Treatment Optimization of Aortocoronary Dissection as a Complication After Heart Catheterization Using Coronary Computerized Tomographic Angiography

We present the case of a 71-year-old patient with a chronic total occlusion of the right coronary artery (RCA) resulting in a retrograde aortic dissection as a complication of coronary intervention. Acute therapy consisted of coronary stent implantation into the proximal RCA to cover the dissection's entry. One day after, computed tomography-guided angiography revealed a progression of the intramural aortic hematoma with a residual dissection at the RCA ostium. Recurrent coronary angiography was performed to implant another stent covering the entry. Imaging at follow-up demonstrated complete coverage of the Dunning dissection and regression of the intramural aortic hematoma.     

Measurement of landing mosquito density on humans

In traditional vector surveillance systems, adult mosquito density and the rate of mosquito-human host contact are estimated from the mosquito numbers captured in mechanical traps. But the design of the traps, their placement in the habitat and operating time, microclimate, and other environmental factors bias mosquito responses such that trapped mosquito numbers may be at variance with the numbers actually making human contact. As an alternative to mechanical traps, direct measurement of landing mosquito density enables real-time estimation of the mosquito–human-host-contact parameter. Based on this paradigm, we studied methods to measure mosquito landing responses to a human host. Our results showed: (a) an 18% difference (P < 0.0001) in the mean number of female Aedes albopictus (Skuse) making initial contact with the skin (9.11 ± 0.74 min^–1) compared with the number remaining on the skin for 5 s (7.42 ± 0.69 min^–1); (b) an increase (P < 0.05) in the mean per minute (min⁻¹) landing responses of Culex nigripalpus Theobald and Cx. quinquefasciatus Say with increased sampling time; (c) no difference (P > 0.55) in the average number of Ae. albopictus landing on the arm (8.6 ± 1.6 min^–1) compared with the leg (9.2 ± 2.5 min^–1) of the same human subject; (d) differences among day-to-day landing patterns for the mosquito species we studied but measurable periodicity (P < 0.05) in each case when daily patterns were averaged for four or more diel periods; and (e) an effect on landing mosquito density from air temperature (P < 0.0001) for Ae. albopictus and Cx. nigripalpus and dew point temperature (P < 0.0001) for Cx. quinquefasciatus. Results from this study were used to develop a procedure for safely and accurately measuring mosquito landing density on a human subject.     

Incremental prognostic value of coronary computed tomographic angiography over coronary artery calcium score for risk prediction of major adverse cardiac events in asymptomatic diabetic individuals

Background

Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored.

Methods

From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1–49%, 50–69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) – inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) – and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification.

Results

Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61–3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75–3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09–1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18–2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29–2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05–1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06).

Conclusion

For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis.     

羟乙基淀粉溶液在复苏肠缺血再灌注休克中的作用

目的　比较不同剂量羟乙基淀粉溶液 ( HES)对兔肠缺血再灌注损伤所致休克的复苏作用。方法　 32只新西兰白兔随机分为 4组 :模型对照、乳酸林格液复苏组 ( L RS,2 0 m l· kg- 1 · h- 1 ) ,小剂量 HES复苏组 ( HES2 ml· kg- 1· h- 1 L RS18m l· kg- 1· h- 1 ) ,大剂量 HES复苏组 ( HES2 0 ml· kg- 1· h- 1 )。采用肠系膜上动脉夹闭 6 0 m in后松夹行再灌注制备肠缺血再灌注休克模型 ,松夹再灌注时同步进行液体复苏。观测各时间点的血流动力学参数 (平均动脉压、心率、心排血量、肠系膜上动脉血流 ) ,并通过测定肠黏膜CO2 分压和动脉血 CO2 分压的差值 (动脉二氧化碳间隙 )、肠黏膜 p H值、动脉血乳酸浓度和氧输送等指标间接评估组织氧合情况。实验结束后累计动物死亡数。结果　 HES能明显提高肠缺血再灌注休克时的血流动力学参数 ,与对照组和 L RS组比较差异均有显著性 ( P均 <0 .0 5 ) ;小剂量 HES比大剂量 HES改善血流动力学参数的作用更平稳 ( P均 <0 .0 5 ) ,且较其他 3组能明显降低血乳酸浓度和动脉二氧化碳间隙 ,减轻 p Hi的降低 ( P均 <0 .0 5 ) ;而大剂量 HES对上述参数的影响不明显 ,并可见动物口鼻出血及死亡 ;小剂量或大剂量HES与其他两组比较均能使氧输送回升 ( P均 <0 .0 5 )。结     

心腔内超声在卵圆孔未闭封堵术中的应用

目的探讨心腔内超声(ICE)在经导管卵圆孔未闭(PFO)封堵术中的应用价值。方法应用ICE观察86例PFO的解剖形态及周围结构，测量PFO通道的直径和长度，监测与引导封堵过程、伞释放后位置，并通过彩色血流显像和超声造影判断有无残余分流。结果ICE清晰地观察到各种形态的PFO，86例中有85例封堵成功，1例失败。结论ICE指导经导管封堵PFO是一种安全、有效、简便和创伤小的方法。     

Comparison of cardiac output determined by bioimpedance, thermodilution, and the Fick method.

BACKGROUND: Cardiac output can be determined by using a variety of methods. OBJECTIVES: To determine the precision and bias between 3 methods for determining cardiac output: bioimpedance, thermodilution, and the Fick method. METHODS: Cardiac output was determined by using bioimpedance via neck and thorax patches and thermodilution via pulmonary artery catheter in 46 patients in the intensive care unit. A subset of 15 patients also had cardiac output determined by using the Fick method. RESULTS: Mean (SD) cardiac output in all patients was 6.3 (2.2) L/min by thermodilution and 5.6 (2.0) L/min by bioimpedance. In the 15 patients in whom all 3 methods were used, mean cardiac output was 6.0 (1.7) L/min by thermodilution, 5.3 (1.7) L/min by bioimpedance, and 8.6 (4.5) L/min by the Fick method. Bias and precision (mean difference +/- 2 SDs) were 0.7 +/- 2.9 L/min between thermodilution and bioimpedance, 1.7 +/- 3.8 L/min between the Fick method and thermodilution, and 2.4 +/- 4.7 L/min between the Fick method and bioimpedance. CONCLUSION: Bioimpedance, thermodilution, and Fick determinations of cardiac outputs are not interchangeable in a heterogeneous population of critically ill patients.