Acute aortic dissection in a patient with Marfan syndrome during advanced pregnancy.

Pregnant patients with Marfan syndrome (MFS) are at high risk of developing aortic dissection or rupture during the third trimester and early postpartum period. This increased likelihood is the consequence of the hyperdynamic and hypervolemic cardiocirculatory state and/or pregnancy-mediated structural changes of the arterial wall in response to hemodynamic and hormonal changes. In this article, we report on the case of a 26-year-old pregnant woman with MFS in the 30th gestation week, who presented with type A aortic dissection at the emergency department. According to the multidisciplinary team decision, an urgent cesarean section was performed, followed by the Bentall procedure. The patient was discharged on the 10th postoperative day, and her premature child was discharged 6 weeks after birth.

Amperometric ascorbic acid sensor based on doped ferrites nanoparticles modified glassy carbon paste electrode.

In this study, a novel electrochemical sensor for quantification of ascorbic acid with amperometric detection in physiological conditions was constructed. For this purpose, cobalt and nickel ferrites were synthesized using microwave and ultrasound assistance, characterized by scanning electron microscopy (SEM), Fourier transform infrared (FTIR) spectroscopy, and X-ray powder diffraction (XRPD), and used for modification of glassy carbon paste electrode (GCPE). It was shown that introducing these nanoparticles to the structure of GCPE led to increasing analytical performance. Co ferrite modified GCPE (CoFeGCPE) showed better characteristics toward ascorbic acid sensing. The limit of detection (LOD) obtained by sensor was calculated to be 0.0270 mg/L, with linear range from 0.1758 to 2.6010 mg/L. This sensor was successfully applied for practical analysis, and the obtained results demonstrated that the proposed procedure could be a promising replacement for the conventional electrode materials and time-consuming and expensive separation methods.

Reborn of Internal-External Carotid Artery Transposition as a Repair Method for Shotgun Injury of Neck Zone 2.

A 26-year-old male presented to the emergency center having been shot in the neck. Multislice computed tomography angiography revealed injury of the right internal carotid artery at level of the carotid bifurcation with hematoma and injury of right internal jugular vein. Under general anesthesia, transposition of internal carotid artery to external carotid artery, with ligation of internal jugular vein, was successfully performed. This case emphasizes the value of "old fashion" surgical treatment in modern endovascular age.

Same evidence different recommendations: a methodological assessment of transatlantic guidelines for the management of valvular heart disease.

OBJECTIVES: The aim of this study was to identify methodological variations leading to varied recommendations between the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) valvular heart disease guidelines and to suggest foundational steps towards standardizing guideline development. METHODS: An in-depth analysis was conducted to evaluate the methodologies used in developing the transatlantic guidelines for managing valvular heart disease. The evaluation was benchmarked against the standards proposed by the Institute of Medicine. RESULTS: Substantial discrepancies were noted in the methodologies utilized in development processes, including Writing Committee composition, evidence evaluation, conflict of interest management and voting processes. Furthermore, despite their mutual differences, both methodologies demonstrate notable deviations from the Institute of Medicine standards in several essential areas, including literature review and evidence grading. These dual variances likely influenced divergent treatment recommendations. For example, the ESC/EACTS recommends transcatheter edge-to-edge repair for patients with chronic severe mitral regurgitation ineligible for mitral valve surgery, while the ACC/AHA recommends transcatheter edge-to-edge repair based on anatomy, regardless of surgical risk. ESC/EACTS guidelines recommend a mechanical aortic prosthesis for patients under 60, while ACC/AHA guidelines recommend it for patients under 50. Notably, the ACC/AHA and ESC/EACTS guidelines have differing age cut-offs for surgical over transcatheter aortic valve replacement (<65 and <75 years, respectively). CONCLUSIONS: Variations in methodologies for developing clinical practice guidelines have resulted in different treatment recommendations that may significantly impact global practice patterns. Standardization of essential processes is vital to increase the uniformity and credibility of clinical practice guidelines, ultimately improving healthcare quality, reducing variability and enhancing trust in modern medicine.

Mastering the Best Practices: A Comprehensive Look at the European Guidelines for Cardiopulmonary Bypass in Adult Cardiac Surgery.

The successful outcome of a cardiac surgery procedure is significantly dependent on the management of cardiopulmonary bypass (CPB). Even if a cardiac operation is technically well-conducted, a patient may suffer CPB-related complications that could result in severe comorbidities, reduced quality of life, or even death. However, the role of clinical perfusionists in perioperative patient care, which is critical, is often overlooked. Therefore, the European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Board of Cardiovascular Perfusion (EBCP) have agreed to develop joint clinical practice guidelines (CPGs) for CPB due to its significant impact on patient care and significant variations in practice patterns between countries. The European guidelines, based on the EACTS standardized framework for the development of CPGs, cover the entire spectrum of CPB management in adult cardiac surgery. This includes training and education of clinical perfusionists, machine hardware, disposables, preparation for initiation of CPB, a complete set of procedures during CPB to help maintain end-organ function and anticoagulation, weaning from CPB, and the gaps in evidence and future research directions. This comprehensive coverage ensures that all aspects of CPB management are addressed, providing clinicians with a standardized approach to CPB management based on the latest evidence and best practices. To ensure better integration of these evidence-based recommendations into daily practice, this review aims to provide a general understanding of guideline development and an overview of essential treatment recommendations for CPB management.

Modeling critical interaction for metastasis between circulating tumor cells (CTCs) and platelets adhered to the capillary wall.

BACKGROUND AND OBJECTIVE: We used a 2D fluid-solid interaction (FSI) model to investigate the critical conditions for the arrest of the CTCs traveling through the narrowed capillary with a platelet attached to the capillary wall. This computational model allows us to determine the deformations and the progression of the passage of the CTC through different types of microvessels with platelet included. METHODS: The modeling process is obtained using the strong coupling approach following the remeshing procedure. Also, the 1D FE rope element for simulating active ligand-receptor bonds is implemented in our computational tool (described below). RESULTS: A relationship between the CTCs properties (size and stiffness), the platelet size and stiffness, and the ligand-receptor interaction intensity, on one side, and the time in contact between the CTCs and platelet and conditions for the cell arrest, on the other side, are determined. The model is further validated in vitro by using a microfluidic device with metastatic breast tumor cells. CONCLUSIONS: The computational framework that is presented, with accompanying results, can be used as a powerful tool to study biomechanical conditions for CTCs arrest in interaction with platelets, giving a prognosis of disease progression.

Turbulent finite element model applied for blood flow calculation in arterial bifurcation.

BACKGROUND AND OBJECTIVE: Due to the relatively low fluid velocities in major arteries and veins, blood flow is by default laminar, however, turbulence can occur as a result of stenosis or other obstacles. Hemodynamic parameters like Wall Shear Stress or Oscillatory Shear Index can be used for plaque formation prediction, and these parameters are depended on the nature of the flow. Implementation of the k-ω turbulent flow in the Finite Element solver aims to improve numerical analysis of cardio-vascular condition development and progression. Calculation of turbulent fluid flow in this paper is performed using a two-equation turbulent finite element model that can calculate values in the viscous sublayer. METHODS: Implicit integration of the equations is used for determining the fluid velocity, turbulent kinetic energy and dissipation of turbulent kinetic energy. These values are calculated in the finite element nodes for each step of the incremental-iterative procedure. Developed turbulent finite element model with the customized generation of finite element meshes is used for calculating complex blood flow problems. RESULTS: Turbulent model is verified on an example of fluid flow in the backward-facing step channel and analysis results correspond well with the experimental ones from the literature. Further, a turbulent model is applied for the simulation of blood flow through artery bifurcation. Verification of numerical examples obtained using different commercial software packages (Ansys, COMSOL Multiphysics) ensuring usage and accuracy of PAK in-house solver. CONCLUSIONS: Analysis results show that turbulence cannot be neglected in the modelling of cardio-vascular conditions and that cardiologists can use the proposed tools and methods for investigating the hemodynamic conditions inside the bifurcation of arteries. Appropriate agreement between experimental results, and results obtained using commercial solutions and the k-ω turbulent flow in the Finite Element solver PAK, validate methodology presented in this paper. However, small deviations between the results underline the importance of the proper boundary condition prescription and mesh size and node distribution, which is also discussed in this paper. Due to the implicit integration implemented in PAK solver, time step size has an insignificant influence on the analysis results, assuming the initial time increments are sufficiently small to ensure proper discretization of velocity and pressure pulsatile functions.

Symptomatic primary cardiac haemangioendothelioma during late pregnancy.

Primary cardiac haemangioendothelioma is an uncommon vascular neoplasm with an infiltrative growth pattern and malignant potential. The treatment of this tumour alone is challenging, but the symptomatic presentation during late pregnancy creates a complex clinical situation for both the mother and physician. To the best of our knowledge, <40 cases of primary cardiac haemangioendothelioma have been reported worldwide, but none of these were associated with pregnancy. We report a case of symptomatic primary haemangioendothelioma in the right atrium of a pregnant woman in the 36th week of gestation. A primary caesarean section, followed by complete resection of the cardiac tumour, was carried out without any complications. The mother and child were discharged home 5 days after the surgical procedure and birth, respectively. At the 2-month follow-up, positron emission tomography showed signs of hypermetabolic activity in the right atrium, without signs of tumour recurrence on the subsequent computed tomography and magnetic resonance imaging, thus a close clinical follow-up was recommended.

A statistical primer on subgroup analyses.

Resources for clinical research are limited. With increasing demand for patient-centred care, which is growing into an integral component of modern medicine, studying outcomes of patients with specific clinical characteristics is becoming increasingly important. Given the high cost of clinical trials and the time it takes to complete an investigation, it has become compulsory for investigators to assess not only treatment effects between the main randomized groups but also to try to identify clinically relevant subgroups that may particularly benefit from specific treatments. Publications of subgroup analyses turned out to be prevalent, and more importantly, these findings play a significant role in strategic planning and decision-making processes. Therefore, raising awareness among clinicians about the concepts and values of subgroup analysis is an aspect of improving patient outcomes. In this statistical primer, we give a broad introduction to the topic of subgroup analysis in scientific research. We furthermore discuss the concept of subgroup analysis; the motivation for assessing subgroups; the types of subgroup analyses and the paradigm of hypothesis-generating research; the proper statistical methods for the examination of subgroup effects; and the optimal approach for interpretation of results. Finally, this review establishes the comprehensive users' guide for analysing and reporting subgroup studies on a point-by-point basis, using real-world examples that may help readers to gain experience to pursue their own subgroup analyses or interpret those of others.

Mapping decision making for bypass surgery in the era of interventional medicine: towards an integrative model of patient-centeredness.

This article reviews the context and evidence of recent myocardial revascularization trials on PCI versus CABG with particular emphasis on patient selection and treatment of surgical patients. Moreover, one of our intended purposes is to identify the values underpinning the integrated care model, which incorporates decision to proceed with surgical myocardial revascularization in conjunction with established pillars of the use of optimal surgical techniques, and aggressive risk-factor modification through guideline-directed pharmacological therapies and lifestyle modifications.

Minimalistic Approach for Transcatheter Aortic Valve Implantation (TAVI): Open Vascular Vs. Fully Percutaneous Approach.

BACKGROUND: Aortic stenosis (AS) is the most common valvular heart disease in elderly people. Transcatheter aortic valve implantation (TAVI) has emerged as a revolutionary treatment for elderly patients with symptomatic severe aortic stenosis. The authors present the first experiences with transcatheter aortic valve implantation treatment in Macedonia and compare their findings in regard to differences between open vascular vs. minimalistic transfemoral TAVI approach. METHODS: The procedure was performed in 54 patients with severe and symptomatic AS in the period from December 2014 until February 2018. All patients were deemed having high surgical risk or were denied surgery. Pre-procedural screening included detailed clinical and echocardiographic evaluation, coronary, peripheral and carotid angiography and computed tomography scan of the aortic root. A self-expandable aortic valve (Core Valve/Evolut R, Medtronic, USA) was implanted in all patients. RESULTS: Mean patient age was 75 ± 7.2 years, 28 (52%) were female, 26 patients (48%) male. All interventions were successfully performed through right transfemoral approach with 100% implantation success. Ancillary right radial and ulnar approach was used for correct valve positioning and control. 22(40%) cases were performed under general anesthesia and open vascular access to the femoral artery. All other 32(60%) cases were performed with minimalistic approach (local anaesthesia and analgosedation of the patients, access site was closed with closure devices). Patients in the minimalistic approach group were older, with more chronic conditions as anaemia, chronic kidney disease, poor mobility and peripheral vascular disease (p<0.0001). Also 4(12.5%) patients in the minimalistic group had bicuspid valve TAVI implantation (p<0.0001). Procedural time and contrast amount spent were shorter in this group with 97± 38 vs. 121± 38.3(p<0.0001) and 287± 122 vs. 330± 115 ml, while fluoroscopy time was similar in both groups. Immediate hemodynamic improvement was obtained in all patients. Echocardiographic peak gradient decreased from 85 ± 25 to 17 ± 8 mmHg (p < 0.001) and mean pressure gradient from 49 ± 26 to 8.3 ± 4.2 mmHg, (p < 0.001). Effective valve orifice area was 1.8±0.4 cm2 after intervention. None of the patients had significant aortic regurgitation after implantation. After intervention 7(12%) patients developed a permanent heart block and required implantation of a permanent pacemaker. There was a larger Hgb drop after intervention with open vs. minimalistic approach 1,9±0.9 vs. 0.7±0,2 g/dL (p<0.0001). 3 (13% vs.0%) patients from the open vascular access group had a major bleeding complication with 2 requiring transfusion after intervention (p<0.0001). Mortality was 5.5%, 2 with open-vascular and 1 with minimalistic approach. MACCE rate that included MI, Stroke, Major bleeding and Death rate, was recorded in 5(18%) patients with open vascular approach vs. 1(3.1%) in minimalistic approach (p<0.0001). Hospital discharge was 8.7±3.1 vs. 4±3.1 days respectively (p<0.0001). All TAVI patients with minimalistic approach were discharged the following day after intervention. All discharged patients had a good neurological condition, which was assessed based on the CPC-1 (Cerebra Performance Categories Scale). After median follow up of 26 months, the survival rate was 95% with clinical improvement in all patients. CONCLUSION: Percutaneous aortic valve implantation can be successfully conducted with high success rate and low rate of complications in patients with severe aortic stenosis. Using a less invasive approach with local anaesthesia and analgosedation is associated with shorter length of stay and a decrease in post-procedural complication rates and MACCE.

Surgical site infection incidence and risk factors in thoracic surgical procedures: A 12-year prospective cohort study.

INTRODUCTION: Surgical site infections (SSI) continue to be a major problem for thoracic surgery patients. We aimed to determine incidence rate (IR) and risk factors for SSI in patients with thoracic surgical procedures. METHODOLOGY: During 12 years of hospital surveillance of patients with thoracic surgical procedures, we prospectively identified SSI. Patients with SSI were compared with patients without SSI. RESULTS: We operated 3,370 patients and 205 (6.1%) developed SSI postoperatively. We detected 190 SSI among open thoracic surgical procedures (IR 7.1%) and 15 SSI after video-assisted thoracic surgery (IR 2.1%). Five independent risk factors for SSI were identified: wound contamination (p = 0.013; relative risk (RR) 2.496; 95%, confidence interval (CI): 1.208-5.156), American Society of Anesthesiologist (ASA) score (p = 0.012; RR: 1.795; 95% CI: 1.136-2.834), duration of drainage (p < 0.001; RR: 1.117; 95% CI: 1.085-1.150), age (p = 0.036; RR: 1.018; 95% CI: 1.001-1.035) and duration of operation (p < 0.001; RR:1.005; 95% CI:1.002-1.008). CONCLUSION: The results are valuable in documenting risk factors for SSI in patients undergoing thoracic surgery. The knowledge and prevention of controllable risk factors is necessary in order to reduce the incidence of SSI.

Bulk and interface quantum states of electrons in multi-layer heterostructures with topological materials.

In this article we describe the bulk and interface quantum states of electrons in multi-layer heterostructures in one dimension, consisting of topological insulators (TIs) and topologically trivial materials. We use and extend an effective four-band continuum Hamiltonian by introducing position dependence to the eight material parameters of the Hamiltonian. We are able to demonstrate complete conduction-valence band mixing in the interface states. We find evidence for topological features of bulk states of multi-layer TI heterostructures, as well as demonstrating both complete and incomplete conduction-valence band inversion at different bulk state energies. We show that the linear k z terms in the low-energy Hamiltonian, arising from overlap of p z orbitals between different atomic layers in the case of chalcogenides, control the amount of tunneling from TIs to trivial insulators. Finally, we show that the same linear k z terms in the low-energy Hamiltonian affect the material's ability to form the localised interface state, and we demonstrate that due to this effect the spin and probability density localisation in a thin film of Sb2Te3 is incomplete. We show that changing the parameter that controls the magnitude of the overlap of p z orbitals affects the transport characteristics of the topologically conducting states, with incomplete topological state localisation resulting in increased backscattering.

Intraperitoneal administration of mesenchymal stem cells ameliorates acute dextran sulfate sodium-induced colitis by suppressing dendritic cells.

Dendritic cells (DCs) have important pathogenic role in the induction and progression of ulcerative colitis (UC), but their role in mesenchymal stem cells (MSCs)-mediated suppression of colon injury and inflammation is not revealed. By using dextran sodium sulfate (DSS)-induced colitis, a well-established murine model of UC, we examined effects of MSCs on phenotype and function of colon infiltrating DCs. Clinical, histological, immunophenotypic analysis and passive transfer of MSCs-primed DCs were used to evaluate capacity of MSC to suppress inflammatory phenotype of DCs in vivo. Additionally, DCs:MSCs interplay was also investigated in vitro, to confirmed in vivo obtained findings. Intraperitoneally administered MSCs (2 × 106) significantly reduced progression of DSS-induced colitis and reduced serum levels of inflammatory cytokines (IL-1ß, IL-12, and IL-6). Passive transfer of in vivo MSCs-primed DCs reduced severity of colitis while passive transfer of MSCs-non-primed DCs aggravated DSS-induced colitis. Through the secretion of immunomodulatory Galectin 3, MSCs, in paracrine manner, down-regulated production of inflammatory cytokines in DCs and attenuated expression of co-stimulatory and major histocompatibility complex class II molecules on their membranes. Taken together, these results indicate that MSCs achieved their beneficial effects in DSS-induced colitis by suppressing inflammatory phenotype of DCs in Gal-3 dependent manner. Therapeutic targeting of DCs by MSCs should be explored in future studies as a useful approach for the treatment of UC.

Enhanced Recovery after Vascular Surgery.

The beginnings of the enhanced recovery after surgery (ERAS) program were first developed for patients in colorectal surgery, and after it was established as the standard of care in this surgical field, it began to be applied in many others surgical areas. This is multimodal, evidence-based approach program and includes simultaneous optimization of preoperative status of patients, adequate selection of surgical procedure and postoperative management. The aim of this program is to reduce complications, the length of hospital stay and to improve the patients outcome. Over the past decades, special attention was directed to the postoperative management in vascular surgery, especially after major vascular surgery because of the great risk of multiorgan failure, such as: respiratory failure, myocardial infarction, hemodynamic instability, coagulopathy, renal failure, neurological disorders, and intra-abdominal complications. Although a lot of effort was put into it, there is no unique acceptable program for ERAS in this surgical field, and there is still a need to point out the factors responsible for postoperative outcomes of these patients. So far, it is known that special attention should be paid to already existing diseases, type and the duration of the surgical intervention, hemodynamic and fluid management, nutrition, pain management, and early mobilization of patients.