[Interpretation of the American Association for Thoracic Surgery expert consensus document: coronary artery bypass grafting in patients with ischemic cardiomyopathy and heart failure in 2021].

An expert consensus on coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy (ICM) was released by the American Association for Thoracic Surgery in May 2021, which contains a vast array of perioperative recommendations. During preoperative period, a comprehensive assessment on ICM including myocardial viability and valve function by a multi-disciplinary team (MDT) approach should be performed. In terms of intraoperative period, multiple arterial conduits and on-pump CABG using cold blood cardioplegia should be considered, meanwhile, other aspects involving concomitant management of mitral valve regurgitation and arrythmia, as well as active use of mechanical cardiac assist devices (e.g., intra-aortic balloon pump) should also be achieved. Finally, a range of postoperative interventions which includes standardized MDT management in intensive care unit (ICU), continuous use of cardiac assist devices, cardiac pacing, close follow-up within 90 days and drug treatment strictly guided by the guidelines after discharge from hospital should be conducted. The above-mentioned perioperative bundled care might reduce perioperative complications and operative mortality, and thus improve the prognosis of the patients with ICM.

[Mid-term multi-center outcomes of bilateral radial artery as conduits in coronary artery bypass grafting].

Objective: To evaluate the mid-term outcomes of bilateral radial artery (BRA) grafts in coronary artery bypass grafting (CABG). Methods: All perioperative medical records and follow-up results of CABG with BRA grafts in multi-centers of China were analyzed retrospectively. Results: A total of 211 patients (170 males and 41 females) underwent CABG grafting with BRA conduits between August 2013 and September 2018, with a mean age of (56.5±9.7) years old (rang 41 to 73 years). There were 161 cases of triple-vessel disease and 50 cases of two-vessel disease. Ninety patients had diabetes mellitus (DM), 35 patients with peripheral vascular disease, 4 patients with chronic obstructive pulmonary disease and 11 with heart valve disease. Two patients underwent off-pump CABG and 209 patients accepted on-pump CABG with commitment valve surgery. There were 210 cases of total arterial revascularization and 161 cases using left thoracic artery conduits, with a graft number of 2-4 (2.7±0.9). No operation-related death occurred, atrial fibrillation happened in 12 patients, hemothorax in 7 cases, and forearm hematoma in one case, hypoxemia in 13 cases and pneumonia in one case. The duration of mechanical ventilation was (8.3±4.7) hours and the mean hospital length of stay was (7.1±2.9) days. Follow-up was completed in 191 patients (90.52%) with a duration of 3-59 (35.5±9.3) months. The mean left ventricular ejection fraction at 3 months after operation was significantly improved, compared to that of the pre-operation (61.0%±7.2% vs 47.1%±5.3%, P=0.017). All patients survived, except that one died from brain injury. No major cardiac events occurred, with a cumulative survival rate of 100% at 1 year and 99.53% at 3 year after operation, respectively. It was showed in coronary CT angiography (CTA) examination that all grafts in 132 patients were patent at the mean follow-up duration of (21.5±6.4) months. Conclusions: BRA grafts as arterial conduit in CABG are proved to be safe, easy for total arterial revascularization and have good mid-term clinical results.

Can we perform esophagectomy for esophageal cancer patients with concomitant liver cirrhosis? A comprehensive systematic review and meta-analysis.

Liver cirrhosis is sometimes encountered in esophageal cancer patients intended for surgery. However, the impact of liver cirrhosis on patients with surgically treated esophageal cancer remains unclear. Therefore, we conducted the first meta-analysis focusing on current topic. We comprehensively searched relevant studies in Pubmed, Embase, and Web of Science on September 3, 2018. Data for analysis included both short-term (including morbidity and mortality rates) and long-term (5-year survival rate) outcomes. Our meta-analysis was conducted by using the STATA 12.0 package. We finally included a total of six cohort studies involving a total of 1426 patients (161 cirrhotic patients and 1265 noncirrhotic patients). Meta-analysis showed that cirrhotic patients had a significantly higher morbidity rate (risk ratio (RR) = 1.226; 95% Confidence interval (CI) = [1.043, 1.442]; P = 0.014) than noncirrhotic patients. For specific complications, cirrhotic patients had a significantly higher rate of pulmonary complications (RR = 2.354; 95%CI = [1.376, 4.026]; P = 0.002) and pleural effusion (RR = 2.414; 95%CI = [1.482, 3.613]; P < 0.001) than noncirrhotic patients and there was a trend toward a higher rate of anastomotic leak (RR = 1.759; 95%CI = [0.945, 3.274]; P = 0.075) in cirrhotic patients. Moreover, cirrhotic patients also had a significantly higher mortality rate (RR = 2.529; 95%CI = [1.480, 4.324]; P = 0.001) than noncirrhotic patients. Cirrhotic patients tended to yield a lower 5-year survival rate than those noncirrhotic patients after surgical resection of esophageal cancer (RR = 0.715; 95%CI = [0.492, 1.039]; P = 0.079). In conclusion, liver cirrhosis was significantly correlated with high morbidity and mortality rates. However, there was no sufficient evidence of unfavorable survival in cirrhotic patients. Esophagectomy can be performed for certain esophageal cancer patients with concomitant liver cirrhosis with acceptable operative risks, providing that careful preoperative evaluation and patient selection have been achieved.

Genomic screening of Fabry disease in young stroke patients: the Taiwan experience and a review of the literature.

BACKGROUND AND PURPOSE: Fabry disease is an X-linked disease, and enzyme-based screening methods are not suitable for female patients. METHODS: In total, 1000 young stroke patients (18-55 years, 661 with ischaemic stroke and 339 with hypertensive intracerebral hemorrhage) were recruited. The Sequenom iPLEX assay was used to detect 26 Fabry related mutation genes. The frequency of Fabry disease in young stroke was reviewed and compared between Asian and non-Asian countries. RESULTS: Two male patients with ischaemic stroke were found to have a genetic mutation of IVS4+919G>A. There was no α-galactosidase A (GLA) gene mutation in female patients. The frequency in Asian stroke patients was 0.62% (male vs. female 0.63% vs. 0.58%) with 0.72% for ischaemic stroke and none for hemorrhagic stroke, compared to 0.88% (0.77% vs. 1.08%) with 0.83% for ischaemic stroke and 1.40% for hemorrhagic stroke reported in western countries. CONCLUSION: IVS4+919G>A is the GLA mutation in Taiwanese young ischaemic stroke patients. Fabry disease is more frequent among non-Asian patients compared to Asian patients.

Pan-cancer methylation and expression profiling of adenocarcinomas revealed epigenetic silencing in the WNT signaling pathway.

Adenocarcinomas are tumors of glandular characteristics. While tissues of common origins have been known to undergo similar epigenetic changes, it is unclear whether adenocarcinomas of different cancer types would exhibit similar DNA methylation and epigenetic regulation profiles. Herein, we studied global methylation and mRNA expression levels in 1214 lung, prostate, colon, and rectal cancer samples from The Cancer Genome Atlas (TCGA). We identified 602 candidate epigenetically silenced genes shared across these cancer types, and 835 associated CpG sites. The shared candidate genes are enriched in developmental processes. Specifically, 15 of these genes were found in the WNT signaling pathway (enrichment test p-value=1.53x10-6). Notably, the subset of silenced WNT pathway genes in each sample may be different, and both WNT activating or inhibiting genes could be suppressed. Clustering analysis showed that each tumor type contained a similar hyper-methylated subset of samples showing strong epigenetic silencing in the WNT pathway genes, and other fractions of samples expressing subset of the genes. Overall, our results showed that aberration in epigenetic regulation of the WNT signaling pathway is a common signature in adenocarcinomas.

An isolated intracranial mucocoele herniated from the frontal sinus.

Mucocoeles are chronic mucosa-lined retention cysts that occur due to sinus ostium obstruction and expand along the path of least resistance, most commonly involving the frontal sinus. A frontal mucocoele typically appears as a smooth and rounded expansile enlargement of a completely opacified frontal sinus, with or without thinning of the bony wall of the sinus. Here we report a rare case of isolated intracranial mucocoele that presented with posterior herniation to the anterior cranial fossa through a small bony defect on the posterior table of the frontal sinus. The findings upon imaging could easily be confused with intracranial abscess, potentially leading to craniotomy drainage. In the present case of mucocoele, the frontal intracranial lesion was completely resolved following endoscopic frontal sinusotomy.

Comparison of therapeutic results in sudden sensorineural hearing loss with/without additional hyperbaric oxygen therapy: a retrospective review of 465 audiologically controlled cases.

OBJECTIVE: To investigate the necessity of routine application of hyperbaric oxygen therapy for sudden sensorineural hearing loss. DESIGN/SETTING AND PARTICIPANTS: A retrospective chart review looked at 465 patients, with 353 of them receiving pharmacologic treatments alone. Among these patients, 76 underwent systemic steroid treatment only (steroid group) and 277 received systemic steroids and dextran (steroid-dextran group). The remaining 112 patients were treated with hyperbaric oxygen in addition to pharmacologic agents (steroid-dextran-hyperbaric oxygen group). MAIN OUTCOME MEASURES: The outcome was determined by comparing the difference of pure-tone thresholds and absolute hearing gains after treatment calculated at each audiometric octave frequency or grouped frequencies of audiograms. On the basis of the severity of initial hearing loss, patients were classified at three scales of hearing impairments measured in decibels hearing level (dBHL): ≦ 70 dBHL, less severe; 71-90 dBHL, severe; and ≧ 91 dBHL, profound. The outcomes of their hearing recovery were classified into three recovery grades: good, fair and poor. RESULTS: In those patients with initial hearing loss >90 dBHL, the addition of hyperbaric oxygen to steroid-dextran gave a significant hearing gain difference (P = 0.030) by showing a greater hearing gain of 24.5 ± 2.7 dB compared with steroid only (12.9 ± 3.7 dB) or steroid-dextran (15.6 ± 2.7 dB). This outcome was confirmed when we compared the outcome using the recovery grading; steroid-dextran-hyperbaric oxygen group showed that more patients with initial profound (≧ 91 dBHL) hearing loss responded to hyperbaric oxygen treatment by exhibiting good and fair recoveries (2% and 70%) as compared with steroid only (0% and 42%) or steroid-dextran (8% and 46%) groups (P = 0.043), while the patients with initial severe (71-90 dBHL) and less severe (≦ 70 dBHL) hearing loss responded to the addition of hyperbaric oxygen treatment with less favourable recoveries. Furthermore, the addition of dextran in steroid-dextran group showed no significant benefit compared with the steroid group (P = 0.435). CONCLUSIONS: When applied as an adjuvant to pharmacologic agents, hyperbaric oxygen benefits patients with initial profound sudden sensorineural hearing loss. Therefore, we recommend the routine application of hyperbaric oxygen in conjunction with pharmacologic agents for those patients. The addition of dextran to steroid has no benefit and cannot be recommended.

Vimentin is a novel AKT1 target mediating motility and invasion.

The PI3K/AKT signaling pathway is aberrant in a wide variety of cancers. Downstream effectors of AKT are involved in survival, growth and metabolic-related pathways. In contrast, contradictory data relating to AKT effects on cell motility and invasion, crucial prometastatic processes, have been reported pointing to a potential cell type and isoform type-specific AKT-driven function. By implication, study of AKT signaling should optimally be conducted in an appropriate intracellular environment. Prognosis in soft-tissue sarcoma (STS), the aggressive malignancies of mesenchymal origin, is poor, reflecting our modest ability to control metastasis, an effort hampered by lack of insight into molecular mechanisms driving STS progression and dissemination. We examined the impact of the cancer progression-relevant AKT pathway on the mesenchymal tumor cell internal milieu. We demonstrate that AKT1 activation induces STS cell motility and invasiveness at least partially through a novel interaction with the intermediate filament vimentin (Vim). The binding of AKT (tail region) to Vim (head region) results in Vim Ser39 phosphorylation enhancing the ability of Vim to induce motility and invasion while protecting Vim from caspase-induced proteolysis. Moreover, vimentin phosphorylation was shown to enhance tumor and metastasis growth in vivo. Insights into this mesenchymal-related molecular mechanism may facilitate the development of critically lacking therapeutic options for these devastating malignancies.

The use of air fuel cell cathodes to remove contaminants from spent chromium plating solutions.

Results from experiments using an impregnation-reduction (I-R) Pt / Nafion membrane electrode assembly (MEA) in an air fuel cell cathode to remove contaminants (Cu(II), Ni(II), and Fe(III)) from spent chromium electroplating baths are presented in this study. A platinum-carbon (Pt-C) / Nafion MEA and a Pb planar cathode were also used for comparison. The average removal rates of Cu(II) and Ni(II) were almost the same (0.39 and 0.40 mM hr(-1) (or 0.117 and 0.12 mmol hr(-1)), respectively) but higher than that of Fe(III) (0.16 mM hr(-1), or 0.048 mmol hr(-1)) in accordance with the Nernst-Planck flux equation. The removal rates for the same cation were independent of the cathode used. The average removal rate of each impurity was approximately proportional to the product of its initial concentration and separator area/anolyte volume ratio using Pb cathodes. Under constant current conditions the system using the Pt-C / Nafion cathode needed the highest cell voltage, about 3 V more than needed for the system with the Pt / Nafion cathode. The cell voltage required using the Pt / Nafion cathode was similar to that using the conventional planar Pb cathode. Analyses of cathode deposits by SEM/EDS and XPS techniques indicated they were minimal on the Pb and Pt / Nafion cathode and more apparent on the Pt-C / Nafion cathode. The primary deposits on the Pb cathode were chromium oxides (e.g., Cr2O3) with minor amount of lead chromate (lead dichromate or lead trichromate) and other chromium solids (Cr black). As expected, the dominant deposit on the lead anode surface was PbO2.

Rapid development of an advanced squamous-cell carcinoma of the esophagus.

This report describes the case of a 42-year-old alcoholic man who developed advanced squamous-cell carcinoma of the esophagus following an endoscopic examination showing grossly normal mucosa only 8 months previously. We believe this is the first case report providing endoscopic images illustrating a progression from grossly normal mucosa to advanced carcinoma of the esophagus in only 8 months.

Endoscopic stenting in the treatment of bile leakage after laparoscopic cholecystectomy.

BACKGROUND: Bile leakage is one of the most common complications after laparoscopic cholecystectomy surgery, and biliary decompression is a key factor in treatment. We retrospectively investigated 6 patients with bile leakage after laparoscopic cholecystectomy who were treated with endoscopic stent. METHODS: From March 1995 to May 1999, six patients (4 men and 2 women) aged 30-64 years (mean, 51 years) with bile leakage after laparoscopic cholecystectomy were enrolled. Biliary stent (10 French, 6-10 cm) placement with (n = 4) or without (n = 2) sphincterotomy was attempted. The symptoms, results and outcomes were reviewed. RESULTS: The interval from operation to presentation of bile leakage ranged from 1 to 10 days. Bile leakage was detected from cystic duct stump in 5 patients (83%) and from right IHD in 1 patient (17%). Plastic stent placement was successfully in all patients. Endoscopic stenting healed bile leakage successfully in 5 cases (83%). One patient required surgical correction due to persistent bile leakage. The mean duration between stent placement and cessation of bile leakage was 6.8 days (range 1 to 24 days). CONCLUSIONS: Endoscopic stenting is a safe, rapid and effective treatment for bile leakage after laparoscopic cholecystectomy.

Dibutyryl cAMP prevents increased vascular permeability caused by air embolism in isolated rat lungs.

BACKGROUND AND HYPOTHESIS: Venous gas bubbles are routinely detected in astronauts undergoing extravehicular activities at lower suit pressure. Venous air embolism increases the pulmonary arterial pressure and the vascular permeability leading to acute lung injury. In the present study we evaluated the protective effect of dibutyryl cAMP, aminophylline, and pentoxifylline on the pulmonary vasculatures after air embolism. METHOD: In isolated and perfused rat lungs, we induced air embolism by introducing air bubbles into the pulmonary artery. We measured the pulmonary arterial pressures and capillary pressure. Vascular permeability was determined by measuring the filtration coefficient (Kf) and the protein concentration in the lung lavage fluid. RESULTS: Air infusion caused pulmonary hypertension and increased vascular permeability, resulting in pulmonary edema. The Kf (in g.min-1.cm H2O-1.100 g-1) increased from 0.44 +/- 0.05 at baseline to 2.98 +/- 0.47 after air infusion. Pretreatment with DBcAMP prevented the increase in Kf (0.63 +/- 0.09) caused by air embolism without altering the hemodynamics. Aminophylline and pentoxifylline did not prevent lung injury induced by air embolism. Although aminophylline did not alter the response of pulmonary arterial pressure to air infusion, it elevated the capillary pressure to 5.1 +/- 0.4 mmHg, which was significantly greater than that in the lung receiving air infusion alone. CONCLUSION: Our results suggest that DBcAMP prevents the increase in vascular permeability caused air embolism. The ineffectiveness of aminophylline and pentoxifylline on the prevention of air embolism-induced lung injury remains for further investigation.

The GST T1 and CYP2E1 genotypes are possible factors causing vinyl chloride induced abnormal liver function.

Vinyl chloride monomer (VCM) is hepatotoxic as well as carcinogenic in humans. There are reports that exposure to VCM seems to induce abnormal liver function, liver fibrosis, cirrhosis, portal hypertension, and angiosarcoma of the liver. In vivo, VCM is metabolized by cytochrome P450 2E1 (CYP2E1) to form the electrophilic metabolites, chloroethylene oxide (CEO) and chloroacetaldehyde (CAA), which may either cause cell damage or be further metabolized and detoxified by glutathione S-transferases (GSTs). This study investigated whether or not the genotypes CYP2E1, glutathione S-transferase theta (GST T1) and mu (GST M1) correlated with abnormal liver function found in vinyl chloride exposed workers. For this study, 251 workers from five polyvinyl chloride plants were enrolled. The workers were classified into two exposure groups (high and low) and the degree of exposure was determined based on their job titles and airborne VCM concentration. The activity of serum alanine aminotransferase (ALT) was used as the parameter of liver function. The genotypes CYP2E1, GST T1 and GST M1 were determined by polymerase chain reaction and restriction fragment length polymorphism on peripheral white blood cell DNA. Other potential risk factors were also ascertained and the confounding effect was adjusted accordingly. Stratified analyses were used to explore the correlation between the alteration of liver function and the genotypes CYP2E1, GST T1 and GST M1 among the workers exposed to different levels of VCM. The following results were obtained (1) at low VCM exposure, the odds ratio (OR) of positive GST T1 on abnormal ALT was 3.8 (95% CI 1.2-14.5) but the CYP2E1 genotype was not associated with abnormal ALT. (2) At high VCM exposure, a c2c2 CYP2E1 genotype was associated with increased OR on abnormal ALT (OR 5.4, 95% CI 0.7-35.1) and positive GST T1 was significantly associated with decreased OR on abnormal ALT (OR 0.3, 95% CI 0.1-0.9). (3) Multiple linear and logistic regression also showed strong interactions of the VCM exposure to CYP2E1 as well as to the GST T1 genotype. These observations suggest that the two genotypes, CYP2E1 and GST T1, may play important roles in the biotransformation of VCM, the effect of which leads to liver damage.