High-risk Clinical Presentations in Atherosclerotic Renovascular Disease： Prognosis and Response to Renal Artery Revascularization

<正>In the latest issue of AJKD,Ritchie et al present an analysis of their database registry of ARVD maintained in Manchester,United Kingdom,that indicates that identifiable high-risk presentations with ARVD have distinctly different outcomes and may receive major benefits from stent placement.The current ongoing Cardiovascular Outcomes in Renal Atherosclerotic Lesions(CORAL)trial may provide more concrete data regarding the role of stenting in RAS.What is clear,however,is that the procedural and technical evolution of renal intervention continues.By objectively identifying patients with clinical     

Middle Cerebral Artery–to–Uterine Artery Pulsatility Index Ratio and Cerebroplacental Ratio Independently Predict Adverse Perinatal Outcomes in Pregnancies at Term

This study aimed to investigate potential predictors, including the cerebroplacental ratio and the middle cerebral artery (MCA)–uterine artery pulsatility index (PI) ratio, for adverse perinatal outcomes in pregnancies at term. This was an observational, prospective study of recruited pregnancies at term. The data were extracted from the medical records in hospital. An adverse perinatal outcome was set as the primary observational endpoint. The receiver operating characteristic curve was plotted to investigate the predictive and cutoff values of risk factors for adverse perinatal outcomes. Univariate and multivariate logistic regression analyses evaluated independent risk factors (maternal, neonatal, prenatal ultrasound and Doppler variables) for adverse perinatal outcomes. There were 392 pregnancies at term included in the study, with 19.4% experiencing adverse perinatal outcomes. The MCA–uterine artery PI ratio was a good predictor of adverse perinatal outcomes by receiver operating characteristic curve analysis (area under the curve = 0.886, p < 0.001), and the cerebroplacental ratio (odds ratio, 0.42; 95% confidence interval, 0.20–0.93; p = 0.032) and MCA–uterine artery PI ratio (odds ratio, 0.25; 95% confidence interval, 0.16–0.42; p = 0.032) were two independent risk factors for adverse perinatal outcomes by univariate and multivariate logistic regression analyses. Notably, both MCA–uterine artery PI ratio and cerebroplacental ratio are significant predictors of adverse perinatal outcome in pregnancies at term.     

Changes in Vertebral Artery Blood Flow in Different Head Positions and Post–Cervical Manipulative Therapy

ObjectiveThe objective of this study was to investigate the hemodynamics of blood flow through the V3 region of the vertebral artery contralateral to the side manipulated during different rotary head positions and post–cervical spinal manipulation.MethodsThis quasi-experimental study was performed on 25 healthy, asymptomatic participants, both male and female, between 20 and 30 years of age. Each participant presented with a C0/C1 or C1/C2 cervical facet restriction (as determined by motion palpation). Participation was voluntary, and participants had no symptoms of vertebrobasilar artery insufficiency or contraindications to cervical spinal manipulation. Doppler ultrasound was used to measure vertebral artery blood flow (V3 region) hemodynamics, contralateral side of manipulation, as close to C1/C2 region as possible in 4 positions of cervical rotation (neutral, 45°, maximum, and post-manipulation neutral). Doppler ultrasound parameters included peak systolic flow velocity, end diastolic flow velocity, mean flow velocity, vessel diameter, and flow rate. The nonparametric Friedman test was used for analysis across each head and neck position, and post manipulation.ResultsNo clinical or statistically significant results (P > .05) were found for any of the hemodynamic parameters in any of the head positions.ConclusionsHemodynamic measurements of the V3 region of the vertebral artery do not show significant changes in the measured head positions or following manipulation of the upper cervical spine in patients without pre-existing risk factors.     

Intelligent Segmentation of Intima–Media and Plaque Recognition in Carotid Artery Ultrasound Images

Ultrasound imaging has been established as an effective method for measuring the thickness of the intima–media, the thickening of which, along with carotid plaque, is an indicator of cerebrovascular diseases. Here, a 2-D V-Net model that can automatically segment the intima–media in carotid artery ultrasound images is proposed. Moreover, a plaque recognition algorithm that automatically identifies plaque-affected areas is described. Performance tests to determine the average accuracy of the intima–media segmentation yielded the following results (expressed as lumen–intima boundary/media–adventitia boundary): intersection over union (IOU) of 0.752/0.813, pixel accuracy of 0.813/0.885 and Dice loss of 0.858/0.897. Finally, average IOU of 0.785, pixel accuracy of 0.825 and Dice loss of 0.866 were obtained for plaque recognition. These results satisfy the threshold for clinical application and indicate that the proposed model can assist doctors in making more efficient and accurate diagnoses.     

Ultrasound Measurement of Carotid Intima–Media Thickness and Plaques in Predicting Coronary Artery Disease

Ultrasound measurement of carotid intima–media thickness (CIMT) and plaque thickness (PT) may be an additional tool for risk stratification of patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). The aim of this study was to evaluate the correlation of CIMT and PT with coronary artery disease (CAD) in risk stratification tests.This prospective observational study was conducted in an academic tertiary care ED. Carotid ultrasound measurements were obtained for emergency patients with suspected ACS. Carotid measurements included PT, mean CIMT and maximum CIMT. The correlations between carotid ultrasound and the results of coronary catheter angiography (CA), coronary computed tomography angiography (CCTA) and stress tests were identified. The convenience sample included 58 patients comprising 39 men and 19 women with a mean age of 60 ± 12 y. Twenty-two percent (13/58) of patients were positive for CAD, as indicated by results of the cardiac risk stratification tests. Presence of plaque correlated with CCTA findings, with a high specificity (92.8%) for a positive test. Max CIMT predicted abnormal CCTA (area under the curve [AUC] = 0.93, 95% confidence interval: 0.80–1). The correlations with stress test (0.78, 0.46–1) and CA (0.55, 0.28–0.82) were weaker. Presence of carotid plaque correlated significantly with findings of CAD on all risk stratification tests, but especially with CCTA. Carotid ultrasound could have a role in risk stratification in the ED, though more research is needed.     

Physician Characteristics and Variation in Treatment Outcomes: Are Better Qualified and Experienced Physicians More Successful in Treating Patients With Chronic Pain With Acupuncture?

The aim of this paper was to quantify the influence of the physician's training and experience in the field of acupuncture on the outcome in patients with chronic pain. Patients visiting their physician because of chronic low back pain, headache, pain due to osteoarthritis of the knee or hip, or neck pain, were included in 4 multicenter, randomized, controlled studies. All patients received routine care; patients in the acupuncture groups received additional acupuncture treatment (on average 10 sessions). The data was pooled, and the 3-month change from baseline of the SF-36 bodily pain subscale as the main outcome defined. A total of 9,990 patients (mean age 49.6 ± 13.6 years, 68% female) treated by 2,781 physicians (mean age 46.3 ± 7 years, 37% female) were analyzed. The physicians had 7.3 ± 5.2 (mean ± sd) years of experience in acupuncture and their mean duration of formal acupuncture training had been 287 ± 321 hours. The outcome was markedly improved in the acupuncture group. We identified only 1 physician characteristic with a significant influence on the outcome: Internists performed better (odds ratio OR = 1.49, confidence interval CI: 1.01;2.18; P = .043); orthopedists worse (OR = .79, CI: .62;1; P = .043) than the average physician. Neither the duration of training nor the duration of experience had any impact on the extent of the acupuncture effect.PerspectiveIn this analysis, physician characteristics such as training did not influence patients' outcome after acupuncture, suggesting that formal training parameters have only a limited influence on treatment effect. Other skills such as the therapeutic relationship, which are difficult to measure, may probably play a more important role and should be taken into consideration.     

Associations of Renal Augmented Velocity Index with Arterial Stiffness,Carotid Intima–Media Thickness and Blood Pressure,in Comparison with Renal Resistive Index

The augmented velocity index (Avi) is a new Doppler index associated with arterial stiffness. We examined associations of renal Avi with blood pressure (BP), aortic stiffness and carotid intima–media thickness (IMT), and compared its performance with that of resistive index (RI). One hundred forty-seven volunteers were recruited. Renal Avi had significant positive correlations with systolic BP (r = 0.37, p < 0.001), diastolic BP (r = 0.2, p = 0.016), mean arterial pressure (r = 0.29, p < 0.001), pulse pressure (r = 0.31, p < 0.001), carotid–femoral pulse wave velocity (r = 0.49, p < 0.001) and carotid IMT (r = 0.23, p = 0.005). RI correlated positively with pulse pressure (r = 0.3, p < 0.001) only. After adjustments for co-variables, the associations remained similar. Patients with abnormal BP values (≥130/80 mm Hg), IMT and aortic stiffness (≥1 standard deviation of mean value) had higher Avi than those with normal values, but not RI. In conclusion, renal Avi had stronger associations with BP, arterial stiffness and carotid IMT than RI in apparently healthy volunteers, and was significantly increased in abnormal patients.     

Renal effects of sodium–glucose cotransporter-2 inhibitors in patients with type 2 diabetes and renal impairment

In patients with type 2 diabetes (T2D), microvascular changes in the kidney often result in diabetic kidney disease (DKD), the progression of which is associated with an increased risk of cardiovascular (CV) and all-cause mortality. Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) are a newer class of oral glucose-lowering therapies that were associated with significant reductions in the risk of major adverse CV events, CV death, and hospitalization for heart failure compared with placebo in CV outcomes trials (CVOTs) of patients with T2D and established CV disease or varying levels of CV risk. In addition, SGLT-2is reduced the risks of clinically relevant renal outcomes in these large randomized studies, indicating the potential for renoprotective effects in patients with T2D and DKD. This review discussed the non-glycemic effects of SGLT-2is in patients with T2D and renal impairment, including reductions in systolic and diastolic blood pressure, decreases in albuminuria and plasma uric acid, changes in estimated glomerular filtration rate, and minimal changes in electrolytes. Potential mechanisms for the renoprotective effects of SGLT-2is observed in CVOTs were considered, including the likely incremental benefits of SGLT-2is when added to renin-aldosterone-angiotensin system inhibitors (RAASis). The possibility of extending the use of SGLT-2is to patients with non-DKD was also discussed. Although the exact mechanisms by which SGLT-2is improve renal outcomes are not fully understood, they are likely to be multifactorial and additive when these drugs are used in combination with RAASis in patients with DKD.     

Psychological Stress–Induced Immune Response and Risk of Alzheimer's Disease in Veterans from Operation Enduring Freedom and Operation Iraqi Freedom

PurposePsychological stress is a significant health problem in veterans and their family members. Traumatic brain injury (TBI) and stress lead to the onset, progression, and worsening of several inflammatory and neurodegenerative diseases in veterans and civilians. Alzheimer's disease (AD) is a progressive, irreversible neuroinflammatory disease that causes problems with memory, thinking, and behavior. TBIs and chronic psychological stress cause and accelerate the pathology of neuroinflammatory diseases such as AD. However, the precise molecular and cellular mechanisms governing neuroinflammation and neurodegeneration are currently unknown, especially in veterans. The purpose of this review article was to advance the hypothesis that stress and TBI-mediated immune response substantially contribute and accelerate the pathogenesis of AD in veterans and their close family members and civilians.MethodsThe information in this article was collected and interpreted from published articles in PubMed between 1985 and 2020 using the key words stress, psychological stress, Afghanistan war, Operation Enduring Freedom (OEF), Iraq War, Operation Iraqi Freedom (OIF), Operation New Dawn (OND), traumatic brain injury, mast cell and stress, stress and neuroimmune response, stress and Alzheimer's disease, traumatic brain injury, and Alzheimer's disease.FindingsChronic psychological stress and brain injury induce the generation and accumulation of beta-amyloid peptide, amyloid plaques, neurofibrillary tangles, and phosphorylation of tau in the brain, thereby contributing to AD pathogenesis. Active military personnel and veterans are under enormous psychological stress due to various war-related activities, including TBIs, disabilities, fear, new environmental conditions, lack of normal life activities, insufficient communications, explosions, military-related noise, and health hazards. Brain injury, stress, mast cell, and other immune cell activation can induce headache, migraine, dementia, and upregulate neuroinflammation and neurodegeneration in veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. TBIs, posttraumatic stress disorder, psychological stress, pain, glial activation, and dementia in active military personnel, veterans, or their family members can cause AD several years later in their lives. We suggest that there are increasing numbers of veterans with TBIs and stress and that these veterans may develop AD late in life if no appropriate therapeutic intervention is available.ImplicationsPer these published reports, the fact that TBIs and psychological stress can accelerate the pathogenesis of AD should be recognized. Active military personnel, veterans, and their close family members should be evaluated regularly for stress symptoms to prevent the pathogenesis of neurodegenerative diseases, including AD.     

The Influence of Xylazine and Clonidine on Lung Ultrasound–Induced Pulmonary Capillary Hemorrhage in Spontaneously Hypertensive Rats

Induction of pulmonary capillary hemorrhage (PCH) by lung ultrasound (LUS) depends not only on physical exposure parameters but also on physiologic conditions and drug treatment. We studied the influence of xylazine and clonidine on LUS-induced PCH in spontaneously hypertensive and normotensive rats using diagnostic B-mode ultrasound at 7.3 MHz. Using ketamine anesthesia, rats receiving saline, xylazine, or clonidine treatment were tested with different pulse peak rarefactional pressure amplitudes in 5 min exposures. Results with xylazine or clonidine in spontaneously hypertensive rats were not significantly different at the three exposure pulse peak rarefactional pressure amplitudes, and thresholds were lower (2.2 MPa) than with saline (2.6 MPa). Variations in LUS PCH were not correlated with mean systemic blood pressure. Similar to previous findings for dexmedetomidine, the clinical drug clonidine tended to increase susceptibility to LUS PCH.     

Renal Damages in Deoxycorticosterone Acetate–Salt Hypertensive Rats: Assessment with Diffusion Tensor Imaging and T2-mapping

Molecular Imaging and Biology - This study aimed to investigate the feasibility of diffusion tensor imaging (DTI) and T2-mapping to assess temporal renal damage in deoxycorticosterone...     

Induced pluripotent stem cell–derived hepatocytes have the functional and proliferative capabilities needed for liver regeneration in mice

The ability to generate induced pluripotent stem (iPS) cells from a patient’s somatic cells has provided a foundation for organ regeneration without the need for immune suppression. However, it has not been established that the differentiated progeny of iPS cells can effectively reverse failure of a vital organ. Here, we examined whether iPS cell–derived hepatocytes have both the functional and proliferative capabilities needed for liver regeneration in mice with fumarylacetoacetate hydrolase deficiency. To avoid biases resulting from random genomic integration, we used iPS cells generated without viruses. To exclude compensation by hepatocytes not derived from iPS cells, we generated chimeric mice in which all hepatocytes were iPS cell derived. In vivo analyses showed that iPS cells were intrinsically able to differentiate into fully mature hepatocytes that provided full liver function. The iPS cell–derived hepatocytes also replicated the unique proliferative capabilities of normal hepatocytes and were able to regenerate the liver after transplantation and two-thirds partial hepatectomy. Thus, our results establish the feasibility of using iPS cells generated in a clinically acceptable fashion for rapid and stable liver regeneration.