Transnasal transesophageal echocardiography: A new approach for the PFO occlusion in awake patients

Objectives : To reduce risks, discomfort, cost, and operative time for percutaneous patent foramen ovale (PFO) closure, we propose to perform this procedure under transesophageal echo‐guidance using a 10 Fr. catheter introduced through nasal way (TEENW). Background : Transesophageal or intracardiac echocardiography is commonly used to guide percutaneous PFO closure. Sedation needed quite frequently during transesophageal echocardiography, increased patients' discomfort, procedure prolongation, costs, use of both femoral veins, and additional intracardiac manipulations are the main limitations of standard techniques. Methods : We enrolled 20 consecutive patients with a history of cerebral ischemia and PFO with right‐to‐left shunt. In 15 patients Amplatzer® PFO occluder was used, whereas in five patients with longer PFO tunnel (>10 mm) Cardia Intrasept® was selected. Without sedation, a multifrequency monoplane probe, developed for intracardiac echocardiography, was introduced into the nostril and advanced forward the esophagus. Then under echo guidance, the closing device was presented, opened and released. Results : Procedure lasted for an average of 33.3 min, and no complications were seen. At procedure's completion, six patients showed persistence of reduced shunt during Valsalva manoeuvre. At six‐month follow‐up, shunts disappeared in all patients. Conclusion : TEENW is safe and well tolerated, and images' quality is high enough to deserve widespread adoption of this technique for PFO closure. © 2008 Wiley‐Liss, Inc.     

Paradoxical emboli through the patent foramen ovale as the suspected cause of myocardial and renal infarction in a 48-year-old woman.

We review the case of a 48-year-old woman who underwent elective percutaneous patent foramen ovale closure following successive renal and myocardial infarction with normal renal and coronary arteries, probably as a consequence of paradoxical emboli.     

238例中成药不良反应报告分析

摘 要 目的:分析我院门诊中成药不良反应（ADR）报告,为临床合理使用中成药提供参考。方法：对我院门诊2013年9月～2014年8月上报的238例中成药ADR报告中的患者年龄、性别、临床表现等进行分析。结果：238例中成药不良反应中,女性例数多于男性;年龄段为50岁以上例数较多;原发疾病主要为心脑血管疾病（40.8%）;不良反应主要为消化系统损害;75种中成药的说明书仅有34种药物的说明书较明确地标注了ADR的具体内容,说明书存在问题的有7种,标注尚不明确的34种(45.3%),1例患者使用中药注射剂发生了严重ADR。结论：中成药的不良反应不容忽视。7种药品可能发现了新的不良反应,药品说明书需完善。     

Traditional Chinese medicine for gouty arthritis: A protocol for meta-analysis

Background:Gouty arthritis (GA) is a chronic disease caused by monosodium urate crystal deposition. Repeated attacks of arthritis may lead to the deposition of urate to form gout stone, resulting in joint deformity and joint damage. Although GA is not fatal, it causes low work productivity and low quality of life. Western drug, such as febuxostat, colchicine, allopurinol, often cannot get satisfying curative effect, and may even lead to serious side effects, such as exfoliative dermatitis or uremia. However, the therapeutic effect of Traditional Chinese medicine is very satisfactory. The treatment effect of simiao powder, a Chinese patent medicine, combined with acupuncture was widely used on treatment of GA. Although it has been widely used in clinical practice, its relative effectiveness and safety have not been confirmed. Therefore, this study will use meta-analysis to verify the efficacy and safety of simiao powder combined with acupuncture in the treatment of GA.Methods:All randomized controlled trial of simiao powder combined with acupuncture for the treatment of RA from their inception 29 October, 2020 will be searched form the China National Knowledge Infrastructure, Wanfang Database, Chinese Science and Technology Periodical Database, Chinese Biomedical Literature Database, Pubmed, Embase, Web of Science, and the Cochrane library. Two authors will independently select studies, extract data based on pre-designed inclusion and exclusion criteria. Methodological quality assessment and risk of bias will be assessed using Cochrane bias risk tool. All data analysis will be conducted using Revman5.3, WinBUGS 1.4.3, and Stata14.2 software.Results:We will compare the different outcome indicators of various studies to provide a synthesis of the efficacy and safety of Simiao powder combined with acupuncture for GA patients. The main outcome measures included efficacy, remission rate (no drug symptoms), recurrence rate, clinical absolute score and relative score. Secondary outcome measures included related adverse reactions and uric acid concentration.Conclusion:The findings of the study will provide helpful evidence for the efficacy and safety of simiao powder combined with acupuncture in the treatment of GA.Registration number:This study protocol have been funded through a protocol registry. The registry number is INPLASY2020110028     

Carbon dioxide: the cause of devastating stroke without hemodynamic compromise during laparoscopic nephrectomy with injury of the inferior vena cava: A case report

Rationale:Carbon dioxide pneumoperitoneum in laparoscopic surgery can bring about occult perioperative cerebral infarction, advancing our understanding of the causes of severe postoperative delayed recovery.Patient concerns:Here, we report the case of a 35-year-old woman who underwent a right renal tumor resection in our institution, during which a raised pneumoperitoneum pressure (from 15 to 20 mm Hg) was adopted by the surgeon to prevent errhysis and to help stop the bleeding. Despite an accidental minor tearing of the inferior vena cava, vital signs remained stable throughout the procedure, and no obvious abnormality was observed in either end tidal carbon dioxide values or blood gas analysis. However, the patient unexpectedly suffered delayed recovery after the operation, presenting incomplete left hemiplegia and a positive Babinski sign.Diagnoses:Perioperative stroke was diagnosed by anesthesiologists, after excluding the effects of anesthesia. Cerebral hemorrhage was excluded, as no obvious abnormality was found in the density of brain parenchyma in the emergency computed tomography examination, and a digital subtraction angiography showed no abnormal thrombosis. Further magnetic resonance diagnosis led us to consider diffuse gas embolisms to be the cause of this acute stroke; a right echocardiography revealed that a patent foramen ovale (PFO) may account for the global cerebral gas embolisms.Interventions:The patient received neuroprotective drugs (Vinpocetine, Edaravone, and Xingnaojing, which are commonly used as a standard of care in China), antiplatelets and other symptomatic treatments, plus dexamethasone to relieve edema. A contrast-enhanced echocardiography of the right heart was performed, the results of which were consistent with the sonography of a PFO.Outcomes:The patient was hospitalized for 14 days and eventually discharged after recovery. At the latest follow-up in August 2019, the patient recovered without residual neurological sequelae.Lessons:Our results emphasize the need for vigilance regarding adverse cardiovascular and neurological events caused by carbon dioxide gas embolisms when encountering the inadvertent situation of vessels rupturing. Timely monitoring of paradoxical gas embolism by transoesophageal echocardiography is necessary and can avert the risk of severe complications. Urgent consideration should be given to stopping pneumoperitoneum and switching to laparotomy for hemostasis so that the patient can obtain the best benefit–risk ratio.     

Patent foramen ovale in a large population of ischemic stroke patients: diagnosis, age distribution, gender, and race

BACKGROUND: Patent foramen ovale (PFO) is a well-recognized risk factor for ischemic strokes. The true prevalence of PFO among stroke patients is still under debate. Transesophageal echocardiography (TEE) is the "gold standard" in diagnosing PFO but the physiology requires right-to-left atrial shunting. In this report, we evaluate the prevalence of PFO in a diverse group of ischemic stroke patients studied by TEE. METHODS: TEE of 1,663 ischemic stroke patients were reviewed for cardiac source of embolism, including PFO and atrial septal aneurysm (ASA). Agitated saline bubble injection was performed to look for right to left atrial shunting. Success of maneuvers to elevate right atrial pressure (RAP) was noted by looking at the atrial septal bulge. RESULTS: Among 1,435 ischemic stroke patients analyzed, the presence or absence of PFO could not be determined in 32.1% because bulging of the septum could not be demonstrated in patients with negative contrast study despite aggressive maneuvers to elevate RAP. Of the remaining 974 patients, 294 patients (30.2%) had a PFO. The mean age was 61.5 years in both groups, with a bimodal distribution of PFO and the highest prevalence occurring in < or =30-year-old group. Prevalence of PFO was similar in men (32.4%) and women (28.15%, P = 0.15); and in Caucasian (32.1%) and African American (27.7%; P = 0.15). ASA was present in 2.02% and hypermobile septum in 2.49% of the 1,435 patients. PFO was seen in 79.3% of the patients with ASA. CONCLUSION: Successful elevation of RAP cannot be achieved in a significant number of patients undergoing TEE and determination of PFO may be difficult. In our series, the true prevalence of PFO among ischemic stroke patients was 30.2% taking into account only those patients who showed no shunting despite bulging of the atrium septum into the left atrium (PFO absent group) during the contrast study. There was no gender or racial difference in the prevalence of PFO, but there was a bimodal distribution in prevalence with age.     

Critical congenital heart disease screening does not predict car seat tolerance screen outcomes

BackgroundCar Seat Tolerance Screening (CSTS) and Critical Congenital Heart Disease (CCHD) screens were both implemented to identify infants with cardiorespiratory distress. We hypothesized that the CCHD screen would be poorly sensitive to predict a failed CSTS for many reasons.MethodsRetrospective record review of infants in 2013 who qualified for CSTS. Calculated sensitivity, specificity, predictive value (PV) of a failed CCHD screen to identify those infants who failed their CSTS.Results270 subjects underwent both screens and 14 failed a CSTS (5.2%). Of these, 1 failed the CCHD and 1 had an equivocal result. None were diagnosed with CCHD. An abnormal CCHD (failed or equivocal) had a sensitivity = 14.3% and a PV = 40% for predicting CSTS failure.ConclusionsCCHD screening is poorly sensitive and has poor PV for identifying those infants who are at risk of failing a CSTS. We therefore cannot recommend replacement of the CSTS with routine CCHD screening.     

我院中成药应用分析

目的：评价本院中成药应用的现状和发展中存在的问题。方法对本院门诊所使用的中成药的金额、数量、种类进行统计分析。结果本院门诊应用的中成药占药品使用的比例很大,以清热类药居多(48.9%),其次为活血化瘀类(24.5%)和止血类(11.0%)。总体使用规范,但仍存在一些不合理现象。结论提高中成药疗效,规范合理使用中成药需全院全社会共同努力。     

The inability of isoproterenol or propranolol to alter the lateral dimensions of experimentally induced myocardial infarcts

Summary The relationship between the blood flow pattern immediately following coronary artery occlusion and the resulting infarct 24 hours later was studied in dogs treated with isoproterenol (0.5 g/kg/min for 2 hours) or with propranolol (2mg/kg every 6 hours). The coronary artery of a closed chest dog was perfused via a special cannula with arterial blood. A 2-mm diameter plastic bead was introduced into the perfusate to embolize a coronary branch. One minute after occlusion, radiolabelled microspheres were injected into the perfusate. The dogs were then allowed to recover. 24 hours later the dogs were reanesthetized and their hearts removed. The hearts were sliced into 4 mm thick sections and the microsphere distribution was visualized by autoradiography of the tissue. Superimposition of developed autoradiographs and tracings of the infarct pattern of stained sections allowed direct comparison of the blood flow pattern immediately after occlusion to the eventual pattern of infarction. In all 8 control dogs, all 6 isoproterenol dogs and all 12 propranolol dogs the lateral borders of blood flow and infarction were superimposable indicating no lateral change in infarct size resulting from treatment. In the control group there was a subepicardial region of the ischemic zone which did not infarct (15.2±2.3% of the ischemic zone). Though isoproterenol did not significantly change the size of this zone, propranolol increased it to 35.9±6,5% (p<0.005) indicating vertical but not lateral salvage.Supported by Grant HL-20648 from NIH: HLBI and a Grant-in-aid from the American Heart Association and with funds contributed in part by the Northwest Ohio Chapter, Inc.