Target blood pressure management during cardiopulmonary bypass improves lactate levels after cardiac surgery: a randomized controlled trial.

BACKGROUND: Hyperlactatemia is associated with a poor prognosis in cardiac surgery patients. This study explored the impact of target blood pressure management during cardiopulmonary bypass (CPB) on blood lactate levels after cardiac surgery. METHODS: Adult patients undergoing cardiac valve surgery between 20/1/2020 and 30/6/2020 at Shanghai Chest Hospital were enrolled. The patients were randomized into a low mean arterial pressure (L-MAP) group (target MAP between 50 and 60 mmHg) or a high mean arterial pressure (H-MAP) group (target MAP between 70 and 80 mmHg), n = 20 for each. Norepinephrine was titrated only during CPB to maintain MAP at the target level. Blood lactate levels in the two groups were detected before the operation (T0), at the end of CPB (T1), at the end of the operation (T2), 1 h after the operation (T3), 6 h after the operation (T4) and 24 h after the operation (T5). The primary outcome was the blood lactate level at the end of the operation (T2). The secondary outcomes included the blood lactate level at T1, T3, T4, and T5 and the dose of epinephrine and dopamine within 24 h after the operation, time to extubation, length of stay in the ICU, incidence of readmission within 30 days, and mortality within 1 year. RESULTS: Forty patents were enrolled and analyzed in the study. The lactate level in the H-MAP group was significantly lower than that in the L-MAP group at the end of the operation (3.1 [IQR 2.1, 5.0] vs. 2.1 [IQR 1.7, 2.9], P = 0.008) and at the end of CPB and 1 hour after surgery. The dose of epinephrine within 24 h after the operation, time to extubation and length of stay in the ICU in the L-MAP group were significantly higher than those in the H-MAP group. CONCLUSIONS: Maintaining a relatively higher MAP during CPB deceased the blood lactate level at the end of surgery, reduced epinephrine consumption, and shortened the time to extubation and length of stay in the ICU after surgery. TRIAL REGISTRATION: This single-center, prospective, RCT has completed the registration of the Chinese Clinical Trial Center at 8/1/2020 with the registration number ChiCTR2000028941 . It was conducted from 20/1/2020 to 30/6/2020 as a single, blinded trial in Shanghai Chest Hospital.

[Promoting of angiogenesis and osteogenesis in radial critical bone defect regions of rabbits with nano-hydroxyapatite/collagen/PLA scaffolds plus endothelial progenitor cells].

OBJECTIVE: To explore the roles of nano-hydroxyapatite/collagen/PLA (nHAC/PLA) plus endothelial progenitor cells (EPCs) in repairing segmental bone defects of rabbit radius and enhancing angiogenesis and new bone formation. METHODS: EPCs isolated from New Zealand white rabbit bone marrow were cultured, identified and seeded into nHAC/PLA scaffolds. And the growth of EPCs in scaffolds was observed under scanning electron microscopy (SEM). Thirty-six were randomly divided into 3 groups to establish segmental bone defect models in radii. Two groups were implanted with EPCs/scaffolds constructs (group A, n = 16) and scaffolds alone (group B, n = 16) respectively. The remaining four rabbits were used as negative control (group C) and nothing was implanted. Animals were sacrificed at different timepoints and radii harvested to undergo radiological examination, histological examination and microvessle density test. RESULTS: These cells isolated from bone marrow were confirmed as EPCs. SEM showed that EPCs attached to the nHAC/PLA scaffolds, grew and proliferated well. Animal experiments revealed that radiological scores (5w: 2.25 ± 0.50 vs 1.00 ± 0.00; 10w: 2.75 ± 0.50 vs 1.75 ± 0.50; 15w: 4.25 ± 0.50 vs 3.0 ± 0.0; each P < 0.05), percentage of new bone formation area in bone defect regions (5w: 29.0% ± 3.5% vs 8.1% ± 0.8%; 10w: 63.4% ± 5.5% vs 16.6% ± 1.3%; 15w: 96.0% ± 4.3% vs 34.0% ± 6.6%; each P < 0.05) and microvessel density (2w: 13.5 ± 0.9 vs 4.3 ± 1.0; 5w:9.8 ± 0.7 vs 4.8 ± 0.3; 10w: 7.0 ± 0.4 vs 4.5 ± 0.4; each P < 0.05) in group A were significantly higher than those in group B. No new bone formation occurred in group C. CONCLUSION: The composite structure of EPCs-nHAC/PLA can enhance angiogenesis and new bone formation in segmental bone defects in rabbit radii. It may become a potential candidate of promoting revascularization of tissue engineering bone and repairing large bone defects.

[Influence of minor back trauma on surgical outcomes in patients with thoracic ossification of ligamentum flavum].

OBJECTIVE: To retrospectively explore the influences of minor back trauma on surgical outcomes in patients with thoracic ossification of ligamentum flavum (TOLF) and preliminarily detect its possible causes. METHODS: A total of 94 TOLF patients were divided into two groups according to the absence or presence of minor back trauma: MT (minor trauma, n = 16) and NT (no trauma, n = 78). They were compared in terms of gender, age, duration of symptoms, levels of involvement, numbers of involved segments, ratio of intramedullary signal changes (IMSC), pre- & post-operative JOA (Japanese Orthopedic Association) score, recovery rate (RR) at the final follow-up. Multiple regression analysis was employed to elucidate the causes related with the surgical outcomes. The MT group was further divided into two subgroups according to the intervals between trauma and surgery to clarify the influences of surgical timing on the efficacies. RESULTS: The JOA scores were 4.0 ± 1.4 and 8.4 ± 1.7 respectively in MT and NT groups at the final follow-up. The neurological status of patients improved in both groups (MT: P = 0.009, NT: P = 0.000). The patients were younger in MT groups (50 ± 11 years) than those in NT groups (58 ± 8 years) (P = 0.046). The ratio of IMSC was higher in MT groups (75.0%) than that in NT groups (25.6%) (P = 0.000). The pre- & post-operative JOA scores were lower in MT groups than those in NT groups (both P = 0.000). Multiple regression analysis revealed that the postoperative JOA score at the final follow-up was positively related with the preoperative JOA score (r = 0.60, P = 0.000) and negatively with trauma and IMSC (r = -1.82 and r = -1.87, P = 0.000) while the final postoperative RR were negatively related with trauma and IMSC (r = -26.26 and r = -33.70, P = 0.000). The surgical timing after trauma did not influence the efficacies (P = 0.147). CONCLUSION: The TOLF patients with minor back trauma have a worse post-operative recovery. A minor trauma might be a risk factor of adverse surgical outcomes.

Percutaneous Vertebroplasty with Side-Opening Cannula or Front-Opening Cannula in the Treatment of Kummell Disease?

OBJECTIVE: To explore the effect of bone cement distribution, cement leakage, and clinical outcomes with side-opening cannula for bone cement injection in percutaneous vertebroplasty (PVP) in treatment of Kummell disease. METHODS: A prospective study of patients with Kummell disease undergoing PVP was conducted from April 2012 to September 2017. In total, 43 patients (11 males, 32 females) with Kummell disease who received bilateral PVP were included in the study. The patients were divided into front-opening cannulas (FOC) group with front-opening cannulas and side-opening cannulas (SOC) group with side-opening cannulas. All patients were followed up for 6 months. The patient general information such as gender, age, bone density, compression ratio, operative time, and location of fracture vertebrae were recorded. Visual analogue scale (VAS), Oswestry Disability Index (ODI), bone cement distribution, radiation exposure time, bone cement leakage rate and vertebral height, and kyphosis angle were measured and compared for two groups before surgery, 1 day and 6 months after surgery. RESULTS: A total of 43 patients were enrolled, including 11 males and 32 females, aged 61-84 years. The bone density (T value) was 2.5 ± 0.6 in FOC group and 2.4 ± 0.6 in SOC group (P > 0.05). The compression ratio and operative time were 36.1% ± 13.0%, 39.3 ± 7.9 min in FOC group and 35.2% ± 13.7%, 40.0 ± 10.7 min in SOC group (P > 0.05). There was no significance between FOC and SOC groups in the location of fracture vertebrae. All patients underwent at least 6 months of follow-up. At 6 months postoperatively, the VAS and ODI were significantly higher in the FOC group (3.0 ± 0.8, 35.7% ± 2.1%) than in the SOC group (1.3 ± 0.4, 18.6% ± 2.4%) (P < 0.05). The cement leakage rate of the SOC group was 4.8%, which was lower than that of the FOC group (31.8%, P < 0.05), and the bone cement distribution ratio was higher than that of the FOC group (63.1% ± 7.9% vs 40.5% ± 8.6%, P < 0.05). At 6 months after operation, the height of the anterior and posterior vertebral bodies of the patients in the SOC group restored better than the FOC group (anterior SOC: FOC 5.1 ± 0.5 mm vs 4.5 ± 0.5 mm; posterior SOC: FOC 0.6 ± 0.1 mm vs 0.3 ± 0.1 mm, P < 0.05), and the kyphosis correction was more obvious than patients in FOC group (SOC: FOC 8.5° ± 1.4° vs 4.6° ± 0.8°, P < 0.05). CONCLUSION: Percutaneous vertebroplasty with side-opening cannula is safe and effective in avoiding bone cement leakage, improving bone cement distribution, and restoring vertebral height.

High expression of WNT7A predicts poor prognosis and promote tumor metastasis in pancreatic ductal adenocarcinoma.

Due to the therapy resistance and frequent metastasis, pancreatic ductal adenocarcinoma(PDAC) remains one of the most malignant carcinoma. WNT7A, an important ligand of Wnt/ß-catenin signaling pathways, has a controversial role in tumor development. The role of WNT7A in PDAC remains unclear. In this study, we analyzed the expression pattern of WNT7A at mRNA and protein levels. We found pancreatic cancer tissue demonstrated a significant high WNT7A expression compared with the adjacent non-tumor tissue and the expression of WNT7A positively correlates with poor prognosis and lymph node metastasis. Then, we performed transwell assays and wound healing assays in vitro and found that WNT7A promotes the migration capacity of cancer cells. Furthermore, we explored the underlying mechanism of the WNT7A inducing cell migration. Results showed that up-regulated WNT7A expression inducing higher expression of N-cadherin and lower expression of E-cadherin while the contrast result was shown in the WNT7A knock-down group, which suggested that WNT7A might contribute to an epithelial-mesenchymal transition. Finally, we found that the hypoxia culture condition remarkably increased the WNT7A expression. In conclusion, our work demonstrated that hypoxia induced high expression of WNT7A might promote the cell migration via enhancing the epithelial-mesenchymal transition in PDAC.

[The clinical report of 21 cases of occlusion of atrial septal defect through right chest small incision].

OBJECTIVE: To evaluate the methods and efficacy of atrial septal defect (ASD) occlusion through right chest incision. METHODS: The clinical data of 21 patients with ASD from July 2004 to May 2005 were analyzed retrospectively. Eight patients were male and 13 patients were female, aged from 1 to 70 years old, with the median age of 21 years old. The diameter of ASD was from 8 to 40 mm. All the 21 patients were under general anaesthesia. A 2 to 3 cm incision was made in the 4th intercostals of right side of sternum. With the help of transesophageal or normal transthoracic echocardiography, the occluder was released using monotube unit. RESULTS: All cases were occluded successfully without death. The types of the occluder were from 14 to 46 mm. None failed and had to choose extracorporeal circulation operations. No transfusion and no serious complication such as the occluder dislocated occurred. And no evident of atrial shunt was found when in review echo. CONCLUSIONS: The ASD occlusion through right chest minimal incision is safe, credit, minimal invasive and worth to use widely.

Risk factors for intraoperative atrial fibrillation: a retrospective analysis of 10,563 lung operations in a single center.

BACKGROUND: Risk factors of postoperative atrial fibrillation (AF) in patients undergoing general thoracic operations have been extensively studied. This study investigated risk factors for intraoperative AF. Identification of patients vulnerable for intraoperative AF during lung operations will benefit from improved preoperative and intraoperative management that will ultimately decrease intraoperative complications. This study retrospectively evaluated the risk factors for intraoperative AF during lung operations. METHODS: Medical records of 10,638 patients who underwent lung operations from January 1, 2006, to May 20, 2011, at the Shanghai Chest Hospital were reviewed. The analysis excluded 75 patients with preoperative AF or nonsinus rhythm or who were taking antiarrhythmic drugs before the operation. The final analysis included 10,563 patients. Univariate and multivariate analyses were performed to identify risk factors for intraoperative AF. RESULTS: The overall incidence of intraoperative AF was 3.27% (346 of 10,563). Multivariable logistic analysis identified increasing age, male sex, lung cancer, general anesthesia plus paravertebral block, open operation, resection of one or more lobes, and increased operation time as risk factors of intraoperative AF. In 40.73% of patients, intraoperative AF occurred during lymph node dissection. CONCLUSIONS: We identified seven risk factors for intraoperative AF in patients receiving lung operations. These findings may eventually help us to improve preoperative and intraoperative management to minimize intraoperative AF.