammasomes; Adult; Chronic Disease; Vascular Diseases; Pregnancy Complications, Cardiovascular; Interleukin-1beta
PubMed: 38791563
DOI: 10.3390/ijms25105528