Personal mastery and quality of life in patients with atrial fibrillation after radiofrequency ablation: The mediating role of health promoting behavior

BACKGROUND

Improving quality of life is vital for patients with atrial fibrillation (AF) after radiofrequency ablation. Quality of life can be affected not only by personal mastery but also by health promoting behavior as previously studied. However, it remains unclear whether health promoting behavior mediates the relationship between personal mastery and quality of life.

OBJECTIVES

To explore whether health promoting behavior mediates the relationship between personal mastery and quality of life in patients with AF after radiofrequency ablation.

METHODS

A cross-sectional design and convenience sampling were conducted at a tertiary hospital in China. Self-reported questionnaires were used to assess personal mastery, health promoting behavior and quality of life. SPSS and AMOS software were used for statistical analysis.

RESULTS

A total of 202 patients with AF after radiofrequency ablation were enrolled (mean age 58.28 ± 12.70 years). The scores for personal mastery and quality of life were 22.52 ± 2.53 points and 62.58 ± 8.59 points, respectively, indicating a limited level. The health promoting behavior exhibited a moderate level, with scores averaging 103.82 ± 8.47 points. There was a positive correlation between the three variables (all P < 0.05). Health promoting behavior played a partial mediating role in the relationship between personal mastery and quality of life in patients with AF after radiofrequency ablation, accounting for 44.79 % of the total effect.

CONCLUSIONS

In order to improve quality of life and prognosis, it is necessary to consider enhancing personal mastery and increasing patient compliance with health promoting behavior, which are important ways to improve their quality of life.

Diabetes is not a negative prognostic factor for 30-days mortality after surgery for acute type A aortic dissection

Background

The correlation between diabetes and aortic dissection is not fully understood yet, although in literature many studies have suggested that there may be an association between the two conditions. The purpose of this study is to evaluate whether diabetes represents a short- and long-term risk factor for mortality from type A acute aortic dissection.

Materials and methods

A total of 340 patients with the diagnosis of type A acute aortic dissection underwent aortic surgery between January 2002 and March 2023. The sample was divided into 2 cohorts according to the presence of diabetes (n = 34) or not (n = 306).

Results

The mean age was 66 (±12.4) years and 60.9% were male. The primary endpoint was 30-day mortality. Hospital mortality was 12 (35.3%) for the diabetes group and 70 (22.9%) for nondiabetes group (P = 0.098). Overall survival at 10 years was 48.3% [95% confidence interval (CI): 41.6-54.7%], while the 10-year survival for people with diabetes was 29.5% (95% CI: 13.2-47.9%) and for nondiabetes group 50.6% (95% CI: 43.4-57.3%) (Log-rank, P = 0.024).

Conclusion

Diabetes was not found to be a risk factor associated with 30-day mortality in patients undergoing surgery for type A acute aortic dissection. It was a risk factor for long-term survival, but this may be related to diabetes complications.

Assessment of early factors for identification or prediction severe acute pancreatitis in pregnancy

BACKGROUND

Acute pancreatitis in pregnancy (APIP) is a rare and serious condition, and severe APIP (SAPIP) can lead to pancreatic necrosis, abscess, multiple organ dysfunction, and other adverse maternal and infant outcomes. Therefore, early identification or prediction of SAPIP is important.

AIM

To assess factors for early identification or prediction of SAPIP.

METHODS

The clinical data of patients with APIP were retrospectively analyzed. Patients were classified with mild acute pancreatitis or severe acute pancreatitis, and the clinical characteristics and laboratory biochemical indexes were compared between the two groups. Logical regression and receiver operating characteristic curve analyses were performed to assess the efficacy of the factors for identification or prediction of SAPIP.

RESULTS

A total of 45 APIP patients were enrolled. Compared with the mild acute pancreatitis group, the severe acute pancreatitis group had significantly increased (P < 0.01) heart rate (HR), hemoglobin, neutrophil ratio (NEUT%), and neutrophil–lymphocyte ratio (NLR), while lymphocytes were significantly decreased (P < 0.01). Logical regression analysis showed that HR, NEUT%, NLR, and lymphocyte count differed significantly (P < 0.01) between the groups. These may be factors for early identification or prediction of SAPIP. The area under the curve of HR, NEUT%, NLR, and lymphocyte count in the receiver operating characteristic curve analysis was 0.748, 0.732, 0.821, and 0.774, respectively. The combined analysis showed that the area under the curve, sensitivity, and specificity were 0.869, 90.5%, and 70.8%, respectively.

CONCLUSION

HR, NEUT%, NLR, and lymphocyte count can be used for early identification or prediction of SAPIP, and the combination of the four factors is expected to improve identification or prediction of SAPIP.

Decoding the role of aldosterone in glycation-induced diabetic complications

Diabetes-mediated development of micro and macro-vascular complications is a global concern. One of the factors is hyperglycemia induced the non-enzymatic formation of advanced glycation end products (AGEs). Accumulated AGEs bind with receptor of AGEs (RAGE) causing inflammation, oxidative stress and extracellular matrix proteins (ECM) modifications responsible for fibrosis, cell damage and tissue remodeling. Moreover, during hyperglycemia, aldosterone (Aldo) secretion increases, and its interaction with mineralocorticoid receptor (MR) through genomic and non-genomic pathways leads to inflammation and fibrosis. Extensive research on individual involvement of AGEs-RAGE and Aldo-MR pathways in the development of diabetic nephropathy (DN), cardiovascular diseases (CVDs), and impaired immune system has led to the discovery of therapeutic drugs. Despite mutual repercussions, the cross-talk between AGEs-RAGE and Aldo-MR pathways remains unresolved. Hence, this review focuses on the possible interaction of Aldo and glycation in DN and CVDs, considering the clinical significance of mutual molecular targets.

Acute aortoiliac thrombosis and mitral valve regurgitation as acute onset of eosinophilic granulomatosis with polyangiitis in a 26-year-old patient

We present a rare case of eosinophilic granulomatosis with polyangiitis (EGPA), involving a 26-year-old woman with a history of asthma and nasal polyps. The patient presented with acute aortoiliac thrombosis and mitral insufficiency, which was successfully treated with thrombolysis, aortic thromboendarterectomy, and valve replacement. Peripheral hypereosinophilia with eosinophilic infiltration of the heart led to the diagnosis of antineutrophilic cytoplasmic antibody-negative EGPA. Treatment with prednisone and mepolizumab was started, resulting in a positive outcome. This case showcases an unusual manifestation of EGPA with large size vessel involvement and requiring surgical and pharmacological treatment. It also highlights the importance of early detection for timely intervention and an improved prognosis.

Improvements in edema and microcirculation in chronic venous insufficiency with Pycnogenol® or elastic compression

BACKGROUND

Chronic venous insufficiency (CVI) is the consequence of venous valve reflux and/or venous flow obstruction and resulting venous hypertension in the lower extremities. The aim of this prospective supplement registry study was to evaluate the efficacy of compression stockings or Pycnogenol® in controlling symptoms and edema in CVI and their efficacy on microcirculatory parameters.

METHODS

Two comparable groups of 30 subjects with CVI were observed for 4 months.

RESULTS

Elastic compression was less tolerated than Pycnogenol® with 12 subjects being unable to follow the compression routine. No side effects due to supplementation were observed; tolerability of the supplementation was optimal. Ambulatory venous pressure (AVP) and refilling time (RT) at inclusion indicated a significant increase in venous pressure and reflux (refilling time <16 seconds). AVP and RT did not change after 4 months. Microcirculatory and clinical measurements were comparable at inclusion between the 2 groups. After 4 months, skin resting flux (RF) and skin PO2-PCO2 were significantly improved with Pycnogenol® compared to compression (P<0.05). The significant increase in skin PO2 and the decrease in PCO2 after Pycnogenol® intake were ascribed to the decrease in the abnormally high skin resting flux, a sign of better perfusion and skin nutritional supply. Pycnogenol® reduced leg volume, on average by 18.3% in the evening compared to 4.4% of reduction with compression (P<0.05) showing an important effect on edema. The venous Clinical Severity Score (VCSS) and the composite symptom score (CSS) decreased significantly in the Pycnogenol® group compared to compression, indicating a better improvement in microcirculatory perfusion and nutritional supply produced by the supplementation of Pycnogenol® in comparison with compression. Pycnogenol® significantly improved microcirculation and clinical symptoms in comparison with compression. The decrease in local oxidative stress (OS) at the distal perimalleolar region with Pycnogenol® was significant in comparison with compression (P<0.05). A lower local OS is an important metabolic indication of a better capillary perfusion with better nutritional exchanges. At the end of the registry study, four small ulcerations and skin breaks in four limbs (between 3 and 5 mm of maximum diameters) were observed in the compression group. No ulcerations or skin breaks were observed in the Pycnogenol® group.

CONCLUSIONS

Pycnogenol® relieved edema, improved microcirculation in CVI patients and reduced stationary, interstitial fluid in comparison with compression. Most symptoms of CVI are associated with interstitial water retention; the presence of extra fluid in limb tissues alters perfusion and nutrient supply. Pycnogenol® supplementation reduced water and fluid accumulation in CVI limbs and improved microcirculation and local oxidative stress thus showing important anti-edema effects.

Esophageal Atresia and Gastric Ectopic Pancreas: Is There a Real Association?

OBJECTIVE

 Heterotopic pancreas (HP) is a condition in which there is well-differentiated pancreatic tissue that lacks any anatomic or vascular contact with the pancreatic gland. It normally arises from the stomach but can be found in other locations. Although it is usually asymptomatic, obstructive symptoms, bleeding, or malignant degeneration can occur. The incidence is very low, but it is significantly more common in patients with esophageal atresia (EA). The aim of this study is to evaluate the incidence of HP in patients with and without EA and to compare the results in both groups.

MATERIAL AND METHODS

 We conducted a 2-year prospective study in pediatric patients who benefited from an upper gastrointestinal endoscopy. Patients were divided into two groups: group "A" comprised patients with EA and group "B" those without EA. The variables analyzed were the clinical presentation, presence of HP, location, associated malformations, genetic disorders, and management.

RESULTS

 A total of 192 consecutive patients were included in the study: 51 (26.6%) in group A and 141 (73.4%) in group B. Indications for endoscopy in group B were eosinophilic esophagitis in 37 (19.2%) patients, celiac disease in 23 (11.95%) patients, and other disorders in 81 (42.2%) patients. Gastric HP was found in seven patients, all of them in group A. All lesions were hosted in the prepyloric antrum. The prevalence of HP in groups A and B was 13.7 and 0%, respectively (p < 0.05). Female gender was predominant in patients with AE and HP, this result being statistically significant (p = 0.044). No other associated malformation or genetic syndrome studied showed association with HP. Only one patient debuted with upper gastrointestinal (GI) bleeding and required excision, while six patients were asymptomatic. The mean follow-up was 54 months (range: 45-78 months).

CONCLUSION

 The incidence of gastric HP is more common in patients with EA, with the female gender being a risk factor for their association. Active search and follow-up is recommended as it may become symptomatic anytime and need resection.

The different roles of homocysteine metabolism in hypertension among normal-weight and obese patients with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is associated with hypertension. However, the differential mechanisms underlying OSA-related hypertension between normal-weight vs. obese patients is limited.

METHODS

We studied 92 patients with OSA and 24 patients with continuous positive airway pressure (CPAP) treatment. Blood pressure (BP) was measured twice during awake and continuously monitored during sleep. Obesity was defined as body mass index ≥28 kg/m2. Serum metabolite levels were assessed by metabolomics.

RESULTS

Among 59 normal-weight and 33 obese patients, 651 and 167 metabolites showed differences between hypertension and normotension or were associated with systolic and diastolic BP (SBP, DBP) after controlling confounders. These metabolites involved 16 and 12 Kyoto Encyclopedia of Genes and Genomes enrichment pathways in normal-weight and obese patients respectively, whereas 6 pathways overlapped. Among these 6 overlapping pathways, 4 were related to homocysteine metabolism and 2 were non-specific pathways. In homocysteine metabolism pathway, 13 metabolites were identified. Interestingly, the change trends of 7 metabolites associated with SBP (all interaction-p≤0.083) and 8 metabolites associated with DBP (all interaction-p≤0.033) were opposite between normal-weight and obese patients. Specifically, increased BP was associated with down-regulated folate-dependent remethylation and accelerated transsulfuration in normal-weight patients, whereas associated with enhanced betaine-dependent remethylation and reduced transsulfuration in obese patients. Similar findings were observed in ambulatory BP during sleep. After CPAP treatment, baseline low homocysteine levels predicted greater decrease in DBP among normal-weight but not obese patients.

CONCLUSIONS

Mechanisms in OSA-related hypertension differ between normal-weight and obese patients, which are explained by different changes in homocysteine metabolism.

Activation and modulation of the AGEs-RAGE axis: Implications for inflammatory pathologies and therapeutic interventions - A review

Chronic inflammation is a common foundation for the development of many non-communicable diseases, particularly diabetes, atherosclerosis, and tumors. The activation of the axis involving Advanced Glycation End products (AGEs) and their receptor RAGE is a key promotive factor in the chronic inflammation process, influencing the pathological progression of these diseases. The accumulation of AGEs in the body results from an increase in glycation reactions and oxidative stress, especially pronounced in individuals with diabetes. By binding to RAGE, AGEs activate signaling pathways such as NF-κB, promoting the release of inflammatory factors, exacerbating cell damage and inflammation, and further advancing the formation of atherosclerotic plaques and tumor development. This review will delve into the molecular mechanisms by which the AGEs-RAGE axis activates chronic inflammation in the aforementioned diseases, as well as strategies to inhibit the AGEs-RAGE axis, aiming to slow or halt the progression of chronic inflammation and related diseases. This includes the development of AGEs inhibitors, RAGE antagonists, and interventions targeting upstream and downstream signaling pathways. Additionally, the early detection of AGEs levels and RAGE expression as biomarkers provides new avenues for the prevention and treatment of diabetes, atherosclerosis, and tumors.

Anatomical variations of the extracranial internal carotid artery: prevalence, risk factors, and imaging insights from CT-angiography

PURPOSE

To determine the prevalence of different extracranial internal carotid artery (EICA) variations in CT angiography (CTA) of the neck and its predisposing factors.

METHODS

In this retrospective study from 2021 to 2023 conducted in the radiology department of Shafa Hospital, Kerman, Iran, all patients who had undergone neck CTA were included. Expert radiologists blindly examined each CTA image for the following: EICA variations-coiling, kinking, straight morphology, and tortuosity-and the distance between the internal carotid artery and the apex of the epiglottis and the C2 lower margin.

RESULTS

Of the 106 patients, the mean age was 55.9 ± 16.9 years. 64.2% were men, and 35.8% were women. Considering each patient's bilateral anatomy, the reported 70.28% (149/212) frequency of EICA variations of all arteries. Tortuosity, kinking, and coiling variation were found in 61.8%, 4.2%, and 4.2% of arteries, respectively. Also, 54.72%, 1.89%, and 0.94% of the participants had bilateral tortuosity, kinking, and coiling, respectively. There was a significant relationship between the prevalence of EICA variations and female sex, age, and hypertension.

CONCLUSION

The frequency of EICA variations in arteries and patients was 70.28% and 73.58%, respectively. Tortuosity was the most common variation. Female sex, old age, and hypertension were significant risk factors for EICA variations.

Unloading in cardiogenic shock: the rationale and current evidence

PURPOSE OF REVIEW

Discussing the rationale and current evidence for left ventricular unloading in cardiogenic shock.

RECENT FINDINGS

Microaxial flow pumps (MFP) and intra-aortic balloon pumps (IABP) augment cardiac output while simultaneously unloading the left ventricle (e.g. reducing left ventricular pressure), thereby targeting a key mechanism of cardiogenic shock. A recent randomized trial has shown a mortality reduction with MFP in selected patients with cardiogenic shock, strengthening the rationale for this strategy, although the evidence for the IABP is so far neutral. MFP/IABP can also be used concomitantly with veno-arterial extracorporeal membrane oxygenation (va-ECMO) to alleviate the va-ECMO-related increase in left ventricular afterload, to facilitate weaning and ultimately to improve myocardial recovery and prognosis of affected patients. However, the use of MFP/IABP in this indication solely relies on retrospective data, which need to be interpreted with caution, especially as these strategies are associated with more complications. Currently ongoing randomized trials will help to further clarify the role of left ventricular unloading in patients on va-ECMO.

SUMMARY

Left ventricular unloading addresses a key mechanism of cardiogenic shock, with strong evidence to support MFP use in selected patients, but further randomized controlled trials are required to clarify the role of different devices/strategies for the overall shock population.

A hybrid endovascular and open approach to rare thyrocervical trunk and subclavian pseudoaneurysms complicated by embolic brachial artery occlusion

Subclavian and thyrocervical trunk pseudoaneurysms are rare pathologies and even more so when they occur simultaneously. Treatment of these vascular injuries can be done endovascularly or with open surgery. We present a novel two-stage, hybrid open and endovascular approach to the management of a healthy 41-year-old man with no personal or family history of connective tissue disorders, who presented with subclavian branch and thyrocervical trunk pseudoaneurysms complicated by brachial artery occlusion. The pseudoaneurysms were treated with microvascular plug deployment, followed by subclavian artery covered stenting, with treatment of the brachial occlusion via open thrombectomy with patch angioplasty. The patient recovered without any complications.

Exploring varied radiologic appearance in pulmonary embolism with CT pulmonary angiography: Case series with literature review

Pulmonary embolism (PE) is a life-threatening condition caused by a sudden blockage of pulmonary arteries. Nonspecific and extremely variable clinical presentation frequently leads to undetected cases, making computed tomography pulmonary angiography (CTPA) hold a crucial role in the diagnosis of PE. This case series presents numerous types and findings of PE in CTPA among patients with different initial presentations followed by a literature review. We presented 3 cases with different initial presentations such as dyspnea with wheezing, productive cough, and hematemesis. All patients were consequently evaluated for D-dimer due to suspicion of PE from cardiac ultrasonography, electrocardiography (ECG), and persistent symptoms. Large to subsegmental PE can be found with various secondary findings such as pleural effusion and Hampton's hump. All patient's conditions were improved after anticoagulant treatment. This case series highlights the significance of CTPA as an imaging modality in the diagnosis of PE, as well as the necessity of evaluating the main to subsegmental pulmonary artery through an in-depth understanding of the images that can be assessed on CTPA.

Assessment of EN-RAGE, sRAGE, and its isoforms: cRAGE, esRAGE in obese patients treated by moderate caloric restriction combined with physical activity conducted in hospital condition

BACKGROUND

AGEs, their receptor (RAGE), and the extracellular newly identified receptor for AGEs product-binding protein (EN-RAGE) are implicated in the pathogenesis of inflammation.

AIM

We analyzed serum EN-RAGE, soluble RAGE (sRAGE), and their isoforms: endogenous secretory - esRAGE and cleaved - cRAGE concentrations in lean controls (n = 74) and in patients with obesity (n = 71) treated for three weeks with moderate calorie restriction (CR) combined with physical activity in a hospital condition.

METHODS

Using the ELISA method, serum sRAGE, esRAGE, and EN-RAGE were measured before and after CR.

RESULTS

The serum level of sRAGE and esRAGE in patients with obesity was lower than that in non-obese individuals, contrary to cRAGE. EN-RAGE concentration was about three times higher in obese patients. Gradually, a rise in BMI resulted in sRAGE, esRAGE reduction, and EN-RAGE increase. The sRAGE concentration was sex-dependent, indicating a higher value in lean men. A moderate negative correlation was observed between BMI and all RAGE isoforms, whereas EN-RAGE displays a positive correlation. CR resulted in an expected decrease in anthropometric, metabolic, and proinflammatory parameters and EN-RAGE, but no RAGE isoforms. The ratio EN-RAGE/sRAGE was higher in obese humans than in control and was not modified by CR.

CONCLUSION

Obesity decreases sRAGE and esRAGE and increases EN-RAGE concentration. Moderate CR and physical activity by decreasing inflammation reduces EN-RAGE but is insufficient to increase sRAGE and esRAGE to the extent observed in lean patients. EN-RAGE instead of sRAGE could be helpful to indicate a better outcome of moderate dietary intervention in obese subjects.

Passive Approximator Vascular Closure Device Use in Patients with Shallow Femoral Artery Depth Increases Puncture-site Complications in Neuroendovascular Treatment

OBJECTIVE

Puncture-site complications in interventional radiology sometimes cause severe conditions. Vascular closure devices play an important role in preventing puncture-site complications. Vascular closure devices are divided into 2 types, the directly suturing or clipping type (active approximators) and adherent sealant types (passive approximators). However, which types of vascular closure device are the safest and most effective for achieving hemostasis remains unclear. We analyzed the efficacy of each type of vascular closure device and risk factors for puncture-site complications.

METHODS

This study investigated 327 consecutive cases of neuroendovascular surgery using a transfemoral procedure during a 2-year study period. Passive approximators (Angioseal [St Jude Medical, Saint Paul, MN] and Exoseal [Cordis Corporation, Miami, FL]) were mainly used in the first half and active approximators (Perclose [Abbot Vascular, Santa Clara, CA]) in the second. We compared groups and estimated risk factors for puncture-site complications.

RESULTS

All procedures were successful. Comparing groups with and without puncture-site complications, use of passive approximators and ≥3 antithrombotic medications tended to be more frequent and distance from skin to femoral artery and body mass index tended to be lower in the group with complications without significance. The cutoff for femoral artery depth calculated from a receiver operating characteristic curve was 16.43 mm. Multivariate analysis revealed ≥3 antithrombotic medications (P = 0.002, OR 15.29, 95% CI 2.76-85.76) and passive approximator use in patients with femoral artery depth <16.43 mm (P < 0.001, OR 17.08, 95% CI 2.95-57.80) were significantly higher in the group with puncture-site complications.

CONCLUSIONS

Passive approximator use in patients with shallow femoral artery depth increases puncture-site complications in neuroendovascular treatment.

In Vitro Comparison of a Closed and Semi-closed Leaflet Design for Adult and Pediatric Transcatheter Heart Valves

Transcatheter heart valve replacements (TVR) are mostly designed in a closed position (c) with leaflets coaptating. However, recent literature suggests fabricating valves in semi-closed (sc) position to minimize pinwheeling. With about 100,000 children in need of a new pulmonary valve each year worldwide, this study evaluates both geometrical approaches in adult as well as pediatric size and condition. Three valves of each geometry were fabricated in adult (30 mm) and pediatric (15 mm) size, using porcine pericardium. To evaluate performance, the mean transvalvular pressure gradient (TPG), effective orifice area (EOA), and regurgitation fraction (RF) were determined in three different annulus geometries (circular, elliptic, and tilted). For both adult-sized valve geometries, the TPG (TPGC = 2.326 ± 0.115 mmHg; TPGSC = 1.848 ± 0.175 mmHg)* and EOA (EOAC = 3.69 ± 0.255 cm2; EOASC = 3.565 ± 0.025 cm2)* showed no significant difference. Yet the RF as well as its fluctuation was significantly higher for valves with the closed geometry (RFC = 12.657 ± 7.669 %; RFSC = 8.72 ± 0.977 %)*. Recordings showed that the increased backflow was caused by pinwheeling due to a surplus of tissue material. Hydrodynamic testing of pediatric TVRs verified the semi-closed geometry being favourable. Despite the RF (RFC = 7.721 ± 0.348 cm2; RFSC = 5.172 ± 0.679 cm2), these valves also showed an improved opening behaviour ((TPGC = 20.929 ± 0.497 cm2; TPGSC = 15.972 ± 1.158 cm2); (EOAC = 0.629 ± 0.017 cm2; EOASC = 0.731 ± 0.026 cm2)). Both adult and pediatric TVR with semi-closed geometry show better fluiddynamic functionality compared to valves with a closed design due to less pinwheeling. Besides improved short-term functionality, less pinwheeling potentially prevents early valve degeneration and improves durability. *Results are representatively shown for a circular annulus geometry.

Optical Coherence Tomography in the Assessment and Management of Cardiac Allograft Vasculopathy

PURPOSE OF REVIEW

Cardiac Allograft vasculopathy (CAV) is a major barrier to improving outcomes after heart transplantation. Coronary angiography has very low sensitivity to detect early CAV and intravascular ultrasound (IVUS) only improves it to some extent. In this article, we detail the current evidence surrounding use of Optical Coherence tomography (OCT) in patients with CAV.

RECENT FINDINGS

OCT has the ability to recognize CAV at earlier stages with intimal thickness < 150 μm, can characterize CAV in almost pathologic / microscopic detail - plaque characteristics are better visualized and novel early features such as layered fibrotic plaques and microchannels have been identified. Progression of CAV can be monitored also, with promise shown in automated serial measurements also. OCT has significantly advanced our understanding of the pathophysiology-as well as permits precise monitoring and surveillance of the disease. Potential treatment options could also be evaluated using OCT.

The genetics of spontaneous coronary artery dissection: a scoping review

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a multifactorial process that involves predisposing factors and precipitating stressors. Genetic abnormality has been implicated to play a mechanistic role in the development of SCAD. This systematic review aims to summarize the current evidence concerning the link between SCAD and genetic abnormalities.

METHODS

We reviewed original studies published until May 2023 that reported SCAD patients with a genetic mutation by searching PubMed, Embase Ovid, and Google Scholar. Registries, cohort studies, and case reports were included if a definitive SCAD diagnosis was reported, and the genetic analysis was performed. Exclusion criteria included editorials, reviews, letters or commentaries, animal studies, meeting papers, and studies from which we were unable to extract data. Data were extracted from published reports.

RESULTS

A total of 595 studies were screened and 55 studies were identified. Among 116 SCAD patients with genetic abnormalities, 20% had mutations in the COL gene, 13.70% TLN1 gene, and 8.42% TSR1 gene. Mutations affecting the genes encoding COL and TLN1 were most frequently reported (20 and 13.7%, respectively). Interestingly, 15 genes of this collection were also reported in patients with thoracic aortic diseases as well. The genetic commonality between fibromuscular dysplasia (FMD) and SCAD was also included.

CONCLUSION

In this review, the inherited conditions and reported genes of undetermined significance from case reports associated with SCAD are collected. A brief description of the encoded protein and the clinical features associated with pathologic genes is provided. Current data suggested that the diagnostic yield of genetic studies for patients with SCAD would be low and routine genetic screening of such patients with no clinical features indicative of associated disorders remains debatable. This review can be used as a guide for clinicians to recognize inherited syndromic and nonsyndromic disorders associated with SCAD.

Multidisciplinary Approach to Pulmonary Embolism and the Role of the Pulmonary Embolism Response Team

PURPOSE OF REVIEW

Acute pulmonary embolism (PE) is a leading cause of cardiovascular death and morbidity, and presents a major burden to healthcare systems. The field has seen rapid growth with development of innovative clot reduction technologies, as well as ongoing multicenter trials that may completely revolutionize care of PE patients. However, current paucity of robust clinical trials and guidelines often leave individual physicians managing patients with acute PE in a dilemma.

RECENT FINDINGS

The pulmonary embolism response team (PERT) was developed as a platform to rapidly engage multiple specialists to deliver evidence-based, organized and efficient care and help address some of the gaps in knowledge. Several centers investigating outcomes following implementation of PERT have demonstrated shorter hospital and intensive-care unit stays, lower use of inferior vena cava filters, and in some instances improved mortality. Since the advent of PERT, early findings demonstrate promise with improved outcomes after implementation of PERT. Incorporation of artificial intelligence (AI) into PERT has also shown promise with more streamlined care and reducing response times. Further clinical trials are needed to examine the impact of PERT model on care delivery and clinical outcomes.

Surgical treatment of a rare brachial artery aneurysm post-arteriovenous fistula closure after kidney transplant: A case report

BACKGROUND

Brachial artery aneurysms are defined as dilations greater than 50% of the normal diameter, which are rare among all peripheral arterial aneurysms. While they are often present as pseudoaneurysms, true brachial artery aneurysms are also detected rarely. In this case report, the surgical repair method of true brachial artery aneurysms, which is a rare condition, is explained.

CASE SUMMARY

Herein, we present a 61-year-old male patient with complaints of swelling and pain in the right arm antecubital region that had been progressing over 6 mo. Upon the diagnosis of a true brachial artery aneurysm associated with arteriovenous fistula, the aneurysm was surgically repaired with an autologous saphenous vein graft. The patient was discharged without any neurovascular complications postoperatively.

CONCLUSION

True brachial artery aneurysms are rare and there are not any recommendations for their management in the current literature. Even though the treatment of true aneurysms in this artery is primarily based on a surgical treatment, endovascular repair also might be an option.

Sex Differences in Cardiovascular Disease-Related Hospitalization and Mortality in Japan - Analysis of Health Records From a Nationwide Claim-Based Database, the Japanese Registry of All Cardiac and Vascular Disease (JROAD)

BACKGROUND

The prevalence of cardiovascular disease (CVD) is rising in Japan with its aging population, but there is a lack of epidemiological data on sex differences in CVD, including acute coronary syndrome (ACS), acute heart failure (AHF), and acute aortic disease.Methods and Results: This retrospective study analyzed data from 1,349,017 patients (January 2012-December 2020) using the Japanese Registry Of All Cardiac and Vascular Diseases database. ACS patients were youngest on average (70.5±12.9 years) and had the lowest female proportion (28.9%). AHF patients had the oldest mean age (79.7±12.0 years) and the highest proportion of females (48.0%). Acute aortic disease had the highest in-hospital mortality (26.1%), followed by AHF (11.5%) and ACS (8.9%). Sex-based mortality differences were notable in acute aortic disease, with higher male mortality in Stanford Type A acute aortic dissection (AAD) with surgery (males: 14.2% vs. females: 10.4%, P<0.001) and similar rates in Type B AAD (males: 6.2% vs. females: 7.9%, P=0.52). Aging was a universal risk factor for in-hospital mortality. Female sex was a risk factor for ACS and acute aortic disease but not for AHF or Types A and B AAD.

CONCLUSIONS

Sex-based disparities in the CVD-related hospitalization and mortality within the Japanese national population have been highlighted for the first time, indicating the importance of sex-specific strategies in the management and understanding of these conditions.

Receptor for advanced glycation end products polymorphisms in coronary artery ectasia

BACKGROUND

Although the implication of receptor of advanced glycation endproducts (RAGE) has been reported in coronary artery disease, its roles in coronary artery ectasia (CAE) have remained undetermined. Furthermore, the effect of RAGE polymorfisms were not well-defined in scope of soluble RAGE (sRAGE) levels. Thus, we aimed to investigate the influence of the functional polymorphisms of RAGE -374T > A (rs1800624) and G82S (rs2070600) in CAE development.

METHODS

This prospective observational study was conducted in 2 groups selected of 2452 patients who underwent elective coronary angiography (CAG) for evaluation after positive noninvasive heart tests. Group-I included 98 patients with non-obstructive coronary artery disease and CAE, and Group-II (control) included 100 patients with normal coronary arteries. SNPs were genotyped by real-time PCR using Taqman® genotyping assay. Serum sRAGE and soluble lectin-like oxidized receptor-1 (sOLR1) were assayed by ELISA and serum lipids were measured enzymatically.

RESULTS

The frequencies of the RAGE -374A allele and -374AA genotype were significantly higher in CAE patients compared to controls (p < 0.001). sRAGE levels were not different between study groups, while sOLR1 levels were elevated in CAE (p = 0.004). In controls without systemic disease, -374A allele was associated with low sRAGE levels (p < 0.05), but this association was not significant in controls with HT. Similarly, sRAGE levels of CAE patients with both HT and T2DM were higher than those no systemic disease (p = 0.02). The -374A allele was also associated with younger patient age and higher platelet count in the CAE group in both total and subgroup analyses. In the correlation analyses, the -374A allele was also negatively correlated with age and positively correlated with Plt in all of these CAE groups. In the total CAE group, sRAGE levels also showed a positive correlation with age and a negative correlation with HDL-cholesterol levels. On the other hand, a negative correlation was observed between sRAGE and Plt in the total, hypertensive and no systemic disease control subgroups. Multivariate logistic regression analysis confirmed that the -374A allele (p < 0.001), hyperlipidemia (p < 0.05), and high sOLR1 level (p < 0.05) are risk factors for CAE. ROC curve analysis shows that RAGE -374A allele has AUC of 0.713 (sensitivity: 83.7 %, specificity: 59.0 %), which is higher than HLD (sensitivity: 59.2 %, specificity: 69.0 %), HT (sensitivity: 62.4 %, specificity: 61.1 %) and high sOLR1 level (≥0.67 ng/ml)) (sensitivity: 59.8 %, specificity: 58.5 %).

CONCLUSION

Beside the demonstration of the relationship between -374A allele and increased risk of CAE for the first time, our results indicate that antihypertensive and antidiabetic treatment in CAE patients causes an increase in sRAGE levels. The lack of an association between the expected -374A allele and low sRAGE levels in total CAE group was attributed to the high proportion of hypertensive patients and hence to antihypertensive treatment. Moreover, the RAGE -374A allele is associated with younger age at CAE and higher Plt, suggesting that -374A may also be associated with platelet activation, which plays a role in the pathogenesis of CAE. However, our data need to be confirmed in a large study for definitive conclusions.

Pivotal role of AGE-RAGE axis in brain aging with current interventions

Brain aging is characterized by several structural, biochemical and molecular changes which can vary among different individuals and can be influenced by genetic, environmental and lifestyle factors. Accumulation of protein aggregates, altered neurotransmitter composition, low-grade chronic inflammation and prolonged oxidative stress have been shown to contribute to brain tissue damage. Among key metabolic byproducts, advanced glycation end products (AGEs), formed endogenously through non-enzymatic reactions or acquired directly from the diet or other exogenous sources, have been detected to accumulate in brain tissue, exerting detrimental effects on cellular structure and function, contributing to neurodegeneration and cognitive decline. Upon binding to signal transduction receptor RAGE, AGEs can initiate pro-inflammatory pathways, exacerbate oxidative stress and neuroinflammation, thus impairing neuronal function and cognition. AGE-RAGE signaling induces programmed cell death, disrupts the blood-brain barrier and promotes protein aggregation, further compromising brain health. In this review, we investigate the intricate relationship between the AGE-RAGE pathway and brain aging in order to detect affected molecules and potential targets for intervention. Reduction of AGE deposition in brain tissue either through novel pharmacological therapeutics, dietary modifications, and lifestyle changes, shows a great promise in mitigating cognitive decline associated with brain aging.

Surgical Removal of a Long-Forgotten, Retained Intravascular Foreign Body: A Case Report and Literature Review

Intravascular foreign body embolization is a potential complication of any vascular operation. Placement of a central venous catheter (CVC) is a common procedure, especially during surgery, hemodialysis, or in critically ill patients. The complete loss of the introducing guidewire into the circulation is a rare complication, with the majority of cases identified immediately or shortly after the procedure. We report an unusual case of an 82-year-old male with a misplaced CVC guidewire, extending from the right common femoral vein (CFV) to the superior vena cava, that was found incidentally 2 years after internal jugular vein cannulation during colorectal surgery. The patient was asymptomatic at the time, without any signs of deep vein thrombosis or post-thrombotic syndrome. Surgical extraction of the guidewire was successfully performed, under local anesthesia, through venotomy of the right CFV. Proper education and advanced awareness are advised in order to minimize the risk of this avoidable complication.

Outcomes of Thoracic and Complex Endovascular Aortic Repair in Patients with Renal Insufficiency

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) and complex endovascular aneurysm repair (cEVAR) are effective and minimally invasive treatment options for preventing rupture and decreasing mortality of aortic aneurysms. Patients with renal insufficiency are prone to worse postoperative cardiovascular morbidity and mortality due to the atherosclerosis burden as well as increased levels of angiotensin II. Nonetheless, knowledge about the outcomes of aortic stent graft therapy in patients with chronic kidney disease (CKD) or dialysis is scarce. This study aimed to examine outcomes after TEVAR and cEVAR in patients on CKD and dialysis.

METHODS

Utilizing data from the Vascular Quality Initiative (VQI) Vascular Implant Surveillance and Interventional Outcomes Network (VISION) database, we retrospectively evaluated patients who underwent TEVAR or cEVRA from 2010 to 2018. Patients were divided into patients with no CKD or dialysis, CKD patients, and dialysis patients. Outcomes were in-hospital stroke, myocardial infarction (MI), spinal cord ischemia (SCI), 30-day mortality, one-year mortality, aneurysmal rupture, and reintervention. In-hospital outcomes were assessed using multivariable logistic regression analysis and one-year outcomes were evaluated using kaplan Meier Survival and Cox regression analyses.

RESULTS

A total of 4,867 patients were included in the study, 2,694 had no CKD or dialysis, 2,047 had CKD, and 126 were on dialysis. Dialysis patients were significantly younger, and more likely to be non-white and of Hispanic/Latino origin. They were also more likely to have medical comorbidities. CKD patients had higher odds of in-hospital MI (OR: 2.02, 95%CI (1.43-2.86), P<0.001) and 30-day mortality (OR: 1.56, 95%CI (1.18-2.07), P<0.001) compared to patients with no CKD or dialysis. Dialysis patients had higher odds of 30-day mortality (OR: 3.31, 95%CI (1.73-6.35), P<0.001). At one year, dialysis was associated with a higher risk of mortality (HR: 3.48, 95%CI (2.39-5.07), P<0.001) and reintervention (HR: 1.72, 95%CI (1.001-2.94), P<0.049). CKD was associated with a higher risk of mortality (HR: 1.45, 95%CI (1.21-1.75), P<0.001) compared to patients with no CKD or dialysis.

CONCLUSIONS

Among patients undergoing TEVAR or cEVAR, there was no significant difference in the risk of in-hospital stroke, SCI, and one-year aneurysmal rupture among dialysis and CKD patients compared to patients with no CKD or dialysis. However, CKD patients had twice the risk of in-hospital MI. Dialysis patients had a higher risk of 1-year reintervention. Both dialysis and CKD patients had a higher risk of 30-day and 1-year mortality.

Diagnostic yield of head-up tilt table test in hypertrophic cardiomyopathy and unexplained syncope: the knot does not seem to be unraveling

BACKGROUND

Conflicting results have been published considering the diagnostic performance of head-up tilt test (HUTT) in patients with hypertrophic cardiomyopathy (HCM). We aimed to conduct a meta-analysis to evaluate the diagnostic value of HUTT in the evaluation of unexplained syncope in patients with HCM.

METHODS

We performed a structured systematic database search using the following keywords: hypertrophic cardiomyopathy, syncope, unexplained syncope, head-up tilt test, tilt table test, tilt testing, orthostatic stress, autonomic function, autonomic response. Studies in which the HUTT was used to define autonomic dysfunction in patients with syncope at baseline or without syncope were included in the final analysis.

RESULTS

A total of 252 HCM patients from 6 studies (159 patients without a history of syncope and 93 with a history of syncope, respectively) were evaluated. HUTT was positive in 50 (19.84%) of 252 patients (in 21 of 93 patients (22.58%) with a history of syncope and in 29 of 159 patients (18.24%) without a history of syncope, respectively). The pooled total sensitivity and specificity of the HUTT for detecting syncope were 22.1% (14.8-35.1%) and 83.6% (73.2-91.6%), respectively. The summary receiver operator curve showed that HUTT had an only modest discriminative ability for syncope with an area under the curve value of 0.565 (0.246-0.794).

CONCLUSION

Although HUTT has significant limitations in diagnosis of unexplained syncope in patients with HCM, it may still be used to determine hypotensive susceptibility. Other autonomic tests can be used in diagnostic workflow in this population.

Predictors of Disease Progression and Adverse Clinical Outcomes in Patients With Moderate Aortic Stenosis Using an Artificial Intelligence-Based Software Platform

Patients with moderate aortic stenosis (AS) have a greater risk of adverse clinical outcomes than that of the general population. How this risk compares with those with severe AS, along with factors associated with outcomes and disease progression, is less clear. We analyzed serial echoes (from 2017 to 2019) from a single healthcare system using Tempus Next (Chicago, Illinois) software. AS severity was defined according to American Heart Association/American College of Cardiology guidelines. Outcomes of interest included death or heart failure hospitalization. We used Cox proportional hazards models and logistic regression to identify predictors of clinical outcome and disease progression, respectively. From 82,805 echoes for 61,546 patients, 1,770; 914; 565; and 1,463 patients had no, mild, moderate, or severe AS, respectively. Both patients with moderate and those with severe AS experienced a similar prevalence of adverse clinical outcomes (p = 0.45) that was significantly greater than that of patients without AS (p <0.01). In patients with moderate AS, atrial fibrillation (hazard ratio 3.29, 95% confidence interval 1.79 to 6.02, p <0.001) and end-stage renal disease (hazard ratio 3.34, 95% confidence interval 1.87 to 5.95, p <0.001) were associated with adverse clinical outcomes. One-third of patients with moderate AS with a subsequent echo (139/434) progressed to severe AS within 1 year. In conclusion, patients with moderate AS can progress rapidly to severe AS and experience a similar risk of adverse clinical outcomes; predictors include atrial fibrillation and low left ventricular ejection fraction. Machine learning algorithms may help identify these patients. Whether these patients may warrant earlier intervention merits further study.

Successful Retrograde Percutaneous Coronary Intervention for Chronic Total Occlusion in a Patient with Dextrocardia

Dextrocardia is a very rare congenital malposition, and most cardiologists are not familiar with the radiographic angiograms of this condition. Here, we first report a case of dextrocardia with a chronic total occlusion (CTO) lesion undergoing retrograde percutaneous coronary intervention (PCI). Significant difficulties in lesion interpretation and device manipulation were encountered with the original angiograms. These challenges were not significantly improved until we adopted the double-inversion technique. The procedure was finally accomplished by using the kissing wire technique with a poor angle of attack. Retrograde CTO PCI for patients with dextrocardia is feasible with adequate techniques.

30-Day Risk Score for Mortality and Stroke in Patients with Carotid Artery Stenosis Using Artificial Intelligence Based Carotid Plaque Morphology

OBJECTIVES

The gold standard for determining carotid artery stenosis intervention is based on a combination of percent stenosis and symptomatic status. Few studies have assessed plaque morphology as an additive tool for stroke prediction. Our goal was to create a predictive model and risk score for 30-day stroke and death inclusive of plaque morphology.

METHODS

Patients with a CT angiography head/neck between 2010-2021 at a single institution and a diagnosis of carotid artery stenosis were included in our analysis. Each CT was used to create a 3D image of carotid plaque based off image recognition software. A stepwise backward regression was used to select variables for inclusion in our prediction models. Model discrimination was assessed with receiver operating characteristic curves (AUC). Additionally, calibration was performed and the model with the least Akaike Information Criterion (AIC) was selected. The risk score was modeled from the Framingham Study. Primary outcome was mortality/stroke.

RESULTS

We created three models to predict mortality/stroke from 366 patients: model A using only clinical variables, model B using only plaque morphology and model C using both clinical and plaque morphology variables. Model A used age, sex, PAD, hyperlipidemia, BMI, COPD, and history of TIA/stroke and had an AUC of 0.737 and AIC of 285.4. Model B used perivascular adipose tissue volume, lumen area, calcified volume, and target lesion length and had an AUC of 0.644 and AIC of 304.8. Finally, model C combined both clinical and software variables of age, sex, matrix volume, history of TIA/stroke, BMI, perivascular adipose tissue, lipid rich necrotic core, COPD and hyperlipidemia and had an AUC of 0.759 and an AIC of 277.6. Model C was the most predictive because it had the highest AUC and lowest AIC.

CONCLUSION

Our study demonstrates that combining both clinical factors and plaque morphology creates the best predication of a patient's risk for all-cause mortality or stroke from carotid artery stenosis. Additionally, we found that for patients with even 3 points in our risk score model have a 20% chance of stroke/death. Further prospective studies are needed to validate our findings.

The Top One Hundred Most Cited Articles in Venous Disease and Management

OBJECTIVE

Advancements in the management of venous disease have been documented in scientific literature. We performed a bibliometric analysis using citations as an indication of impact to analyze the most influential articles on venous disease and treatment.

METHODS

A retrospective search of the Web of Science database was conducted in May 2023. Key search terms were queried to generate relevant articles. Articles were ranked on total number of citations and average number of citations per year. Metrics analyzed included top journals, impact factor, journal discipline, institution and country of publication, author degree and gender, number of publications per year, level of evidence, and article topic area.

RESULTS

The top 100 articles on venous disease were published between 1994 and 2020, with a total of 102,856 citations, average 1028 citations/article, and mean of 70 citations/year. The most popular article was "Incidence of thrombotic complications of in critically ill ICU patients with COVID-19" with 3,482 citations in total. The most popular journals were New England Journal of Medicine (22 articles), Lancet (14 articles), and CHEST (13 articles), pertaining to management of deep venous thrombosis (DVT). The Journal of Vascular surgery had 2 influential articles, focused on management of chronic venous disease. Many articles were published in the United States (52), Canada (38), and Netherlands (25). Prolific authors were predominantly male (96%) and 59% were MDs versus 29% combined MD/PhD and 12% PhDs. Popular venous articles included guidelines/standards for DVT management (12%), epidemiology of venous thromboembolism (VTE) (12%), and anticoagulation for DVT (12%). Specific VTE risk factors within popular literature included prothrombotic genes, malignancy, pregnancy, trauma, and COVID-19. Articles on surgical interventions included inferior vena cava filter placement, catheter-directed thrombolysis, and risks of femoral and subclavian vein catheterization. Venous stenting and mechanical thrombectomy were not within the top articles.

CONCLUSIONS

Top cited articles on venous disease emphasized management of DVT, followed by chronic venous disease, through the collaboration of multiple medical and surgical specialties. The largest number of citations in recent DVT literature was driven by COVID-19 complications.

Anticoagulant and antiplatelet treatment effects on the incidence of major cardiovascular events in patients with coronary artery ectasia: an updated systematic review

INTRODUCTION

Coronary artery ectasia (CAE), widenings in sections of the arteries, is a rare condition found in up to 3-5% of angiography cases. Sometimes recurrence of major adverse cardiac events (MACE) has been reported in the CAE subjects. The present systematic review aims to collect and summarize reports on whether the use of anticoagulants in addition to single antiplatelet/dual antiplatelet therapy (SAPT/DAPT) in CAE patients with significant occlusion/ heavy thrombus is efficient and safe in decreasing the incidence/recurrence of MACE.

MATERIAL AND METHODS

A systematically comprehensive search was performed covering PubMed, Scopus, ISI Web of Science, and Google Scholar databases.

RESULTS

Twenty-five studies were found including 20 case reports, four case series, and one randomized clinical trial. Of 20 case reports 15 were male (75%), and five were female (25%). Of the four the case series, all showed positive outcomes after DAPT plus anticoagulant in more than 50% of patients; two took only DAPT and 13 took anticoagulant ± DAPT, and five compared both. Cases received DAPT only experienced recurrences of MACE. The other cases were uneventful with less MACE and better outcomes after the use of anticoagulant ± DAPT. Results of these case-series included 457 CAE patients showed that more than 80% of subjects were male, and in all studies tailored pharmacological interventions, including antiplatelet and anticoagulant (warfarin) therapies, resulted in less MACE and mortality.

CONCLUSION

It can be concluded that antiplatelet (SAPT/DAPT) must be applied in combination with anticoagulants to provide more efficient protection against MACE in CAE patients. However, further high-quality randomized clinical trials are needed to confirm the results.

Diagnostic and therapeutic considerations in cases of civilian intravascular ballistic embolism: a review of case reports

Background

Ballistic embolism (BE) is a rare complication of firearm injuries notoriously associated with a vexing clinical picture in the trauma bay. Unless considered early, the associated confusion can lead to needless delay in the management of the patient with a gunshot wound. Despite this known entity, there is a relative paucity of high-grade evidence regarding complications, management, and follow-up in these patients.

Methods

An electronic database literature search was conducted to identify cases of acute intravascular BE in pediatric and adult civilians occurring during index hospitalization, filtered to publications during the past 10 years. Exclusion criteria included non-vascular embolization, injuries occurring in the military setting, and delayed migration defined as occurring after discharge from the index hospitalization.

Results

A total of 136 cases were analyzed. Nearly all cases of BE occurred within 48 hours of presentation. Compared with venous emboli, arterial emboli were significantly more likely to be symptomatic (71% vs. 7%, p<0.001), and 43% of patients developed symptoms attributable to BE in the trauma bay. In addition, arterial emboli were significantly less likely to be managed non-invasively (19% vs. 49%, p<0.001). Open retrieval was significantly more likely to be successful compared with endovascular attempts (91% vs. 29%, p<0.001). Patients with arterial emboli were more likely to receive follow-up (52% vs. 39%) and any attempt at retrieval during the hospitalization was significantly associated with outpatient follow-up (p=0.034). All but one patient remained stable or had clinically improved symptoms after discharge.

Conclusion

Consideration for BE is reasonable in any patient with new or persistent unexplained signs or symptoms, especially during the first 48 hours after a penetrating firearm injury. Although venous BE can often be safely observed, arterial BE generally necessitates urgent retrieval. Patients who are managed non-invasively may benefit from follow-up in the first year after injury.

Chronic Venous Disease: Pathophysiological Aspects, Risk Factors, and Diagnosis

Chronic venous disease (CVD) is highly prevalent in the general population and encompasses a range of pathological and hemodynamic changes in the veins of the lower extremities. These alterations give rise to a variety of symptoms, with more severe forms resulting in venous ulceration, which causes morbidity and high socioeconomic burden. The origins and underlying mechanisms of CVD are intricate and multifaceted, involving environmental factors, genetics, hormonal factors, and immunological factors that bring about structural and functional alterations in the venous system. This review offers the latest insights into the epidemiology, pathophysiology, and risk factors of CVD, aiming to provide a comprehensive overview of the current state of knowledge. Furthermore, the diagnostic approach for CVD is highlighted and current diagnostic tools are described.

The Effect of Revascularization on Lower Limb Circulation Parameters in Symptomatic Peripheral Arterial Disease

Background: The prevalence of peripheral arterial disease and the number of revascularization procedures performed in symptomatic patients are steadily increasing. However, uncertainties remain regarding hemodynamic monitoring after revascularization and the prediction of clinical outcomes. This study aimed to investigate hemodynamic parameters with a focus on the microvasculature. Methods: This prospective, single-center study included 29 patients (15 with intermittent claudication [IC] and 14 with chronic limb-threatening ischemia [CLTI]). Before and after the revascularization procedure, in addition to the ankle-brachial index (ABI), microperfusion parameters, including microvascular blood flow, capillary oxygen saturation (SO2), and relative hemoglobin content (rHb), were assessed with lightguide spectrophotometry combined with laser Doppler flowmetry using an oxygen-to-see (O2C) device in the horizontal and elevated leg positions. Results: At baseline, SO2 in the elevated leg position was significantly lower in patients with CLTI than in those with IC (p = 0.0189), whereas the other microcirculatory parameters and ABI values were not significantly different. Patients with diabetes mellitus had a higher flow rate than those without in the horizontal leg position (p = 0.0162) but not in the elevated leg position. After successful revascularization, the flow increased immediately and significantly in both positions, whereas SO2, rHb, and the ABI did not. Conclusions: Elevated leg SO2 was significantly lower in CLTI than in clinically compensated peripheral arterial disease, whereas microvascular flow was a suitable surrogate parameter indicating successful revascularization. In studies using surgical or interventional revascularization procedures, noninvasive hemodynamic monitoring of the microcirculation at the foot level might be beneficial.

Evolution of Pulmonary Embolism Response Teams in the United States: A Review of the Literature

Pulmonary embolism (PE) is a significant cause of cardiovascular mortality, with varying presentations and management challenges. Traditional treatment approaches often differ, particularly for submassive/intermediate-risk PEs, because of the lack of clear guidelines and comparative data on treatment efficacy. The introduction of pulmonary embolism response teams (PERTs) aims to standardize and improve outcomes in acute PE management through multidisciplinary collaboration. This review examines the conception, evolution, and operational mechanisms of PERTs while providing a critical analysis of their implementation and efficacy using retrospective trials and recent randomized trials. The study also explores the integration of advanced therapeutic devices and treatment protocols facilitated by PERTs. PERT programs have significantly influenced the management of both massive and submassive PEs, with notable improvements in clinical outcomes such as decreased mortality and reduced length of hospital stay. The utilization of advanced therapies, including catheter-directed thrombolysis and mechanical thrombectomy, has increased under PERT guidance. Evidence from various studies, including those from the National PERT Consortium, underscores the benefits of these multidisciplinary teams in managing complex PE cases, despite some studies showing no significant difference in mortality. PERT programs have demonstrated potentials to reduce morbidity and mortality, streamlining the use of healthcare resources and fostering a model of sustainable practice across medical centers. PERT program implementation appears to have improved PE treatment protocols and innovated advanced therapy options, which will be further refined as they are employed in clinical practice. The continued expansion of the capabilities of PERTs and the forthcoming results from ongoing randomized trials are expected to further define and optimize management protocols for acute PEs.

Prediction of Osteoporotic Hip Fracture Outcome: Comparative Accuracy of 27 Immune-Inflammatory-Metabolic Markers and Related Conceptual Issues

Objectives: This study, based on the concept of immuno-inflammatory-metabolic (IIM) dysregulation, investigated and compared the prognostic impact of 27 indices at admission for prediction of postoperative myocardial injury (PMI) and/or hospital death in hip fracture (HF) patients. Methods: In consecutive HF patient (n = 1273, mean age 82.9 ± 8.7 years, 73.5% females) demographics, medical history, laboratory parameters, and outcomes were recorded prospectively. Multiple logistic regression and receiver-operating characteristic analyses (the area under the curve, AUC) were used to establish the predictive role for each biomarker. Results: Among 27 IIM biomarkers, 10 indices were significantly associated with development of PMI and 16 were indicative of a fatal outcome; in the subset of patients aged >80 years with ischaemic heart disease (IHD, the highest risk group: 90.2% of all deaths), the corresponding figures were 26 and 20. In the latter group, the five strongest preoperative predictors for PMI were anaemia (AUC 0.7879), monocyte/eosinophil ratio > 13.0 (AUC 0.7814), neutrophil/lymphocyte ratio > 7.5 (AUC 0.7784), eosinophil count < 1.1 × 109/L (AUC 0.7780), and neutrophil/albumin × 10 > 2.4 (AUC 0.7732); additionally, sensitivity was 83.1-75.4% and specificity was 82.1-75.0%. The highest predictors of in-hospital death were platelet/lymphocyte ratio > 280.0 (AUC 0.8390), lymphocyte/monocyte ratio < 1.1 (AUC 0.8375), albumin < 33 g/L (AUC 0.7889), red cell distribution width > 14.5% (AUC 0.7739), and anaemia (AUC 0.7604), sensitivity 88.2% and above, and specificity 85.1-79.3%. Internal validation confirmed the predictive value of the models. Conclusions: Comparison of 27 IIM indices in HF patients identified several simple, widely available, and inexpensive parameters highly predictive for PMI and/or in-hospital death. The applicability of IIM biomarkers to diagnose and predict risks for chronic diseases, including OP/OF, in the preclinical stages is discussed.

Comparing the efficacy and safety of endovascular therapy versus surgical revascularization for critical limb-threatening ischemia: A systematic review and meta-analysis

INTRODUCTION

Critical limb-threatening ischemia (CLTI) is a severe manifestation of peripheral artery disease (PAD) that can lead to limb amputation and significantly reduce the quality of life. In addition to guideline-directed medical therapy (GDMT), endovascular therapy and surgical revascularization are the two revascularization options for CLTI. In recent years, there has been an ongoing debate about the best approach for CLTI patients. The purpose of this meta-analysis is to examine the current evidence and compare the clinical outcomes of endovascular therapy and surgical revascularization for CLTI.

METHODS

We conducted a systematic search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) for studies comparing the outcomes of endovascular therapy versus surgery in patients with CLTI. The primary outcomes were major adverse limb events (MALE) and major adverse cardiovascular events (MACE), while secondary outcomes included risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and length of hospital stay. Pooled data was analyzed using the fixed-effect model or the random-effect model in Review Manager 5.3. The Newcastle-Ottawa Scale and Cochrane risk of bias assessment tool were used to assess the bias of included studies.

RESULTS

A total of 16 studies (47,609 patients) were included in this meta-analysis. The overall effect favors surgery over endovascular intervention in terms of MALE [odds ratio (OR) 1.13, 95% CI (1.01-1.28), P = 0.04]. Endovascular therapy is associated with lower MACE rates compared to surgery [OR 0.62, 95% CI (0.51-0.76), P < 0.00001]. Furthermore, the risk of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure as well as the length of hospital stay was lower for endovascular intervention. Finally, there was no statistically significant difference in 30-day mortality between the two groups [OR 0.94, 95% CI 0.79-1.12, P = 0.52; Fig. 3i], and the pooled studies were homogeneous [P = 0.39; I2 = 5%].

CONCLUSION

Surgery may be the preferred treatment option for CLTI patients, as it is associated with a lower risk of MALE than endovascular therapy. However, endovascular therapy may be associated with a lower risk of MACE and lower rates of bleeding, wound complications, readmission, unplanned reoperation, acute renal failure, and shorter hospital stays. There was no statistically significant difference in 30-day mortality between the two groups. Ultimately, the decision to use endovascular therapy or surgery as the primary treatment strategy should be based on a multi-disciplinary team approach with careful consideration of patient characteristics and anatomy.

Hypertension in an ageing population: Diagnosis, mechanisms, collateral health risks, treatments, and clinical challenges

Ageing population is considerably increasing worldwide, which is considered to reflect an improved quality of life. However, longevity in the human lifespan has increased the burden of late-life illnesses including cancer, neurodegeneration, and cardiovascular dysfunction. Of these, hypertension is the most common condition with huge health risks, with an increased prevalence among the elderly. In this review, we outline the current guidelines for defining hypertension and examine the detailed mechanisms underlying the relationship between hypertension and ageing-related outcomes, including sodium sensitivity, arterial stiffness, endothelial dysfunction, isolated systolic hypertension, white coat effect, and orthostatic hypertension. As hypertension-related collateral health risk increases among the elderly, the available management strategies are necessary to overcome the clinical treatment challenges faced among elderly population. To improve longevity and reduce adverse health effects, potential approaches producing crucial information into new era of medicine should be considered in the prevention and treatment of hypertension among elderly population. This review provides an overview of mechanisms underlying hypertension and its related collateral health risk in elderly population, along with multiple approaches and management strategies to improve the clinical challenges among elderly population.

Evaluation of hepatosteatosis and gallstone disease in patients with chronic kidney disease

INTRODUCTION

The prevalence rates of hepatosteatosis and gallstones are increasing owing to the multifactorial causes of chronic kidney disease, and the prevalence may change with the availability of different forms of renal replacement therapy. We aimed to determine the incidence or prevalence rates of hepatosteatosis, cholelithiasis, and acute cholecystitis in patients with chronic kidney disease and compare them between renal replacement therapy modalities.

METHODS

A total of 270 patients (90 with chronic kidney disease stages III-V, 90 undergoing peritoneal dialysis, and 90 undergoing hemodialysis) were included and categorized into the pre-dialysis, hemodialysis, and peritoneal dialysis groups. The patients were questioned about previous gallbladder surgeries and chronic diseases. The results of abdominal ultrasonography, tomography, and magnetic resonance imaging were retrospectively evaluated with respect to the findings on the hepatobiliary system. Hepatosteatosis and cholelithiasis were diagnosed by expert radiologists on the basis of abdominal ultrasonography, tomography, and magnetic resonance imaging findings. The prevalence rates of hepatosteatosis, cholelithiasis, and other liver findings were compared between the groups.

FINDINGS

Hepatosteatosis and cholelithiasis were detected in 16.7% and 21.5% of the 270 cases, respectively. Hepatosteatosis was present in 17.8%, 25.6%, and 6.7% of patients in the pre-dialysis, hemodialysis, and peritoneal dialysis groups, respectively. The prevalence of hepatosteatosis was significantly higher in patients undergoing hemodialysis than in patients undergoing peritoneal dialysis (p = 0.002). However, no statistically significant difference was found between the peritoneal dialysis and pre-dialysis groups or between the hemodialysis and pre-dialysis groups (p >0.05). The prevalence rates of cholelithiasis were 15.6%, 28.9%, and 20.0%, in the pre-dialysis, hemodialysis, and peritoneal dialysis groups, respectively, and there were no statistically significant differences among the groups. The incidence of acute cholecystitis was significantly higher in the hemodialysis group than in the pre-dialysis group (p = 0.006).

DISCUSSION

Our study showed that the hepatobiliary system is frequently affected in chronic kidney disease and that the findings may differ depending on the renal replacement therapy modality.

Semen quality and metabolic profile in people with type 1 diabetes with and without erectile dysfunction: a cross-sectional study

PURPOSE

The aim of the present study is to evaluate the association of metabolic and glycemic variables with semen parameters in patients with type 1 diabetes (T1D) with and without erectile dysfunction (ED).

METHODS

The study population included 88 adults with T1D using a continuous glucose monitoring, of whom 28 with ED (ED group) and 60 without it (NO ED group). All men completed the International Index of Erectile Function (IIEF-5) and underwent body composition analysis (BIA) and semen analysis.

RESULTS

ED group showed worse HbA1c levels [median (IQR), 8.4 (7.7, 9.9) vs 7.4 (7, 8.2) %, P < 0.001)], higher insulin dose [60 (51, 65) vs 45 (38, 56) UI/die, P = 0.004)] and a higher total body water and intracellular water as compared with ED group. Men in the ED group presented higher semen volume [2.8 (2.6, 4.2) vs 2.5 (2.2, 2.7) mL, P < 0.001] and sperm concentration [24 (19, 29) vs 20 (12, 23) mil/mL, P = 0.010], but reduced sperm progressive motility [28 (25, 35) vs 35 (25, 36) %, P = 0.011], higher rate of non-progressive motility [15 (10, 15) vs 10 (5, 10) %, P < 0.001] and higher rate of typical morphology [7(5, 8) vs 5 (4, 5) %, P = 0.001]. Based on multivariate logistic regression analysis performed to assess the association between clinical variables and ED, intracellular water (OR 3.829, 95% CI 1.205, 12.163, P = 0.023) resulted as the only independent predictor of ED.

CONCLUSION

Men with T1D and ED showed worse metabolic profile which is associated with poor semen quality, as compared with those without ED.

2024 RECOVER Guidelines: Monitoring. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

OBJECTIVE

To systematically review evidence on and devise treatment recommendations for patient monitoring before, during, and following CPR in dogs and cats, and to identify critical knowledge gaps.

DESIGN

Standardized, systematic evaluation of literature pertinent to peri-CPR monitoring following Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Prioritized questions were each reviewed by Evidence Evaluators, and findings were reconciled by Monitoring Domain Chairs and Reassessment Campaign on Veterinary Resuscitation (RECOVER) Co-Chairs to arrive at treatment recommendations commensurate to quality of evidence, risk:benefit relationship, and clinical feasibility. This process was implemented using an Evidence Profile Worksheet for each question that included an introduction, consensus on science, treatment recommendations, justification for these recommendations, and important knowledge gaps. A draft of these worksheets was distributed to veterinary professionals for comment for 4 weeks prior to finalization.

SETTING

Transdisciplinary, international collaboration in university, specialty, and emergency practice.

RESULTS

Thirteen questions pertaining to hemodynamic, respiratory, and metabolic monitoring practices for identification of cardiopulmonary arrest, quality of CPR, and postcardiac arrest care were examined, and 24 treatment recommendations were formulated. Of these, 5 recommendations pertained to aspects of end-tidal CO2 (ETco2) measurement. The recommendations were founded predominantly on very low quality of evidence, with some based on expert opinion.

CONCLUSIONS

The Monitoring Domain authors continue to support initiation of chest compressions without pulse palpation. We recommend multimodal monitoring of patients at risk of cardiopulmonary arrest, at risk of re-arrest, or under general anesthesia. This report highlights the utility of ETco2 monitoring to verify correct intubation, identify return of spontaneous circulation, evaluate quality of CPR, and guide basic life support measures. Treatment recommendations further suggest intra-arrest evaluation of electrolytes (ie, potassium and calcium), as these may inform outcome-relevant interventions.

Incremental value of ABI and CAC beyond traditional risk markers in long-term prediction of cardiovascular disease incidence in participants with diabetes and impaired fasting glucose: Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Subclinical atherosclerosis (SA) diagnosis is key to primary prevention of atherosclerotic cardiovascular disease (ASCVD). SA is common among diabetics. Ankle brachial index (ABI) and coronary artery calcium (CAC) are markers of SA. This study examined whether adding ABI and CAC to diabetic individuals improved ASCVD risk prediction beyond established risk factors.

METHODS

MESA is an observational cohort of 6814 participants without clinical cardiovascular disease. All participants with diabetes and impaired fasting glucose were included in the analysis. The association between CAC, ABI, and incident ASCVD, and all-cause mortality was examined using Cox proportional hazard regression. The risk prediction models including ABI and/or CAC in addition to standard risk factors alone were compared.

RESULTS

Of the 1719 participants, 55% were male and average age was 64 (±9.6) years old. Participants with diabetes or impaired fasting glucose with higher CAC and lower ABI had higher ASCVD and all-cause mortality. ABI and CAC enhanced ASCVD discrimination over standard risk factors, with C-index (95% CI) of 0.689 (0.66, 0.718) for risk factors alone, 0.696 (0.668, 0.724) for ABI, 0.719 (0.691, 0.747) for CAC, and 0.721 (0.693, 0.749) for CAC + ABI. Similarly, for all-cause mortality, both CAC and ABI improved risk discrimination in addition to standard risk factors alone.

CONCLUSIONS

In a large population-based study of individuals with diabetes or impaired fasting glucose, the addition of ABI and CAC to conventional risk factors improved 10-year ASCVD risk prediction. ABI and CAC are non-invasive and cost-effective tests; therefore, these markers should be included into ASCVD risk stratification for primary prevention in the diabetic and impaired fasting glucose population.

Ruptured abdominal aortic aneurysm in psoriasis: A case report and review of literature

INTRODUCTION

Psoriasis, a chronic inflammatory skin condition, affects 4 % of the population and is associated with various comorbidities, making it a public health concern.

CASE REPORT

We discuss the case of a 50-year-old man with severe erythrodermic psoriasis who presented with a ruptured saccular abdominal aortic aneurysm (AAA), requiring emergency surgery with good postoperative follow-up. shedding light on the link between psoriasis and cardiovascular complications.

DISCUSSION

Psoriasis severity correlates with cardiovascular risk and shares common development pathways with aortic aneurysms such as systemic and aortic inflammation, and arterial stiffness, emphasizing the importance of managing both skin symptoms and systemic inflammation to reduce vascular comorbidities. Psoriasis patients have a higher risk of AAA, warranting consideration for AAA screening. Controversies exist regarding corticosteroid therapy and choice of surgical intervention for AAA in psoriatic patients.

CONCLUSION

Psoriasis patients face an increased risk of AAA, highlighting the need for vigilant screening and comprehensive management. Further research is essential to understanding the pathophysiological connections between psoriasis and arterial diseases, guiding preventive strategies and optimal medical treatments for these high-risk patients.

The correlation between smoking cumulative dose based on Brinkman Index with peak expiratory flow rate

Background

Indonesia is the country with the highest prevalence of smokers above 15 years old according to WHO, with a percentage of 76.2%. Smoking-induced lung damage is characterized by inflammation, leading to the destruction of lung parenchyma and airway obstruction, ultimately worsening lung function parameters. This study aims to find correlation between cumulative dose of smoking based on Brinkman index (BI) with Peak Expiratory Flow Rate (PEFR).

Methods

This is a cross-sectional correlative study conducted on January-March 2020. Data were collected through history taking and PEFR measured with a peak flowmeter by taking the average of three peak flowmeter measurements, each separated by a 2-min interval. Inclusion criteria include male active smokers, aged 30 to 40 years, who have had a smoking history for at least 1 year. Exclusion criteria are as follows: uses e-cigarretes for smoking, has a history of chronic lung diseases such as tuberculosis, pneumonia, post-COVID-19 syndrome, asthma, and has not smoked in the last 28 days.

Results

A total of 48 male smokers are included in this study. The mean age of participants was 35.91 years, with a history of smoking of 18.12 years, and 12.5 cigarettes smoked daily. Patients included in this study had BI classified as mild (47.91%), moderate (47.91%), and severe (4.16%). PEFR in patients was classified into green (10.41%), yellow (83.33%), and red (6.25%). Analysis showed significant negative correlation between BI and PEFR (r = -0.721; p < 0.001) suggesting that increasing Brinkman Index may lead to a decrease in PEFR.

Conclusion

Higher BI correlates with a decrease in PEFR. PEFR may prove to be useful in early detection of reduced pulmonary function. Further trials conducted on larger sample sizes and evaluating other lung function parameters are recommended.

Tomographic 3D ultrasound for grading stenosis of superficial femoral artery

INTRODUCTION

Treatment decision of lower extremity peripheral arterial disease (PAD) is governed by the severity of stenosis. Tomographic 3D ultrasound (t3DUS) is a reliable imaging technique for measuring vessel stenosis. In this study we attempted to provide a precise measurement of superficial femoral artery (SFA) stenosis using t3DUS in patients with PAD.

METHODS

t3DUS was used to measure maximum stenosis percentage in SFA from 50 patients with lower extremity PAD. The maximum stenosed segment in SFA was defined using Duplex 2DUS aliasing was noted. The peak systolic velocity (PSV) was measured at the maximum stenotic site and proximal to aliasing for calculating the velocity ratio. The association between blood flow velocity ratio and the degree of stenosis measured using Duplex 2DUS and t3DUS, respectively, was assessed using Spearman rank correlation.

RESULTS

There was a strong positive correlation between velocity ratio and degree of stenosis in SFA measured using t3DUS (correlation value (r) = 0.99, p < 0.001). The correlation between Stenosis percentage and velocity ratio in SFA are as followed: <50:<2; 50-54:2-2.4; 55-59:2.5-2.9; 60-64:3-3.4; 65-69:3.5-3.9; 70-74:4-4.4; 75-79:4.5-4.9; >80:>5.

t3DUS can be used to provide precise measurement of the severity of SFA stenosis in patients with lower extremities arterial disease. The established criteria for grading SFA stenosis in this study can be applied to the current practice alongside Duplex 2DUS as it showed a strong positive correlation with velocity ratio. Further studies investigating the sensitivity and specificity of t3DUS in the assessment of stenosis in lower limbs arteries are required.

Intra-aortic balloon pump is associated with the lowest whereas Impella with the highest inpatient mortality and complications regardless of severity or hospital types

Impella and intra-aortic balloon pumps (IABP) are commonly utilized in patients with cardiogenic shock. However, the effect on mortality remains controversial. The goal of this study was to evaluate the effect of Impella and IABP on mortality in patients with cardiogenic shock the large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of IABP or Impella on outcome. ICD-10 codes for Impella, IABP, and cardiogenic shock for available years 2016-2020 were utilized. A total of 844,020 patients had a diagnosis of cardiogenic shock. A total of 101,870 patients were treated with IABP and 39645 with an Impella. Total inpatient mortality without any device was 34.2% vs only 25.1% with IABP use (OR = 0.65, CI 0.62-0.67) but was highest at 40.7% with Impella utilization (OR = 1.32, CI 1.26-1.39). After adjusting for 47 variables, Impella utilization remained associated with the highest mortality (OR: 1.33, CI 1.25-1.41, p < 0.001), whereas IABP remained associated with the lowest mortality (OR: 0.69, CI 0.66-0.72, p < 0.001). Separating rural vs teaching hospitals revealed similar findings. In patients with cardiogenic shock, the use of Impella was associated with the highest whereas IABP was associated with the lowest in-hospital mortality regardless of comorbid condition.