Pulmonary artery flotation catheter (PAFC) combined with pump-controlled retrograde trial off (PCRTO) as a trial for weaning VA-ECMO patients: A retrospective study.

OBJECTIVES: Pump-controlled retrograde trial off (PCRTO) has been recently proposed as an effective and safe VA-ECMO weaning method. However, reports of haemodynamic monitoring during PCRTO are rare. Therefore, the purpose of this study was to investigate the changes in the left and right heart function during the PCRTO process combined with a pulmonary artery flotation catheter (PAFC). METHODS: Between March 2019 and May 2021, 20 adult VA-ECMO patients who underwent PCRTO in combination with PAFC were enrolled in this study. The patients' general characteristics, PCRTO results, haemodynamic parameters during PCRTO progression, complications, and clinical prognoses were analysed. Those who survived for 48 h after withdrawal and did not require ECMO assistance were defined as the success group, and those who did not survive for 48 h after withdrawal or who required ECMO assistance were defined as the failure group. RESULTS: Of the 20 patients, 13 (65%) were included in the success group, and 7 (35%) were included in the failure group. Compared with the success group, the heart rate (HR) of the failure group was significantly increased 30 min after PCRTO (p < .01), and the pulmonary artery wedge pressure (PAWP) was significantly higher at all time points (p < .01). Compared with pre-PCRTO in the success group, the HR at 2 min in the success group was significantly increased, but decreased to the baseline levels at 15 min and 30 min. The PAWP was also significantly increased at 2 min, but decreased at 15 min and dropped to the baseline level at 30 min in the success group. Compared with pre-PCRTO in the failure group, the HR and PAWP increased significantly at 2 min, 15 min and 30 min in the failure group. No new embolism-related complications were found in the success group after the withdrawal from ECMO. CONCLUSIONS: PCRTO is a safe and reliable VA-ECMO weaning method. Combined with haemodynamic monitoring through PAFC, PCRTO can better assess the cardiac reserve function.

Temperature Variability Does Not Attenuate the Beneficial Effects of Therapeutic Hypothermia on Cellular Apoptosis and Endoplasmic Reticulum Stress in the Cerebral Cortex of a Swine Cardiac Arrest Model.

BACKGROUND: Endoplasmic reticulum stress (ERS) plays a vital role in mediating apoptosis in the brain following cardiac arrest (CA). Studies have shown that therapeutic hypothermia (TH) provides neuroprotection through anti-apoptosis; however, the effects of temperature variability in TH on the brain remain unclear. In this study, we investigated the different effects of temperature variability through extracorporeal membrane oxygenation on apoptosis and ERS in the brain following CA. METHODS: Eighteen male domestic pigs underwent 6-min duration of no-flow induced by ventricular fibrillation. Extracorporeal cardiopulmonary resuscitation was then performed, and the return of spontaneous circulation (ROSC) was achieved. The animals were randomly assigned to the following groups: normothermia, non-temperature variability, and temperature variability. TH (core temperature, 33-35 °C) was maintained for 24 h post-ROSC, and the animals were rewarmed for 8 h. Quantitative real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry for Bax and Bcl-2 transcripts and proteins, respectively, were used to investigate apoptosis in the cerebral cortex. Expression levels of the ERS molecules, GRP78 and CHOP, were also detected by qRT-PCR, and cellular morphology was evaluated using transmission electron microscopy. RESULTS: qRT-PCR and immunohistochemistry results revealed that TH significantly increased the expression levels of Bcl-2 and GRP78 and decreased that of Bax and CHOP than under normothermia conditions. Compared to the non-temperature variability group, temperature variability did not decrease the expression levels of Bcl-2 and GRP78 and not increase the levels of Bax and CHOP. Endoplasmic reticulum ultrastructural changes were significantly improved under TH. No statistical difference was observed between the temperature variability and non-temperature variability groups. CONCLUSION: TH can reduce neuronal apoptosis by ERS, while temperature variability does not attenuate this beneficial effect.

Nutritional practice in critically ill COVID-19 patients: A multicenter ambidirectional cohort study in Wuhan and Jingzhou.

BACKGROUND AND OBJECTIVES: The novel coronavirus disease (COVID-19) epidemic is spreading all over the world. With the number of cases increasing rapidly, the epidemiological data on the nutritional practice is scarce. In this study, we aim to describe the clinical characteristics and nutritional practice in a cohort of critically ill COVID-19 patients. METHODS AND STUDY DESIGN: This is a multicenter, ambidirectional cohort study conducted at 11 hospitals in Hubei Province, China. All eligible critical COVID-19 patients in the study hospital intensive care units at 00:00, March 6th, 2020, were included. Data collection was performed via written case report forms. RESULTS: A total of 44 patients were identified and enrolled, of whom eight died during the 28-day outcome follow- up period. The median interval between hospital admission and the study day was 24 (interquartile range, 13- 26) days and 52.2% (23 of 44) of patients were on invasive mechanical ventilation. The median nutrition risk in critically ill (mNUTRIC) score was 3 (interquartile range, 2-5) on the study day. During the enrolment day, 68.2% (30 of 44) of patients received enteral nutrition (EN), while 6.8% (3 of 44) received parenteral nutrition (PN) alone. Nausea and aspiration were uncommon, with a prevalence of 11.4% (5 of 44) and 6.8% (3 of 44), respectively. As for energy delivery, 69.7% (23 of 33) of patients receiving EN and/or PN were achieving their prescribed targets. CONCLUSIONS: The study showed that EN was frequently applied in critical COVID-19 patients. Energy delivery may be suboptimal in this study requiring more attention.

Metagenomic next-generation sequencing in the diagnosis of severe pneumonias caused by Chlamydia psittaci.

PURPOSE: Chlamydia psittaci infection in humans can lead to serious clinical manifestations, including severe pneumonia, adult respiratory distress syndrome, and, rarely, death. Implementation of metagenomic next-generation sequencing (mNGS) gives a promising new tool for diagnosis. The clinical spectrum of severe psittacosis pneumonia is described to provide physicians with a better understanding and to highlight the rarity and severity of severe psittacosis pneumonia. METHODS: Nine cases of severe psittacosis pneumonia were diagnosed using mNGS. Retrospective analysis of the data on disease progression, new diagnosis tool, treatments, and outcomes, and the findings were summarised. RESULTS: Frequent symptoms included chills and remittent fever (100%), cough and hypodynamia (100%), and headache and myalgia (77.8%). All patients were severe psittacosis pneumonia developed respiratory failure, accompanied by sepsis in 6/9 patients. mNGS takes 48-72 h to provide the results, and help to identify diagnosis of psittacosis. Laboratory data showed normal or slightly increased leucocytes, neutrophils, and procalcitonin but high C-reactive protein levels. Computed tomography revealed air-space consolidation and ground-glass opacity, which began in the upper lobe of one lung, and spread to both lungs, along with miliary, nodular, or consolidated shadows. One patient died because of secondary infection with Klebsiella pneumoniae, while the other eight patients experienced complete recoveries. CONCLUSIONS: The use of mNGS can improve accuracy and reduce the delay in diagnosis of psittacosis. Severe psittacosis pneumonia responds well to the timely use of appropriate antibiotics.

JQ1, a BET-bromodomain inhibitor, inhibits human cancer growth and suppresses PD-L1 expression.

Most traditional cytotoxic chemotherapeutic agents have poor aqueous solubility and significant toxicity. Hence, there is a need to develop molecule-targeted drugs. Programmed death-ligand 1 (PD-L1) is associated with the prognosis of several cancer types, and blockade of PD-1/PD-L1 signaling increases the amplitude of anti-tumor immunity. In the present study, we investigated the effects of JQ1, a bromodomain and extraterminal-bromodomain inhibitor, on cell growth, and messenger RNA (mRNA) and protein levels of PD-L1 in renal cell carcinoma primary culture cells, and prostate, liver, and lung cancer cell lines. The results of the cell counting kit-8 assay suggested that JQ1 inhibits cell growth in a dose-dependent manner. The mRNA and protein levels of PD-L1 decreased in the primary culture of JQ1-treated renal carcinoma, prostate cancer, liver cancer, and lung cancer cell lines. In addition, the mRNA level of PD-L2 also decreased in the JQ1-treated cells. Overall, JQ1 might be a potential anti-tumor agent.

Clinical features of fatal severe fever with thrombocytopenia syndrome that is complicated by invasive pulmonary aspergillosis.

INTRODUCTION: Severe fever with thrombocytopenia syndrome (SFTS) has been prevalent in parts of Asia during recent years. However, SFTS with invasive pulmonary aspergillosis (IPA) is rare, and it is important to understand its clinical features. MATERIALS AND METHODS: Total four cases of SFTS with IPA are reviewed and detailing the disease progression, treatment options, and prognosis were summarized and analyzed. RESULTS: The patients with SFTS-associated IPA first presented with fever, gastrointestinal symptoms, thrombocytopenia, leukopenia, and multiple organ failure. After 1-2 weeks, the patients developed mild polypnea and wheezing rales, and quickly developed dyspnea and respiratory failure. Tracheal intubation was usually performed, but did not relieve the intractable airway spasm and pulmonary ventilation failure. Bronchoscopy confirmed that the antifungal treatment was ineffective and the aspergillosis had worsened. All patients died of type 2 respiratory failure caused by continued airway obstruction and spasticity. CONCLUSIONS: Given the high mortality rate in this series, there is a need for increased awareness of SFTS-associated IPA. Additional examinations should be performed in these cases, and early-stage antifungal treatment with organ support may be helpful.

Substance P Attenuates Hypoxia/Reoxygenation-Induced Apoptosis via the Akt Signalling Pathway and the NK1-Receptor in H9C2Cells.

BACKGROUND: Myocardial ischaemia/reperfusion (I/R) injury is a major cause of morbidity and mortality associated with coronary heart disease. During I/R injury, cardiomyocytes undergo cell death including apoptosis and necrosis with increased frequency, and this leads to compensatory cardiac hypertrophy, dysfunction, ventricular remodelling, and ultimately, heart failure. Accumulating evidence indicates that substance P is cardio-protective following I/R primarily due to its potent coronary vasodilator actions. However, its direct effect on cardiomyocytes in vitro remains controversial. METHODS: An hypoxia/reoxygenation (H/R)-induced cell death model was established to mimic I/R injury, in which the effect of substance P (SP) pretreatment on H9C2 cardiomyocytes and the mechanism of action were explored. RESULTS: Substance P was demonstrated to inhibit H/R-induced apoptosis. Phosphorylated-Akt (p-Akt) was decreased in H/R groups and was increased by SP pretreatment. Inhibition of p-Akt reduced the beneficial effects of SP in reducing apoptosis, whereas activation of Akt failed to provide additional improvement in the presence of SP. This suggests a key role for Akt in the process of reduced apoptosis by SP following H/R injury. In addition, the NK1-receptor antagonist prohibited the anti-apoptotic effect of SP. CONCLUSIONS: This study indicates that SP pretreatment attenuates H/R-induced apoptosis via the Akt signalling pathway and the NK1-receptor.

Analysis of rainfall infiltration law in unsaturated soil slope.

In the study of unsaturated soil slope stability under rainfall infiltration, it is worth continuing to explore how much rainfall infiltrates into the slope in a rain process, and the amount of rainfall infiltrating into slope is the important factor influencing the stability. Therefore, rainfall infiltration capacity is an important issue of unsaturated seepage analysis for slope. On the basis of previous studies, rainfall infiltration law of unsaturated soil slope is analyzed. Considering the characteristics of slope and rainfall, the key factors affecting rainfall infiltration of slope, including hydraulic properties, water storage capacity (θs - θr), soil types, rainfall intensities, and antecedent and subsequent infiltration rates on unsaturated soil slope, are discussed by using theory analysis and numerical simulation technology. Based on critical factors changing, this paper presents three calculation models of rainfall infiltrability for unsaturated slope, including (1) infiltration model considering rainfall intensity; (2) effective rainfall model considering antecedent rainfall; (3) infiltration model considering comprehensive factors. Based on the technology of system response, the relationship of rainfall and infiltration is described, and the prototype of regression model of rainfall infiltration is given, in order to determine the amount of rain penetration during a rain process.

Shear wave elastographic characterization of normal and torn achilles tendons: a pilot study.

OBJECTIVES: The purpose of this study was to investigate the feasibility of using quantitative shear wave elastography for assessing the functional integrity of the Achilles tendon and to summarize the changes in elasticity of ruptured Achilles tendons in comparison with normal controls. METHODS: Thirty-six normal and 14 ruptured Achilles tendons were examined with shear wave elastography coupled with a linear array transducer (4-15 MHz). The elasticity value of each Achilles tendon in a longitudinal view was measured. RESULTS: The mean elasticity value ± SD for the normal Achilles tendons was 291.91 ± 4.38 kPa (note that there are saturated measurement phenomena for the normal Achilles tendon, so the actual value will be >300 kPa), whereas the ruptured Achilles tendons had an elasticity value of 56.48 ± 68.59 kPa. A statistically significant difference was found in relation to the findings in healthy volunteers (P = .006). CONCLUSIONS: Our results suggest that shear wave elastography is a valuable tool that can provide complementary biomechanical information for evaluating the function of the Achilles tendon.

Increased matrix metalloproteinase-9 activity and mRNA expression in lung injury following cardiopulmonary bypass.

To determine whether the presence of Matrix metalloproteinases (MMPs) is associated with acute lung injury following cardiopulmonary bypass (CPB), we evaluated the activity and gene expression of matrix metalloproteinases-9 (MMP-9) and tissue inhibitor of metalloproteinase-1 (TIMP-1) of lungs using rat model of CPB. Adult male Sprague-Dawley rats were randomly divided into three groups: Group I (underwent cannulation + heparinization only); group II (underwent 60 min of normothermic CPB); and group III (underwent 60 min of normothermic of CPB, which rats received doxycycline treat by filling stomach 1 week ahead of CPB). Lung injury was evaluated histologically. The enzyme activity of MMP-9 and TIMP-1 in the bronchoalveolar lavage fluid was detected by western-blot analysis. The expression of MMP-9 and TIMP-1 in lung tissue was assessed using reverse transcriptase-polymerase chain reaction method. We found there was significantly pulmonary edema and lung injury in groups II and III compared with group I, and the histological markers of pulmonary edema in the Group III were less pronounced in comparison with Group II. The MMP-9 activity and gene expression were increased significantly, but the TIMP-1 increased slowly in group II, and the ratio of MMP-9/TIMP-1 was imbalanced severely. More significantly, the MMP-9 decreased significantly and the TIMP-1 mRNA increased gradually in group III compared with group II, and the ratio of MMP-9/TIMP-1 was improved significantly. We concluded MMP-9 might have an important role in acute lung injury following CPB. TIMP-1 increased in the rats treated with doxycycline ahead and might compensate for the activity of MMP-9. The doxycycline might have the protective effect against acute lung injury following CPB.

[Clinical study on the predictive value of regional cerebral oxygen saturation for the occurrence of sepsis-associated encephalopathy].

OBJECTIVE: To evaluate the predictive value of regional cerebral oxygen saturation (rScO2) for the occurrence of sepsis-associated encephalopathy (SAE). METHODS: The data of 94 patients with sepsis admitted to the intensive care unit of Nanjing Drum Tower Hospital from September 2019 to June 2021 were collected. The patients were divided into SAE group and non-SAE group according to the evaluation results of daily intensive care unit confusion assessment method (CAM-ICU) during ICU treatment. The general data such as age and gender of the patients, rScO2 on 1, 2, 3, 5, and 7 days of ICU admission, and prognostics were recorded. Receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of rScO2 on SAE during ICU stay. RESULTS: All 94 patients were enrolled in the analysis, of whom 59.6% (56/94) were male, and the mean age was (50.1±15.1) years old; the incidence of SAE was 31.9% (30/94). The levels of rScO2 within first 3 days of ICU admission in the SAE group were significantly lower than those in the non-SAE group (1 day: 0.601±0.107 vs. 0.675±0.069, 2 days: 0.592±0.090 vs. 0.642±0.129, 3 days: 0.662±0.109 vs. 0.683±0.091, all P < 0.05). However, there was no significant difference in rScO2 level on the 5th or the 7th day between the SAE and non-SAE groups (5 days: 0.636±0.065 vs. 0.662±0.080, 7 days: 0.662±0.088 vs. 0.690±0.077, both P > 0.05). ROC curve analysis showed that 1-day rScO2 had the greatest predictive value for SAE [1 day: area under the ROC curve (AUC) = 0.77, 95% confidence interval (95%CI) was 0.65-0.89, P < 0.01; 2 days: AUC = 0.60, 95%CI was 0.48-0.72, P > 0.05; 3 days: AUC = 0.55, 95%CI was 0.41-0.68, P > 0.05]; with 1-day rScO2 = 0.640 as the diagnostic threshold, the sensitivity was 73.4%, the specificity was 80.0%. Compared with the non-SAE group, the length of ICU stay and hospital stay in the SAE group were significantly longer [length of ICU stay (days): 13.6±7.1 vs. 9.0±4.3, length of hospital stay (days): 20.1±8.0 vs. 15.8±6.1, both P < 0.05], but the ICU mortality between the two groups was not statistically different. CONCLUSIONS: The incidence of SAE is relatively high in ICU patients, and the occurrence of SAE can be predicted by monitoring rScO2. The rScO2 value on the first day of ICU admission is closely related to the occurrence of SAE, and may be the target of sepsis resuscitation to guide the treatment and improve the long-term prognosis.

[Application of extracorporeal membrane oxygenation in critically ill pregnant women].

OBJECTIVE: To investigate the safety and effectiveness of extracorporeal membrane oxygenation (ECMO) in emergency treatment of critically ill pregnant women. METHODS: Clinical data of 8 pregnant women with severe cardiopulmonary dysfunction during the perinatal period treated by ECMO in the department of intensive care unit (ICU) of Nanjing Drum Tower Hospital, the Affiliated Hospital to Nanjing University Medical School from September 2017 to November 2020 were retrospectively analyzed. RESULTS: For the 8 pregnant women, the mean age was (32.5±6.3) years old. Body weight was (73.5±8.1) kg. Gestational age was (31.0±4.4) weeks. Acute physiology and chronic health evaluation II (APACHE II) score was 13.0±6.6, and sequential organ failure assessment (SOFA) score was 8.3±3.8. Among them, 5 pregnant women suffered from severe pneumonia and were treated with venous-venous ECMO (VV-ECMO). Another 3 pregnant women with heart failure underwent venous-arterial ECMO (VA-ECMO). The initial ECMO flow rate was set to 2.0-3.0 L/min. Then the highest flow rate was (3.1±0.6) L/min, and the average ECMO running time was (174±36) hours. The length of ICU stay was (16.0±5.4) days. Six pregnant women (5 with severe pneumonia and 1 with peripartum cardiomyopathy) successfully evacuated from ECMO and survived. Two pregnant women with pulmonary hypertension showed poor prognosis. In total, seven babies survived. Two of them were delivered after ECMO evacution, and one underwent emergency cesarean section with ECMO support. In another case, the fetus could not be delivered due to under-gestational weeks. During this period, there were no serious bleeding complications. One pregnant woman developed heparin-induced thrombocytopenia and thrombosis (HITT), then she received another anticoagulant treatment. One pregnant woman got sequential anticoagulation therapy for 3 months on account of thrombosis in the puncture vessel. CONCLUSIONS: ECMO has played an active role in the rescue of critically ill pregnant women. For those with reversible severe cardiopulmonary dysfunction, it is necessary to evaluate the application of ECMO as early as possible to improve the survival rate of mothers and infants.

[Relationship between D-dimer concentration and inflammatory factors or organ function in patients with coronavirus disease 2019].

OBJECTIVE: To explore the relationship between D-dimer concentration and inflammatory factors or organ function in patients with coronavirus disease 2019 (COVID-19). METHODS: A retrospective study was conducted. The clinical data of 72 patients with COVID-19 admitted to intensive unit of Tongji Guanggu Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology in Wuhan, Hubei Province from February 10th to 29th in 2020 were collected, including their general information, routine blood test, coagulation function, inflammatory parameters, cytokines, and organ function related laboratory parameters at admission. The patients were divided into two groups, namely D-dimer normal group (< 0.5 mg/L) and D-dimer elevated group (≥ 0.5 mg/L). The differences of general data, inflammatory parameters and cytokines between the two groups were compared. Besides, the correlation between D-dimer and organ function was analyzed by linear regression. The change in sequential organ failure assessment (SOFA) between the first visit after the onset of the disease and admission to intensive unit ≥ 2 was defined as being combined with organ damage. Receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of D-dimer on organ damage in patients with COVID-19. RESULTS: 65.3% of the 72 patients had abnormal coagulation. The D-dimer level of COVID-19 patients gradually increased with the aggravation of the disease, and the levels of ordinary type (n = 14), severe type (n = 49), and critical type (n = 9) were 0.43 (0.22, 0.89), 0.66 (0.26, 1.36), and 2.65 (0.68, 15.45) mg/L, respectively, with statistically significant difference (P < 0.05). Thirty-two patients (44.4%) had normal D-dimer, and 40 (55.6%) had elevated D-dimer. Compared with the normal D-dimer group, the patients in the D-dimer elevated group were older (years old: 67.7±11.6 vs. 54.0±13.1), and the levels of white blood cell count (WBC), neutrophil count (NEU), procalcitonin (PCT), high-sensitivity C-reactive protein (hs-CRP), interleukins (IL-6, IL-8, IL-10), IL-2 receptor (IL-2R) and tumor necrosis factor-α (TNF-α) at admission were significantly higher [WBC (×109/L): 7.16 (5.55, 9.75) vs. 5.25 (4.59, 6.98), NEU (×109/L): 7.11±5.46 vs. 3.33±1.58, PCT (µg/L): 0.08 (0.06, 0.21) vs. 0.05 (0.04, 0.06), hs-CRP (mg/L): 27.9 (3.4, 58.8) vs. 1.3 (0.8, 6.6), IL-6 (ng/L): 11.80 (2.97, 30.61) vs. 1.98 (1.50, 4.73), IL-8 (ng/L): 19.90 (13.33, 42.28) vs. 9.40 (12.35, 15.30), IL-10 (ng/L): 5.00 (5.00, 8.38) vs. 5.00 (5.00, 5.00), IL-2R (kU/L): 907.90±458.42 vs. 572.13±274.55, TNF-α (ng/L): 10.94±5.95 vs. 7.77±3.67], while lymphocyte (LYM) and monocyte (MON) counts were lower [LYM (×109/L): 1.14±0.49 vs. 1.46±0.42, MON (×109/L): 0.63±0.25 vs. 0.87±0.21], with significant differences (all P < 0.05). Linear regression analysis showed that D-dimer level was negatively related with pulse oxygen saturation (SpO2), oxygenation index (PaO2/FiO2) and platelet count (PLT) with ß values of -0.493, -11.615, and -0.018, respectively (all P < 0.05). However, D-dimer level was positively related with respiratory rate (RR), aspartate aminotransferase (AST), total bilirubin (TBil) and direct bilirubin (DBil) with ß values of 0.485, 0.107, 0.291, and 0.404 (all P < 0.05). ROC curve analysis showed that the area under ROC curve (AUC) of D-dimer for predicting organ injury in COVID-19 patients was 0.889, and the 95% confidence interval (95%CI) was 0.753-1.000. When the optimal cut-off value was 2.36 mg/L, the sensitivity was 85.7%, and the specificity was 78.1%. CONCLUSIONS: D-dimer levels in COVID-19 patients are correlated with inflammatory factors and organ function, and it can be used to predict organ injury.

Corticosteroid treatment in severe COVID-19 pneumonia: two cases and literature review.

Coronavirus disease 2019 (COVID-19) pneumonia, firstly reported in Wuhan, Hubei province, China, has rapidly spread around the world with high mortality rate among critically ill patients. The use of corticosteroids in COVID-19 remains a major controversy. Available evidences are inconclusive. According to WHO guidance, corticosteroids are not recommended to be used unless for another reason. Chinese Thoracic Society (CTS) proposes an expert consensus statement that suggests taking a prudent attitude of corticosteroid usage. In our clinical practice, we do not use corticosteroids routinely; only low-to-moderate doses of corticosteroids were given to several severely ill patients prudently. In this paper, we will present two confirmed severe COVID-19 cases admitted to isolation wards in Optical Valley Campus of Tongji hospital, Tongji Medical College, Huazhong University of Science and Technology. We will discuss questions related to corticosteroids usages.

Detection and Pathologic Evaluation of Sentinel Lymph Nodes in the VX2 Tumor Model Using a Novel Ultrasound/Near-Infrared Dual-Modality Contrast Agent.

This study was conducted with the aim of developing a microbubble agent for near-infrared (NIR) fluorescence and ultrasound dual-modality contrast microbubbles applicable to imaging of sentinel lymph nodes in the VX2 rabbit tumor model. Specific ligands of phosphatidylserine (PS) and Cy7 NIR fluorescent dyes with long emission wavelengths (750-900 nm) were conjugated to the surface of ultrasound contrast microbubbles (MBs), termed Cy7 PS MBs. Ultrasound lymphography and NIR fluorescence imaging were performed using subcutaneous injection of Cy7 PS MBs to visualize the sentinel lymph node. Sentinel lymph node detection rates using the patent blue method, ultrasound lymphography and NIR fluorescence imaging were 95%, 79% and 95%, respectively, and sensitivity was 87%, 74% and 92%, respectively. With 2-D ultrasound, the diagnostic sensitivity for detection of sentinel lymph node metastases was 60% and the specificity was 74%, whereas Cy7 PS MB-enhanced ultrasound had a sensitivity of 80% and a specificity of 87%. The results indicate that dual-modality Cy7 PS MBs combined with ultrasound lymphography and NIR fluorescence may be useful in the detection of normal and metastasized sentinel lymph nodes.