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Carmo LS, Baima DC, Blefari V, Zonta V, Troncon LE, Rossi MA. Involvement of the microvasculature in the pathogenesis of terlipressin-related myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 5:505-511. [PMID: 24855284 DOI: 10.1177/2048872614534921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 04/18/2014] [Indexed: 11/16/2022]
Abstract
We report an autopsy case of a 24-year-old man with diagnoses of advanced alcoholic liver cirrhosis, portal hypertension, and esophageal variceal bleeding that presented extensive myocardial infarction after treatment with terlipressin. On postmortem examination the cut surface of the heart presented myocardial infarction implicating the left ventricle free wall, apex of the heart and ventricular septum. Light microscopic examination revealed that the extensive area of cardiac infarction was the result of the sum of diffuse foci of microinfarction of various ages interspersed with small clusters of preserved myocytes. Moreover, the epicardial vessels were patent while the small intramyocardial vessels presented thickened wall, apparent reduction in lumen diameter and disruption of endothelial cells indicative of spasm. The observations in this case allow clear insight into the involvement of the microcirculation in the pathogenesis of myocardial infarction with the use of terlipressin.
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Affiliation(s)
- Lucas S Carmo
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Diego C Baima
- Department of Medicine, Division of Gastroenterology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Valdecir Blefari
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Vaniela Zonta
- Department of Medicine, Division of Gastroenterology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Luiz Ea Troncon
- Department of Medicine, Division of Gastroenterology, Ribeirão Preto Medical School, University of São Paulo, Brazil
| | - Marcos A Rossi
- Department of Pathology, Ribeirão Preto Medical School, University of São Paulo, Brazil.,Marcos A Rossi passed away on 9 May 2013
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Chen YX, Li CS. The prognostic and risk-stratified value of heart-type fatty acid-binding protein in septic patients in the emergency department. J Crit Care 2014; 29:512-6. [PMID: 24768564 DOI: 10.1016/j.jcrc.2014.03.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/23/2014] [Accepted: 03/25/2014] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate the prognostic and risk-stratified ability of heart-type fatty acid-binding protein (H-FABP) in septic patients in the emergency department (ED). MATERIALS AND METHODS From August to November 2012, 295 consecutive septic patients were enrolled. Circulating H-FABP was measured. The predictive value of H-FABP for 28-day mortality, organ dysfunction on ED arrival, and requirement for mechanical ventilation or a vasopressor within 6 hours after ED arrival was assessed by the receiver operating characteristic curve and logistic regression and was compared with Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mortality in Emergency Department Sepsis (MEDS) score, and Sequential Organ Failure Assessment score. RESULTS The 28-day mortality, APACHE II, MEDS, and Sequential Organ Failure Assessment scores were much higher in H-FABP-positive patients. The incidence of organ dysfunction at ED arrival and requirement for mechanical ventilation or a vasopressor within 6 hours after ED arrival was higher in H-FABP-positive patients. Heart-type fatty acid-binding protein was an independent predictor of 28-day mortality and organ dysfunction. The area under the receiver operating characteristic curve for H-FABP predicting 28-day mortality and organ dysfunction was 0.784 and 0.755, respectively. Combination of H-FABP and MEDS improved the performance of MEDS in predicting organ dysfunction, and the difference of AUC was statistically significant (P<.05). The combinations of H-FABP and MEDS or H-FABP and APACHE II also improved the prognostic value of MEDS and APACHE II, but the areas under the curve were not statistically different. CONCLUSIONS Heart-type fatty acid-binding protein was helpful for prognosis and risk stratification of septic patients in the ED.
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Affiliation(s)
- Yun-Xia Chen
- Emergency Department of Beijing Chao-Yang Hospital, Affiliated to Capital Medical University, Chaoyang District, Beijing 100020, China
| | - Chun-Sheng Li
- Emergency Department of Beijing Chao-Yang Hospital, Affiliated to Capital Medical University, Chaoyang District, Beijing 100020, China.
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Abstract
Cardiorenal syndrome (CRS) includes a broad spectrum of diseases within which both the heart and kidneys are involved, acutely or chronically. An effective classification of CRS in 2008 essentially divides CRS in two main groups, cardiorenal and renocardiac CRS, based on primum movens of disease (cardiac or renal); both cardiorenal and renocardiac CRS are then divided into acute and chronic, according to onset of disease. The fifth type of CRS integrates all cardiorenal involvement induced by systemic disease. This article addresses the pathophysiology, diagnosis, treatment, and outcomes of the 5 distinct types of CRS.
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Affiliation(s)
- Claudio Ronco
- International Renal Research Institute, S. Bortolo Hospital, Viale F. Ridolfi 37, Vicenza 36100, Italy
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi-Delfino Hospital, Piazza A. Moro, Colleferro, Roma 1-00034, Italy.
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54
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Virzì GM, Day S, de Cal M, Vescovo G, Ronco C. Heart-kidney crosstalk and role of humoral signaling in critical illness. Crit Care 2014; 18:201. [PMID: 24393300 PMCID: PMC4059499 DOI: 10.1186/cc13177] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Organ failure in the heart or kidney can initiate various complex metabolic, cell-mediated and humoral pathways affecting distant organs, contributing to the high therapeutic costs and significantly higher morbidity and mortality. The universal outreach of cells in an injured state has myriad consequences to distant organ cells and their milieu. Heart performance and kidney function are closely interconnected and communication between these organs occurs through a variety of bidirectional pathways. The term cardiorenal syndrome (CRS) is often used to describe this condition and represents an important model for exploring the pathophysiology of cardiac and renal dysfunction. Clinical evidence suggests that tissue injury in both acute kidney injury and heart failure has immune-mediated inflammatory consequences that can initiate remote organ dysfunction. Acute cardiorenal syndrome (CRS type 1) and acute renocardiac syndrome (CRS type 3) are particularly relevant in high-acuity medical units. This review briefly summarizes relevant research and focuses on the role of signaling in heart-kidney crosstalk in the critical care setting.
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Affiliation(s)
- Grazia Maria Virzì
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
- IRRIV – International Renal Resarch Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
- Clinical Genetics Unit, Department of Women’s and Children’s Health, University of Padua, Padua, Italy
| | - Sonya Day
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
- IRRIV – International Renal Resarch Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
| | - Massimo de Cal
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
- IRRIV – International Renal Resarch Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
| | - Giorgio Vescovo
- Internal Medicine, San Bortolo Hospital, Vicenza, Via Giustiniani, Padua 35128, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, International Renal Research Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
- IRRIV – International Renal Resarch Institute Vicenza, Via Rodolfi 37, Vicenza 36100, Italy
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55
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Coba V, Jaehne AK, Suarez A, Dagher GA, Brown SC, Yang JJ, Manteuffel J, Rivers EP. The incidence and significance of bacteremia in out of hospital cardiac arrest. Resuscitation 2013; 85:196-202. [PMID: 24128800 DOI: 10.1016/j.resuscitation.2013.09.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/14/2013] [Accepted: 09/24/2013] [Indexed: 01/25/2023]
Abstract
BACKGROUND The most common etiology of cardiac arrest is presumed of myocardial origin. Recent retrospective studies indicate that preexisting pneumonia, a form of sepsis, is frequent in patients who decompensate with abrupt cardiac arrest without preceding signs of septic shock, respiratory failure or severe metabolic disorders shortly after hospitalization. The contribution of pre-existing infection on pre and post cardiac arrest events remains unknown and has not been studied in a prospective fashion. We sought to examine the incidence of pre-existing infection in out-of hospital cardiac arrest (OHCA) and assess characteristics associated with bacteremia, the goal standard for presence of infection. METHODS AND RESULTS We prospectively observed 250 OHCA adult patients who presented to the Emergency Department (ED) between 2007 and 2009 to an urban academic teaching institution. Bacteremia was defined as one positive blood culture with non-skin flora bacteria or two positive blood cultures with skin flora bacteria. 77 met pre-defined exclusion criteria. Of the 173 OHCA adults, 65 (38%) were found to be bacteremic with asystole and PEA as the most common presenting rhythms. Mortality in the ED was significantly higher in bacteremic OHCA (75.4%) compared to non-bacteremic OHCA (60.2%, p<0.05). After adjustment for potential confounders, predictive factors associated with bacteremic OHCA were lower initial arterial pH, higher lactate, WBC, BUN and creatinine. CONCLUSIONS Over one-third of OHCA adults were bacteremic upon presentation. These patients have greater hemodynamic instability and significantly increased short-term mortality. Further studies are warranted to address the epidemiology of infection as possible cause of cardiac arrest.
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Affiliation(s)
- Victor Coba
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States; Department of Surgery, Henry Ford Hospital, Detroit, MI, United States.
| | - Anja Kathrin Jaehne
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Arturo Suarez
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States; Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, United States
| | - Gilbert Abou Dagher
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Samantha C Brown
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - James J Yang
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, United States
| | - Jacob Manteuffel
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Emanuel P Rivers
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States; Department of Surgery, Henry Ford Hospital, Detroit, MI, United States
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56
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What's new in Shock? September 2013. Shock 2013; 40:163-5. [PMID: 23949390 DOI: 10.1097/shk.0b013e3182a3d400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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57
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Celes MRN, Malvestio LM, Suadicani SO, Prado CM, Figueiredo MJ, Campos EC, Freitas ACS, Spray DC, Tanowitz HB, da Silva JS, Rossi MA. Disruption of calcium homeostasis in cardiomyocytes underlies cardiac structural and functional changes in severe sepsis. PLoS One 2013; 8:e68809. [PMID: 23935889 PMCID: PMC3720843 DOI: 10.1371/journal.pone.0068809] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 06/02/2013] [Indexed: 01/29/2023] Open
Abstract
Sepsis, a major cause of morbidity/mortality in intensive care units worldwide, is commonly associated with cardiac dysfunction, which worsens the prognosis dramatically for patients. Although in recent years the concept of septic cardiomyopathy has evolved, the importance of myocardial structural alterations in sepsis has not been fully explored. This study offers novel and mechanistic data to clarify subcellular events that occur in the pathogenesis of septic cardiomyopathy and myocardial dysfunction in severe sepsis. Cultured neonatal mice cardiomyocytes subjected to serum obtained from mice with severe sepsis presented striking increment of [Ca2+]i and calpain-1 levels associated with decreased expression of dystrophin and disruption and derangement of F-actin filaments and cytoplasmic bleb formation. Severe sepsis induced in mice led to an increased expression of calpain-1 in cardiomyocytes. Moreover, decreased myocardial amounts of dystrophin, sarcomeric actin, and myosin heavy chain were observed in septic hearts associated with depressed cardiac contractile dysfunction and a very low survival rate. Actin and myosin from the sarcomere are first disassembled by calpain and then ubiquitinated and degraded by proteasome or sequestered inside specialized vacuoles called autophagosomes, delivered to the lysosome for degradation forming autophagolysosomes. Verapamil and dantrolene prevented the increase of calpain-1 levels and preserved dystrophin, actin, and myosin loss/reduction as well cardiac contractile dysfunction associated with strikingly improved survival rate. These abnormal parameters emerge as therapeutic targets, which modulation may provide beneficial effects on future vascular outcomes and mortality in sepsis. Further studies are needed to shed light on this mechanism, mainly regarding specific calpain inhibitors.
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Affiliation(s)
- Mara R N Celes
- Department of Pathology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil.
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Coldewey SM, Rogazzo M, Collino M, Patel NSA, Thiemermann C. Inhibition of IκB kinase reduces the multiple organ dysfunction caused by sepsis in the mouse. Dis Model Mech 2013; 6:1031-42. [PMID: 23649820 PMCID: PMC3701222 DOI: 10.1242/dmm.012435] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Nuclear factor κB (NF-κB) plays a pivotal role in sepsis. Activation of NF-κB is initiated by the signal-induced ubiquitylation and subsequent degradation of inhibitors of kappa B (IκBs) primarily via activation of the IκB kinase (IKK). This study was designed to investigate the effects of IKK inhibition on sepsis-associated multiple organ dysfunction and/or injury (MOD) and to elucidate underlying signaling mechanisms in two different in vivo models: male C57BL/6 mice were subjected to either bacterial cell wall components [lipopolysaccharide and peptidoglycan (LPS/PepG)] or underwent cecal ligation and puncture (CLP) to induce sepsis-associated MOD. At 1 hour after LPS/PepG or CLP, mice were treated with the IKK inhibitor IKK 16 (1 mg/kg body weight). At 24 hours, parameters of organ dysfunction and/or injury were assessed in both models. Mice developed a significant impairment in systolic contractility (echocardiography), and significant increases in serum creatinine, serum alanine aminotransferase and lung myeloperoxidase activity, thus indicating cardiac dysfunction, renal dysfunction, hepatocellular injury and lung inflammation, respectively. Treatment with IKK 16 attenuated the impairment in systolic contractility, renal dysfunction, hepatocellular injury and lung inflammation in LPS/PepG-induced MOD and in polymicrobial sepsis. Compared with mice that were injected with LPS/PepG or underwent CLP, immunoblot analyses of heart and liver tissues from mice that were injected with LPS/PepG or underwent CLP and were also treated with IKK 16 revealed: (1) significant attenuation of the increased phosphorylation of IκBα; (2) significant attenuation of the increased nuclear translocation of the NF-κB subunit p65; (3) significant attenuation of the increase in inducible nitric oxide synthase (iNOS) expression; and (4) a significant increase in the phosphorylation of Akt and endothelial nitric oxide synthase (eNOS). Here, we report for the first time that delayed IKK inhibition reduces MOD in experimental sepsis. We suggest that this protective effect is (at least in part) attributable to inhibition of inflammation through NF-κB, the subsequent decrease in iNOS expression and the activation of the Akt-eNOS survival pathway.
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Affiliation(s)
- Sina M Coldewey
- Queen Mary University of London, Barts and The London School of Medicine and Dentistry, The William Harvey Research Institute, London, EC1M 6BQ, UK.
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Dadkhah A, Fatemi F, Ashrafihelan J. Investigation of STW 5 (Iberogast®) preventive effects in experimental sepsis. PHARMACEUTICAL BIOLOGY 2013; 51:474-481. [PMID: 23336345 DOI: 10.3109/13880209.2012.740487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
CONTEXT STW 5 (Iberogast(®)) is a well known herbal combination drug containing glycosides and flavonoids for which multiple pharmacological properties have been shown. OBJECTIVE In this study, attempts were made to assess whether STW 5, an aqueous ethanol solution, has a preventive effect against liver and lung pathological damage in rats after experimental induction of sepsis [cecal ligation and puncture (CLP)]. MATERIALS AND METHODS Experimental sepsis was induced in rats using CLP operation. The rats (n = 36) were divided into six groups (six/group): Sham-operated (SOP); CLP; CLP + STW 5 (2.5, 5 and 10 mg/kg) and CLP + indomethacin. The drugs were injected intraperitoneally immediately after sepsis induction. RESULTS It was found that induction of sepsis 24 h after CLP was associated with significant liver and lung damage, also remaining after STW 5 administration. DISCUSSION AND CONCLUSION It appears that STW 5, which has a pronounced efficacy in functional gastro-intestinal diseases, has no effect on septic liver and lung damage in the CLP rat model.
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Affiliation(s)
- A Dadkhah
- Faculty of Medicine, Qom Branch, Islamic Azad University, Qom, Iran.
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ZHANG MINGHAO, WANG XIUYU, WANG XIUMEI, HOU XIAOLIN, TENG PENG, JIANG YIDENG, ZHANG LINNA, YANG XIAOLING, TIAN JUE, LI GUIZHONG, CAO JUN, XU HUA, LI YUNHONG, WANG YIN. Oxymatrine protects against myocardial injury via inhibition of JAK2/STAT3 signaling in rat septic shock. Mol Med Rep 2013; 7:1293-9. [DOI: 10.3892/mmr.2013.1315] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 01/21/2013] [Indexed: 11/05/2022] Open
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Gao M, Ha T, Zhang X, Wang X, Liu L, Kalbfleisch J, Singh K, Williams D, Li C. The Toll-like receptor 9 ligand, CpG oligodeoxynucleotide, attenuates cardiac dysfunction in polymicrobial sepsis, involving activation of both phosphoinositide 3 kinase/Akt and extracellular-signal-related kinase signaling. J Infect Dis 2013; 207:1471-9. [PMID: 23359590 DOI: 10.1093/infdis/jit036] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Toll-like receptors (TLRs) play a role in the pathophysiology of sepsis and multiple organ failure. This study examined the effect of CpG oligodeoxynucleotide (CpG-ODN), the TLR9 ligand, on polymicrobial sepsis-induced cardiac dysfunction. METHODS Male C57BL/6 mice were treated with CpG-ODN, control CpG-ODN (control-ODN), or inhibitory CpG-ODN (iCpG-ODN) 1 hour prior to cecal ligation and puncture (CLP)-induced sepsis. Mice that underwent sham surgery served as sham controls. Cardiac function was examined by echocardiography before and 6 hours after CLP. RESULTS Cardiac function was significantly decreased 6 hours after CLP. CpG-ODN prevented CLP-induced cardiac dysfunction, as evidenced by maintenance of the ejection fraction and fractional shortening. Control-ODN or iCpG-ODN did not alter CLP-induced cardiac dysfunction. CpG-ODN significantly attenuated CLP-induced myocardial apoptosis and increased myocardial Akt and extracellular-signal-related kinase (ERK) phosphorylation levels following CLP. In vitro experiments demonstrated that CpG-ODN promotes an association between TLR9 and Ras, resulting in Akt and ERK phosphorylation. Inhibition of phosphoinositide 3-kinase (PI3K) by Ly294002 or inhibition of ERK by U0126 in vivo abolished CpG-ODN attenuation of CLP-induced cardiac dysfunction. CONCLUSIONS CpG-ODN prevents CLP-induced cardiac dysfunction, in part through activation of PI3K/Akt and ERK signaling. Modulation of TLR9 could be an effective approach for treatment of cardiovascular dysfunction in patients with sepsis or septic shock.
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Affiliation(s)
- Ming Gao
- Department of Surgery, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN 37614-0575, USA
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