PIP2 corrects cerebral blood flow deficits in small vessel disease by rescuing capillary Kir2.1 activity.

Cerebral small vessel diseases (SVDs) are a central link between stroke and dementia-two comorbidities without specific treatments. Despite the emerging consensus that SVDs are initiated in the endothelium, the early mechanisms remain largely unknown. Deficits in on-demand delivery of blood to active brain regions (functional hyperemia) are early manifestations of the underlying pathogenesis. The capillary endothelial cell strong inward-rectifier K+ channel Kir2.1, which senses neuronal activity and initiates a propagating electrical signal that dilates upstream arterioles, is a cornerstone of functional hyperemia. Here, using a genetic SVD mouse model, we show that impaired functional hyperemia is caused by diminished Kir2.1 channel activity. We link Kir2.1 deactivation to depletion of phosphatidylinositol 4,5-bisphosphate (PIP2), a membrane phospholipid essential for Kir2.1 activity. Systemic injection of soluble PIP2 rapidly restored functional hyperemia in SVD mice, suggesting a possible strategy for rescuing functional hyperemia in brain disorders in which blood flow is disturbed.

Risk Factors, Management, and Outcome of Gastric Venous Congestion After Total Pancreatectomy: An Underestimated Complication Requiring Standardized Identification, Grading, and Management.

BACKGROUND: Gastric venous congestion (GVC) after total pancreatectomy (TP) is rarely studied despite its high 5% to 28% incidence and possible association with mortality. This study aimed to provide insight about incidence, risk factors, management, and outcome of GVC after TP. METHODS: This retrospective observational single-center study included all patients undergoing elective TP from 2008 to 2021. The exclusion criteria ruled out a history of gastric resection, concomitant (sub)total gastrectomy for oncologic indication(s) or celiac axis resection, and postoperative (sub)total gastrectomy for indication(s) other than GVC. RESULTS: The study enrolled 268 patients. The in-hospital major morbidity (Clavien-Dindo grade ≥IIIa) rate was 28%, and the 90-day mortality rate was 3%. GVC was identified in 21% of patients, particularly occurring during index surgery (93%). Intraoperative GVC was managed with (sub)total gastrectomy for 55% of the patients. The major morbidity rate was higher for the patients with GVC (44% vs 24%; p = 0.003), whereas the 90-day mortality did not differ significantly (5% vs 3%; p = 0.406). The predictors for major morbidity were intraoperative GVC (odds ratio [OR], 2.207; 95% confidence interval [CI], 1.142-4.268) and high TP volume (> 20 TPs/year: OR, 0.360; 95% CI, 0.175-0.738). The predictors for GVC were portomesenteric venous resection (PVR) (OR, 2.103; 95% CI, 1.034-4.278) and left coronary vein ligation (OR, 11.858; 95% CI, 5.772-24.362). CONCLUSIONS: After TP, GVC is rather common (in 1 of 5 patients). GVC during index surgery is predictive for major morbidity, although not translating into higher mortality. Left coronary vein ligation and PVR are predictive for GVC, requiring vigilance during and after surgery, although gastric resection is not always necessary. More evidence on prevention, identification, classification, and management of GVC is needed.

New Releasable Nonabsorbable Polypropylene 8.0 Suturing Technique for Sclerotomy Sealing in 23-Gauge Vitrectomy.

PURPOSE: We propose a new releasable 8.0 polypropylene suture for leaking sclerotomies at the end of vitrectomy. Characteristic of this suture is that it can be easily removed the day after surgery at the slit-lamp examination. METHODS: Patients undergoing 23-gauge pars plana vitrectomy with the need for at least 2 sclerotomy sutures and having a preoperative Ocular Surface Disease Index score <12 were consecutively allocated to sealing with either polyglactin 910 absorbable suture (VY GROUP) or nonabsorbable 8.0 polypropylene releasable suture (PR GROUP). Evaluation of adverse events, Ocular Surface Disease Index score, and conjunctival hyperemia (through the Efron scale) was performed at 1, 7, and 30 days postoperatively. RESULTS: Both methods effectively sealed sclerotomies. PR GROUP showed a significantly lower Ocular Surface Disease Index score and lower degree of conjunctival hyperemia at both 7 and 30 days follow-up. The Ocular Surface Disease Index score decreased significantly after 7 days in PR GROUP while in VY GROUP improved at 30 days postoperatively. PR GROUP showed a lower degree of conjunctival hyperemia both at 7 and 30 days follow-up. CONCLUSION: Polypropylene 8-0 releasable sutures proved to be effective in 23-gauge pars plana vitrectomy wound sealing while inducing less ocular surface inflammation and patient discomfort compared with the standard polyglactin 910 suture.

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps.

BACKGROUND: Abdominally based free flaps are commonly used in breast reconstruction. A frequent complication is venous congestion, which might contribute to around 40% of flap failures. One way to deal with it is venous supercharging. The primary aim of this study was to investigate the scientific evidence for the effects of venous supercharging. METHODS: A systematic literature search was conducted in PubMed, CINAHL, Embase, and Cochrane library. The included articles were critically appraised, and certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS: Thirty-six studies were included. Most studies had serious study limitations and problems with directness. Three studies report 'routine' use of venous supercharging and performed it prophylactically in patients who did not have clinical signs of venous congestion. Seventeen studies report on flap complications, of which one is a randomised controlled trial demonstrating statistically significant lower complication rates in the intervention group. The overall certainty of evidence for the effect of a venous supercharging on flap complications, length of hospital stay and operative time, in patients without clinical signs of venous congestion, is very low (GRADE ⊕ ⊕ ⊝ ⊝), and low on and surgical takebacks (GRADE ⊕ ⊕ ⊝ ⊝). Twenty-one studies presented data on strategies and overall certainty of evidence for using radiological findings, preoperative measurements, and clinical risk factors to make decisions on venous supercharging is very low (GRADE ⊕ ⊝ ⊝ ⊝). CONCLUSION: There is little scientific evidence for how to predict in which cases, without clinical signs of venous congestion, venous supercharging should be performed. The complication rate might be lower in patients in which a prophylactic venous anastomosis has been performed. TRIAL REGISTRATION: PROSPERO (CRD42022353591).

Misdiagnosis and Treatment of Corneal Complications Caused by Suture Exposure After Buried-Suture Double-Eyelid Blepharoplasty.

PURPOSE: The purpose of this study was to summarize the misdiagnosis and treatment of corneal complications associated with suture exposure in cases of buried-suture double-eyelid blepharoplasty. METHODS: This study retrospectively analyzed 14 patients with palpebral conjunctival and corneal complications due to suture exposure after buried-suture double-eyelid blepharoplasty at the First Affiliated Hospital of Harbin Medical University from January 2020 to July 2022. The patients' clinical symptoms included photophobia, lacrimation, pain, foreign body sensation, swelling of the eyelids, conjunctival hyperemia, secretion, etc. We recorded the patient's sex, age, surgical method, length of exposed suture, suture type, number of double-eyelid surgeries, surgical site, timepoint when eye discomfort occurred, misdiagnosed disease and treatment. RESULTS: Three patients were misdiagnosed with dry eye, nine patients were misdiagnosed with viral keratitis, and two patients were misdiagnosed with allergic conjunctivitis. All 14 patients had manifestations of photophobia, lacrimation, pain, foreign body sensation and conjunctival hyperemia. Eight patients had manifestations of swelling of the eyelids. Five patients had manifestations of eye secretions. There were 8 patients with corneal epithelial injuries and 6 patients with corneal ulcers. All patients underwent suture removal without further progression. Ten patients were treated with artificial tears, and 4 patients were treated with calf serum deproteinized gel after suture removal. CONCLUSION: If there is postoperative eye discomfort caused by eyelid and corneal complications in patients after buried-suture double-eyelid blepharoplasty, clinicians should carefully check whether there is suture exposure and determine the cause in a timely manner. Suture removal is the best way to treat this complication. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reactive Hyperemia and Cardiovascular Autonomic Neuropathy in Type 2 Diabetic Patients: A Systematic Review of Randomized and Nonrandomized Clinical Trials.

Objective: This work aimed to determine the relationship between the autonomic nervous system and reactive hyperemia (RH) in type 2 diabetes patients with and without cardiovascular autonomic neuropathy (CAN). Methodology: A systematic review of randomized and nonrandomized clinical studies characterizing reactive hyperemia and autonomic activity in type 2 diabetes patients with and without CAN was performed. Results: Five articles showed differences in RH between healthy subjects and diabetic patients with and/or without neuropathy, while one study did not show such differences between healthy subjects and diabetic patients, but patients with diabetic ulcers had lower RH index values compared to healthy controls. Another study found no significant difference in blood flow after a muscle strain that induced reactive hyperemia between normal subjects and non-smoking diabetic patients. Four studies measured reactive hyperemia using peripheral arterial tonometry (PAT); only two found a significantly lower endothelial-function-derived measure of PAT in diabetic patients than in those without CAN. Four studies measured reactive hyperemia using flow-mediated dilation (FMD), but no significant differences were reported between diabetic patients with and without CAN. Two studies measured RH using laser Doppler techniques; one of them found significant differences in the blood flow of calf skin after stretching between diabetic non-smokers and smokers. The diabetic smokers had neurogenic activity at baseline that was significantly lower than that of the normal subjects. The greatest evidence revealed that the differences in RH between diabetic patients with and without CAN may depend on both the method used to measure hyperemia and that applied for the ANS examination as well as the type of autonomic deficit present in the patients. Conclusions: In diabetic patients, there is a deterioration in the vasodilator response to the reactive hyperemia maneuver compared to healthy subjects, which depends in part on endothelial and autonomic dysfunction. Blood flow alterations in diabetic patients during RH are mainly mediated by sympathetic dysfunction. The greatest evidence suggests a relationship between ANS and RH; however, there are no significant differences in RH between diabetic patients with and without CAN, as measured using FMD. When the flow of the microvascular territory is measured, the differences between diabetics with and without CAN become evident. Therefore, RH measured using PAT may reflect diabetic neuropathic changes with greater sensitivity compared to FMD.

Gastric Venous Congestion After Total Pancreatectomy is Frequent and Dangerous.

OBJECTIVE: The aim of this study was to determine the role of GVC in mortality after TP. BACKGROUND: Data from a nationwide administrative database revealed that TP is associated with a 23% mortality rate in Germany. Methods: A total of 585 consecutive patients who had undergone TP (n = 514) or elective completion pancreatectomy (n = 71) between January 2015 and December 2019 were analyzed. Univariable and multivariable analyses were performed to identify risk factors for GVC and 90-day mortality. Results: GVC was observed in 163 patients (27.9%) requiring partial or total gastrectomy. Splenectomy (odds ratio 2.14, 95% confidence interval 1.253.80, P = 0.007) and coronary vein resection (odds ratio 5.49,95% confidence interval 3.19-9.64, P < 0.001) were independently associated with GVC. The overall 90-day mortality after TP was 4.1% (24 of 585 patients), 7.4% in patients with GVC and 2.8% in those without GVC ( P = 0.014). Of the 24 patients who died after TP, 12 (50%) had GVC. CONCLUSION: GVC is a frequent albeit not well-known finding after TP, especially when splenectomy and resection of the coronary vein are performed. Adequate decision making for partial gastrectomy during TP is crucial. Insufficient gastric venous drainage after TP is life-threatening.

Intraoperative venous congestion rather than hypotension is associated with acute adverse kidney events after cardiac surgery: a retrospective cohort study.

BACKGROUND: The pathophysiological mechanisms by which venous congestion and hypotension lead to acute adverse kidney events after cardiac surgery with cardiopulmonary bypass have not been elucidated. We tested the hypothesis that intraoperative hypotension and venous congestion are associated with acute kidney injury and acute kidney disease. METHODS: Primary exposures were venous congestion and intraoperative hypotension defined by central venous pressure ≥12, 16, or 20 mm Hg or mean arterial pressure ≤55, 65, or 75 mm Hg. The primary outcomes were acute kidney injury and acute kidney disease. Multivariable logistic regression and Cox proportional hazard models were used, adjusted for relevant confounding factors and multiple comparisons. RESULTS: Of 5127 eligible subjects, 1070 (20.9%) and 327 (7.2%) developed acute kidney injury and acute kidney disease, respectively. The occurrence of acute kidney injury was statistically associated with both venous congestion and intraoperative hypotension. The cumulative incidence rate for new onset acute kidney disease was 1.34 (95% confidence interval [CI], 1.21-1.60) per 100 person-days. Acute kidney disease was significantly associated with each 10 min epoch of central venous pressure ≥12 mm Hg (hazard ratio [HR]=1.03; 99% CI, 1.01-1.06; P<0.001), ≥16 mm Hg (HR=1.04; 99% CI, 1.01-1.07; P<0.001), and ≥20 mm Hg (HR=1.07; 99% CI, 1.02-1.13; P<0.001). Venous congestion was associated with an 8-17% increased risk for de novo renal replacement therapy. In contrast, intraoperative hypotension was not associated with development of acute kidney disease. CONCLUSION: Although both venous congestion and intraoperative hypotension are associated with acute kidney injury, only venous congestion correlates with acute kidney disease among patients undergoing cardiac surgery requiring cardiopulmonary bypass. The reported associations are suggestive of a pathophysiological role of venous congestion in acute kidney disease.

MR elastography-based staging of liver fibrosis in Fontan procedure associated liver disease is confounded by effects of venous congestion.

AIM: To compare targeted and global liver stiffness measured by magnetic resonance elastography (MRE) with liver biopsy in patients who have undergone the Fontan procedure, and to assess the relationship between liver stiffness and fibrosis stage. MATERIALS AND METHODS: Targeted and global liver stiffness was compared with a quantification of liver fibrosis measured by percentage of Sirius Red (%SR) staining of biopsy samples. MRE values were compared with three other biopsy-scoring methods: Ishak, Scheuer/Ludwig-Batts/Metavir, and congestive hepatic fibrosis score (CHFS). Additionally, in patients who had two or more MRE studies, global liver stiffness was compared for longitudinal assessment. RESULTS: Thirty-four patients were included in the study, with a mean age of 16.2 years. There was no statistically significant correlation between MRE-derived liver stiffness and Ishak score, Metavir score, %SR staining, and CHFS score. Twenty patients had multiple MRE studies, with a mean age of 16.5 years, and these showed a statistically significant increase in mean liver stiffness from 3.72 to 4.68 (26% increase) within an average period of 24 months. CONCLUSIONS: The lack of correlation of liver stiffness with fibrosis stage observed in this study indicates that the effects of venous congestion in Fontan patients can confound the use of liver stiffness as a biomarker for fibrosis as assessed by percentage of SR staining, Ishak score, Metavir score, and CHFS score. These results provide motivation for further development of magnetic resonance imaging-based biomarkers to increase the specificity in the assessment of Fontan-associated liver disease. A steady increase in liver stiffness observed in these patients may be useful for longitudinal follow-up of liver health.

Multiple non-invasive peripheral vascular function parameters with obesity and cardiometabolic risk indicators in school-aged children.

BACKGROUND: The Peripheral Arterial Tonometry (PAT) technique measured by Endo-PAT™, is recently introduced for peripheral vascular assessment in youth, primarily benefits from its easy and non-invasive operation. However, the value of Endo-PAT as early indicator of obesity-related cardiometabolic risk factors remains unclear, with few studies focusing solely on Reactive Hyperemia Index (RHI). A wider coverage of Endo-PAT algorithms is recommended to be applied simultaneously in youth. We evaluated the value of multiple Endo-PAT parameters on obesity and cardiometabolic risk indication in school-aged children, in comparison with another non-invasive Brachial-ankle Pulse Wave Velocity (BaPWV) method. METHODS: This cross-sectional sample included 545 youth (80 with overweight and 73 with obesity) aged 7-17 years. RHI, Framingham-Reactive Hyperemia Index (F-RHI), peak response and Augmentation Index normalized to Heart Rate 75 bpm (AIx75) were measured by Endo-PAT™ 2000 device. Spearman correlations of abovementioned Endo-PAT parameters and BaPWV, with adiposity (weight, waist circumference, BMI, body fat mass) and cardiometabolic indicators (glycemic response, blood pressure, lipid profiles) were calculated with non-linear adjustment on age, height, gender and baseline pulse-wave amplitude (PWA) using fractional polynomials. Analysis was repeated in students with obesity only [median BMI z score: 3.0 (2.5,3.5)] for sensitivity analysis. RESULTS: The correlations of Endo-PAT parameters with adiposity measures and cardiometabolic indicators were overall mixed and weak (DBP: r ranged from - 0.20 to - 0.13, others: |r| < 0.1) after adjustment. Except that body fat mass (AIx75: r = 0.52 p < 0.01) and triglyceride level (RHI: r = - 0.32 p < 0.01, F-RHI: r = - 0.21 p > 0.05) was moderately reversed in students with obesity. In contrast, BaPWV showed consistently moderate correlations (|r| ranged from 0.123 to 0.322, p < 0.05) with almost all adiposity measures and cardiometabolic indicators regardless of obesity status. CONCLUSION: Contrary to previous suggestion, various Endo-PAT parameters performed similarly weak for early cardiometabolic risk indication in school-aged children, and less preferable than that by another non-invasive BaPWV method. Despite further investigation is needed to improve certainty of relevant research evidence, innovative technology and algorithms taking into account specifics of young population are worthy of consideration.

Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique.

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report pre-sents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

Cavernous sinus dural arteriovenous fistula complicated by hippocampus venous congestion: A case report.

BACKGROUND: Hippocampal venous congestion is a rare complication associated with cavernous sinus dural arteriovenous fistulas (CS-DAVFs). CASE DESCRIPTION: A 74-year-old woman was admitted to the hospital with a swollen left eye. Isolated lesions were found in the left hippocampus and the middle cerebellar peduncle. Cerebral angiography revealed retrograde venous drainage of the bilateral inferior petrosal sinuses from the left CS-DAVF. The patient underwent transcatheter arterial embolization, resulting in complete resolution of the hippocampal lesions and neurological symptoms. CONCLUSION: Hippocampal injury is a rare complication of CS-DAVF. Attentive diagnosis and treatment can effectively prevent adverse consequences.

Association between hysteroscopic features of chronic endometritis and pregnancy outcomes of patients after in vitro fertilization: a retrospective cohort study.

This retrospective cohort study explored the morphological features of chronic endometritis (CE) and pregnancy outcomes during in vitro fertilization (IVF) in women with CE (429) at Yantai Yuhuangding Hospital between January 2017 and September 2018. The primary outcome was the clinical pregnancy rate (CPR). The women displayed haemorrhagic spots (175), hyperaemia (122), micropolyps (75), hyperaemia combined with micropolyps (49) and others (8). The CPR and live birth rate (LBR) were different among the hysteroscopic features of CE in fresh embryo transfer cycles (p = .002, p = .011). The miscarriage and premature birth rates were not significantly different among groups (p > .05). Hyperaemia (0.47 [95% CI, 0.29; 0.77]), micropolyps (0.40 [95% CI, 0.23; 0.72]), hyperaemia combined with micropolyps (0.35 [95% CI, 0.18; 0.69]) and others (0.36 [95% CI, 0.19; 0.69]) were associated with the CPR. In conclusion, the hysteroscopic features of CE are associated with IVF pregnancy outcomes, and there were differences in pregnancy outcomes with different CE hysteroscopic features.IMPACT STATEMENTWhat is already known on this subject? Chronic endometritis (CE) is associated with adverse pregnancy outcomes such as infertility, premature delivery and miscarriage. CE can reduce the success rate of pregnancy and even lead to obstetric and neonatal complications, and is an adverse factor for the success of in vitro fertilization (IVF). There are different types of CE, but their impact on IVF outcomes is unknown.What the results of this study add? The CPR and LBR were different among the hysteroscopic features of CE in fresh embryo transfer cycles (p = .002, p = .011). The miscarriage and premature birth rates were not significantly different among groups (p > .05). After adjustment, the multivariable analysis showed that hyperaemia (OR = 0.47, p = .002), micropolyps (OR = 0.40, p = .002), hyperaemia combined with micropolyps (OR = 0.35, p = .002) and others (OR = 0.36, p = .002) were associated with the CPR among patients with CE.What the implications are of these findings for clinical practice and/or further research? The hysteroscopic features of CE are associated with IVF pregnancy outcomes, and there were differences in pregnancy outcomes with different CE hysteroscopic features. Hence, women with repeated IVF failure should undergo hysteroscopy to examine for the presence of CE and its nature.

Intraoperative venous congestion and acute kidney injury in cardiac surgery: an observational cohort study.

BACKGROUND: Increased intravascular volume has been associated with protection from acute kidney injury (AKI), but in patients with congestive heart failure, venous congestion is associated with increased AKI. We tested the hypothesis that intraoperative venous congestion is associated with AKI after cardiac surgery. METHODS: In patients enrolled in the Statin AKI Cardiac Surgery trial, venous congestion was quantified as the area under the curve (AUC) of central venous pressure (CVP) >12, 16, or 20 mm Hg during surgery (mm Hg min). AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria and urine concentrations of tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ([TIMP-2]⋅[IGFBP7]), a marker of renal stress. We measured associations between venous congestion, AKI and [TIMP-2]⋅[IGFBP7], adjusted for potential confounders. Values are reported as median (25th-75th percentile). RESULTS: Based on KDIGO criteria, 104 of 425 (24.5%) patients developed AKI. The venous congestion AUCs were 273 mm Hg min (81-567) for CVP >12 mm Hg, 66 mm Hg min (12-221) for CVP >16 mm Hg, and 11 mm Hg min (1-54) for CVP >20 mm Hg. A 60 mm Hg min increase above the median venous congestion AUC above each threshold was independently associated with increased AKI (odds ratio=1.06; 95% confidence interval [CI], 1.02-1.10; P=0.008; odds ratio=1.12; 95% CI, 1.02-1.23; P=0.013; and odds ratio=1.30; 95% CI, 1.06-1.59; P=0.012 for CVP>12, >16, and >20 mm Hg, respectively). Venous congestion before cardiopulmonary bypass was also associated with increased [TIMP-2]⋅[IGFBP7] measured during cardiopulmonary bypass and after surgery, but neither venous congestion after cardiopulmonary bypass nor venous congestion throughout surgery was associated with postoperative [TIMP-2]⋅[IGFBP7]. CONCLUSION: Intraoperative venous congestion was independently associated with increased AKI after cardiac surgery.

Left ventricular inflow obstruction due to a coronary arteriovenous fistula: a paediatric case report.

BACKGROUND: We report a rare case of left ventricular inflow obstruction from a branch of the left circumflex coronary artery to the right atrium caused by a coronary arteriovenous fistula (CAVF) in a young Japanese male child. CASE PRESENTATION: The patient was diagnosed with CAVF following a heart murmur shortly after birth. The left-to-right shunt caused right ventricular volume overload and pulmonary congestion. An emergency surgical intervention was performed for the CAVF on day 6 after birth. However, by 5 years of age, his left ventricular inflow obstruction worsened. We found an abnormal blood vessel originating from the proximal part of a branch of the left circumflex coronary artery, circling the outside of the mitral valve annulus along the medial side of the coronary sinus. As the child gets older, the blood inflow into the left ventricle might get restricted further, resulting in left-sided heart failure. CONCLUSION: Our findings suggest that even after CAVF closure surgery, it is essential to monitor for complications caused by progressive dilatation of a persistent CAVF.

Cortisol level after dexamethasone suppression test in patients with non-functioning adrenal incidentaloma is positively associated with the duration of reactive hyperemia response on microvascular bed.

PURPOSE: Data on endothelial derangements in patients with non-functioning adrenal incidentaloma (NFAI) are scarce. METHODS: We investigated if NFAI patients present clinical, biochemical and endothelial alterations compared to individuals without an adrenal lesion and also the associations among these variables. Forty-two NFAI and 40 controls were evaluated. NFAI diagnosis and controls were defined according to the current guidelines and based on a normal adrenal imaging exam, respectively. Body composition was evaluated by dual emission X-ray absorptiometry. Endothelial reactivity was assessed by two methods: tonometry (Endo-PAT®) and laser speckle contrast imaging (LSCI). RESULTS: There were no differences between groups regarding age, gender, ethnicity, smoking status, and statin use. The frequency of metabolic syndrome according to the International Diabetes Federation criteria was 69% and 57.9%, respectively in NFAI and controls (p = 0.36), whereas the atherosclerotic cardiovascular disease (ASCVD) risk was 63.4% and 66.7% (p = 0.81). The clinical, laboratory, and anthropometric characteristics, as well as body composition, were similar between the groups. Additionally, any differences between groups were observed on endothelial reactivity tests. Nevertheless, we noted an association between cortisol levels after 1 mg-dexamethosone suppression test (1 mg-DST) and the duration of post-occlusive reactive hyperemia tested on microcirculation (r = 0.30; p = 0.03). NFAI patients require more antihypertensive drugs to achieve blood pressure control (p = 0.04). The number of antihypertensive drugs used to control blood pressure correlated with cortisol levels after 1 mg-DST (r = 0.29; p = 0.03). CONCLUSIONS: Since both groups herein investigated had a high frequency of metabolic syndrome and ASCVD risk, it might explain similarities observed on endothelial reactivity. Nevertheless, prolonged reactive hyperemia response on microcirculation was correlated with cortisol levels under suppression.

Meta-analysis of the effects of venous super-drainage in deep inferior epigastric artery perforator flaps for breast reconstruction.

INTRODUCTION: Venous congestion is the most common vascular complication of the deep inferior epigastric artery perforator (DIEP) flaps. Adding a second venous drainage by anastomosing a flap vein and a recipient vein (super-drainage) is considered the solution of choice. Evidence to support this procedure, had not yet been confirmed by an analysis of the literature. We aimed to provide this evidence. MATERIALS AND METHODS: We searched the literature (MedLine, Scopus, EMBASE, Cochrane Library, and Google Scholar), for studies discussing venous congestion and venous super-drainage in DIEP flap for breast reconstruction. Thirteen of the 35 articles compared results between one or two venous anastomoses. Meta-analysis was performed following PRISMA guidelines. Pooled risk ratio (RRs) for congestion, fat necrosis, partial necrosis, and total necrosis with corresponding 95% confidence intervals (CI) were calculated using a fixed-effect model with the Mantel-Haenszel method. The need to return to surgery (95% CI) was estimated with a random effect model using the DerSimonian and Liard method. RESULTS: We showed a statistically significant advantage of super-drainage to reduce the venous congestion of the flap (RR: 0.12, 95% CI: 0.04-0.34, p-value <.001), partial flap necrosis (RR: 0.50, 95% CI: 0.30-0.84, p-value .008), total flap necrosis (RR: 0.31, 95% CI: 0.11-0.85, p-value .023), and the need to take the patient back to surgery for perfusion-related complications (RR: 0.45, 95% CI: 0.21-0.99, p value .048). CONCLUSIONS: Performing a second venous anastomosis between the SIEV and a recipient vein (venous superdrainage) reduces venous congestion and related complications in DIEP flaps for breast reconstruction.

NO-mediated activation of KATP channels contributes to cutaneous thermal hyperemia in young adults.

Local skin heating to 42°C causes cutaneous thermal hyperemia largely via nitric oxide (NO) synthase (NOS)-related mechanisms. We assessed the hypothesis that ATP-sensitive K+ (KATP) channels interact with NOS to mediate cutaneous thermal hyperemia. In 13 young adults (6 women, 7 men), cutaneous vascular conductance (CVC) was measured at four intradermal microdialysis sites that were continuously perfused with 1) lactated Ringer solution (control), 2) 5 mM glibenclamide (KATP channel blocker), 3) 20 mM NG-nitro-l-arginine methyl ester (NOS inhibitor), or 4) a combination of KATP channel blocker and NOS inhibitor. Local skin heating to 42°C was administered at all four treatment sites to elicit cutaneous thermal hyperemia. Thirty minutes after the local heating, 1.25 mM pinacidil (KATP channel opener) and subsequently 25 mM sodium nitroprusside (NO donor) were administered to three of the four sites (each 25-30 min). The local heating-induced prolonged elevation in CVC was attenuated by glibenclamide (19%), but the transient initial peak was not. However, glibenclamide had no effect on the prolonged elevation in CVC in the presence of NOS inhibition. Pinacidil caused an elevation in CVC, but this response was abolished at the glibenclamide-treated skin site, demonstrating its effectiveness as a KATP channel blocker. The pinacidil-induced increase in CVC was unaffected by NOS inhibition, whereas the increase in CVC elicited by sodium nitroprusside was partly (15%) inhibited by glibenclamide. In summary, we showed an interactive effect of KATP channels and NOS for the plateau of cutaneous thermal hyperemia. This interplay may reflect a vascular smooth muscle cell KATP channel activation by NO.

Focal hyperemia in Wernicke's encephalopathy: a preliminary arterial spin labeling MRI study.

Although a perturbed cerebral blood flow (CBF) has been reported in patients with Wernicke's encephalopathy (WE), its clinical meaning is still elusive. A retrospective analysis of 10 patients (male, 6; mean age, 57.7 years) with WE between October 2012 and May 2018 was performed. Brain imaging was performed using fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), arterial spin labeling (ASL) perfusion-weighted imaging (PWI), and contrasted enhanced T1-weighted imaging. All patients had symmetric high signal intensity lesions in the vulnerable areas on FLAIR or DWI with focal hyperintensity on ASL-PWI (100% sensitivity). CBFlesion was variable (from 70 mL/100 g/min to 190.0 mL/100 g/min). CBFlesion/CBFwhite matter was elevated, ranging from 2.5 to 5.5. Focal hyperintensity on ASL in the vulnerable areas can be a diagnostic clue for WE.

Localized Bronchial Hyperemia in Cases of Iatrogenic Hemoptysis: Clinical Presentations and Pathophysiological Mechanisms.

Hemoptysis is a frequently encountered symptom in many clinical settings, and etiologic diagnosis can sometimes prove challenging. Bronchoscopy may not promptly reveal the source or the cause of bleeding and few reports have focused so far on the abnormalities of bronchial mucosa vasculature that may unveil the underlying pathophysiology. In this special feature article, we present a series of cases presenting with hemoptysis after angiographic interventions in the thoracic vessels. Localized hyperemia and vascular dilatations in the bronchial mucosa observed during bronchoscopy as unique findings became clues enabling the correct diagnosis and management. We suggest the relevant pathophysiological mechanisms and discuss the available published experience on similar clinical entities.