The ratio of superior mesenteric artery diameter to superior mesenteric vein diameter based on non-enhanced computed tomography in the early diagnosis of spontaneous isolated superior mesenteric artery dissection.

BACKGROUND: Spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) is a rare cause of abdominal pain. The aim of the study is to investigate the role of a new parameter, the ratio of the SMA diameter to the superior mesenteric vein (SMV) diameter (SMA/SMV) based on non-enhanced computed tomography (CT), in the early diagnosis of SISMAD. METHODS: In a registry study from December 2013 to June 2021, 97 abdominal pain SISMAD patients (SISMAD group) admitted to our hospital were enrolled. Meanwhile, the matched sex and age abdominal pain non-SISMAD patients at 1:2 were collected in reverse chronological order as the control group. Student's t-test, Wilcoxon rank-sum test, and Chi-square test were used to compare differences between the SISMAD and control groups. MedCalc was used to generate receiver operating characteristic (ROC) curve. RESULTS: A total of 291 abdominal pain patients, including 97 SISMAD patients and 194 non-SISMAD patients, were included in the current study. The maximum SMA diameter, perivascular exudation, and SMA/SMV based on non-enhanced CT were significant between the two groups (all P<0.05). ROC curves showed that for the maximum SMA diameter, the area under the curve (AUC), cut-off, sensitivity, and specificity were 0.926, 9.80, 93.8%, and 79.4%, respectively. For SMA/SMV, its AUC, cut-off, sensitivity, and specificity were 0.956, 0.83, 88.7%, and 92.3%, respectively. The diagnostic efficiency of SMA/SMV was better than that of the maximum SMA diameter (P<0.05). The combined parameters of SMA/SMV and maximum SMA diameter had the best diagnostic efficiency (AUC=0.970). CONCLUSION: SMA/SMV may be a potential marker for SISMAD.

Clinical characteristics and misdiagnosis of spontaneous isolated superior mesenteric artery dissection.

BACKGROUND: Spontaneous isolated superior mesenteric artery (SMA) dissection (SISMAD) is a rare disease with a potentially fatal pathology. Due to the lack of specificity of clinical characteristics and laboratory tests, misdiagnosis and missed diagnosis are often reported. Therefore, the aim of this study was to investigate the clinical characteristics and misdiagnosis of SISMAD. METHODS: In a registry study from January 2013 to December 2020, 110 patients with SISMAD admitted to the First Affiliated Hospital of Wenzhou Medical University were enrolled. Descriptive methods were used to analyse clinical characteristics, laboratory data, diagnostic method or proof, misdiagnosed cases, plain computed tomography (CT) findings and dissection features. To study the relationship between dissection features and treatment modality, the selected patients were classified into the conservative group (n = 71) and the non-conservative group (n = 39). The Chi-square test and Student's t-test were used to compare the conservative and non-conservative groups. RESULTS: One hundred ten patients with SISMAD, including 100 (90.9%) males and 10 (9.1%) females, with a mean age of 52.4 ± 7.6 years, were enrolled in the study. Relevant associated comorbidities included a history of hypertension in 43 cases (39.1%), smoking in 46 cases (41.8%), and alcohol consumption in 34 cases (30.9%). One hundred four patients (94.5%) presented with abdominal pain. Abnormalities in the C-reactive protein lever, white blood cells count and D-dimer lever were the 3 most common abnormal findings. There were 32 misdiagnosis or missed diagnosis. Fourteen cases were misdiagnosed because of insufficient awareness. Twelve cases were misdiagnosed because of disease features. Twenty cases were misdiagnosed as SMA embolism. Among them, There were 15 cases of Yun type IIb SISMAD. Sixty-six patients underwent plain CT. The maximum SMA diameter was 12.1 (11.3-13.1) mm, and the maximum SMA diameter was located on the left renal vein (LRV) plane in 68.2% of cases. Dissection features observed on contrast-enhanced CT (CECT), CT angiography (CTA), or digital subtraction angiography (DSA) showed that there were 70 cases (63.6%) of Yun type IIb SISMAD, the maximum SMA diameter was 13.0 ± 2.4 mm, the location of the maximum SMA diameter was on the LRV plane in 64.5% of cases, and 7.3% of cases were complicated with intestinal obstruction, including bowel necrosis in 3.6% of cases. There were differences between the conservative group and non-conservative groups in the residual true lumen diameter or degree of true lumen stenosis and the presence of intestinal obstruction or bowel necrosis (all P < 0.05). CONCLUSION: For SISMAD, misdiagnosis and missed diagnosis were usually caused by insufficient awareness and disease features. SISMAD should be considered in the differential diagnosis of patients presenting with unexplained abdominal pain, especially males, patients in the 5th decade of life, patients with hypertension, and patients with an enlarged SMA diameter or a maximum SMA diameter located on the LRV plane on plain CT. Mesenteric CTA or CECT should be recommended for the investigation of these conditions.

Role of electrocardiograms in assessment of severity and analysis of the characteristics of ST elevation in acute myocarditis: A two-centre study.

Acute myocarditis is a severe disease with a high mortality rate and various dynamic changes visible on electrocardiograms (ECGs). The purpose of the present study was to investigate ECG findings of patients with acute myocarditis, ECG findings associated with fulminant myocarditis (FM) and the characteristics of ST elevation on admission. A retrospective analysis of 1,814 ECGs of 274 consecutive patients with acute myocarditis aged ≥13 years, who were hospitalized in two centres between August 2007 and November 2019, was performed. A total of 251 patients with myocarditis (91.6%) presented with ECG abnormalities. The most common ECG findings were T-wave inversion and ST elevation. Univariate logistic regression analysis demonstrated that 12 ECG findings were associated with FM. Multivariate regression analysis revealed that the independent predictive factors for FM included ventricular tachycardia, high-degree atrioventricular block, sinus tachycardia, low voltage and QRS duration of ≥120 msec (all P<0.05). A total of 112 cases displayed ST elevation at admission. Of these, ST elevation without T-wave inversion (n=87) was associated with a shorter duration of cardiac symptoms (1.5 vs. 3.1 days; P<0.001) compared with ST elevation with T-wave inversion (n=25). Of the aforementioned 87 patients, 71 (81.6%) presented with T-wave inversion at the hospital. The median time from the onset of cardiac symptoms to T-wave inversion was 4.0 days. In conclusion, patients with acute myocarditis exhibited various dynamic changes on ECG. Thus, ECGs should be widely used for the assessment of severity and the characteristics of ST elevation on admission.

Type A aortic dissection in pregnant patients with fibrillin-1 gene mutations: Two case reports and a literature review.

In acute aortic dissection (AD) in pregnancy, increased cardiovascular stress due to pregnancy is an important factor leading to an emergent aortic event. It is rare but often results in a devastating event for both the pregnant patient and the foetus. Two cases of acute AD (Stanford type A) in pregnant females are presented in the present study. The patients were diagnosed via echocardiography, and the diagnosis was confirmed with computed tomography angiography prior to aortic surgery. Up to 50% of ADs in pregnancy occur in patients with fibrillin-1 (FBN1) gene mutations. The FBN1 gene was sequenced in both patients, and notable, novel pathogenic mutations of FBN1 were identified in both patients. A literature review was also performed on available diagnostic imaging and other measurements regarding AD during pregnancy. The authors suggest that the relevant content may have important clinical implications in raising disease awareness, arranging test rationally and choosing an intervention method.

N,N-dimethylformamide-induced acute hepatic failure: A case report and literature review.

N,N-dimethylformamide (DMF) is a major solvent predominantly used in the chemical industry. The main toxic effects following exposure to DMF are gastric irritation, skin eruption and hepatotoxicity. However, hepatic failure induced by DMF is rare. In this report, we present a case of acute hepatic failure following exposure to a toxic dose of DMF via respiratory tract inhalation and skin absorption with detailed abdominal computed tomography scan, sequential laboratory data and polymorphisms. The patient recovered satisfactorily following artificial liver support therapy and pharmacological agents to protect the liver in addition to plasma, blood platelet and albumin transfusions. In view of the high mortality rate and rare occurrence rate of acute hepatic failure, the clinical characteristics, polymorphisms and therapeutic strategy of DMF poisoning are discussed.

Advances in clinical studies of cardiopulmonary resuscitation.

BACKGROUND: The survival rate of patients after cardiac arrest (CA) remains lower since 2010 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) was published. In clinical trials, the methods and techniques for CPR have been overly described. This article gives an overview of the progress in methods and techniques for CPR in the past years. DATA SOURCES: Original articles about cardiac arrest and CPR from MEDLINE (PubMed) and relevant journals were searched, and most of them were clinical randomized controlled trials (RCTs). RESULTS: Forty-two articles on methods and techniques of CPR were reviewed, including chest compression and conventional CPR, chest compression depth and speed, defibrillation strategies and priority, mechanical and manual chest compression, advanced airway management, impedance threshold device (ITD) and active compression-decompression (ACD) CPR, epinephrine use, and therapeutic hypothermia. The results of studies and related issues described in the international guidelines had been testified. CONCLUSIONS: Although large multicenter studies on CPR are still difficult to carry out, progress has been made in the past 4 years in the methods and techniques of CPR. The results of this review provide evidences for updating the 2015 international guidelines.

Factors influencing outcomes after cardiopulmonary resuscitation in emergency department.

BACKGROUND: The outcome of cardiopulmonary resuscitation (CPR) may depend on a variety of factors related to patient status or resuscitation management. To evaluate the factors influencing the outcome of CPR after cardiac arrest (CA) will be conducive to improve the effectiveness of resuscitation. Therefore, a study was designed to assess these factors in the emergency department (ED) of a city hospital. METHODS: A CPR registry conforming to the Utstein-style template was conducted in the ED of the First Affiliated Hospital of Wenzhou Medical College from January 2005 to December 2011. The outcomes of CPR were compared in various factors groups. The primary outcomes were rated to return of spontaneous circulation (ROSC), 24-hour survival, survival to discharge and discharge with favorable neurological outcomes. Univariate analysis and multivariable logistic regression analysis were performed to evaluate factors associated with survival. RESULTS: A total of 725 patients were analyzed in the study. Of these patients, 187 (25.8%) had ROSC, 100 (13.8%) survived for 24 hours, 48 (6.6%) survived to discharge, and 23 (3.2%) survived to discharge with favorable neurologic outcomes. A logistic regression analysis demonstrated that the independent predictors of ROSC included traumatic etiology, first monitored rhythms, CPR duration, and total adrenaline dose. The independent predictors of 24-hour survival included traumatic etiology, cardiac etiology, first monitored rhythm and CPR duration. Previous status, cardiac etiology, first monitored rhythms and CPR duration were included in independent predictors of survival to discharge and neurologically favorable survival to discharge. CONCLUSIONS: Shockable rhythms, CPR duration ≤15 minutes and total adrenaline dose ≤5 mg were favorable predictors of ROSC, whereas traumatic etiology was unfavorable. Cardiac etiology, shockable rhythms and CPR duration ≤15 minutes were favorable predictors of 24-hour survival, whereas traumatic etiology was unfavorable. Cardiac etiology, shockable rhythms, CPR duration ≤15 minutes were favorable predictors of survival to discharge and neurologically favorable survival to discharge, but previous terminal illness or multiple organ failure (MOF) was unfavorable.

Rapid detection of recurrent intraventricular hemorrhage by ultrasound in a multiple trauma patient who had undergone craniectomy.

Ultrasound may be a useful tool to evaluate intracranial abnormalities in critically ill patients undergoing decompressive craniectomy. We present a multiple trauma patient who had undergone craniectomy and in whom recurrent intraventricular hemorrhage and patterns of cerebral blood flow were rapidly detected by ultrasound.

Effects of Hemin on neuroglobin expression after cardiopulmonary resuscitation in rats.

BACKGROUND: Despite a large amount of resuscitation research, the survival rate after cardiac arrest remains low, and brain injury is the key issue. Neuroglobin (NGB) is an oxygen-binding heme protein found in the brain with a protection role against ischemic-hypoxic brain injury. Hemin is an effective activator of neuroglobin. This study was undertaken to assess the effect of hemin on expression of neuroglobin (NGB) in the cerebral cortex, neuro-deficit score (NDS) and pathological changes after cardiopulmonary resuscitation (CPR) in rats. METHODS: A total of 120 male Sprague-Dawley (SD) rats were randomly divided into a control group (A), a CPR group (B) and a Hemin group (C). The animal model of cardiac arrest (CA) induced by asphyxia and CPR was established. NGB expression in the cerebral cortex with immunohistochemistry, NDS and pathological changes in the cerebral cortex were examined at 3, 6, 12, 24 hours after recovery of spontaneous circulation (ROSC) in each group. Experimental data were treated as one-factor analysis of variance and the Tukey test. RESULTS: In comparison with group A, NGB expression was increased significantly at 12 and 24 hours after ROSC (P<0.05 or P<0.01), NDS was decreased significantly at each time point after ROSC (P<0.01), and pathological changes were severe at each time point after ROSC in group B. In comparison with group A, NGB expression was increased significantly at 6, 12, 24 hours after ROSC (P<0.05 or P<0.01), NDS was decreased significantly at 3, 6, 12 hours after ROSC (P<0.01) in group C. In comparison with group B, NGB expression was increased significantly at 12 and 24 hours after ROSC, NDS was increased significantly at 12 and 24 hours after ROSC, and pathological changes were milder in group C. CONCLUSION: There were increased NGB expression in the cerebral cortex, decreased NDS, and severe pathological changes after CPR in rats. Hemin treatment up-regulated expression of NGB, improved NDS, mitigated pathological changes, and alleviated cerebral injury after CPR.

Effect of exogenous phosphocreatine on cardiomycytic apoptosis and expression of Bcl-2 and Bax after cardiopulmonary resuscitation in rats.

BACKGROUND: Ischemia-reperfusion injury in the myocardium after cardiac arrest (CA) and cardiopulmonary resuscitation (CPR) is an important pathologic basis of post-cardiac arrest of syndrome (PCAS), and apoptosis is one of the major mechanisms in myocardial ischemia-reperfusion injury. To lessen myocardial ischemia-reperfusion injury after cardiac arrest and CPR, it is important to reduce energy consumption and to increase energy supply in the myocardium. This study aimed to observe changes of cell apoptosis and expression of Bcl-2 and Bax protein on the myocardium after CPR in rats, and the protective effects of different doses of exogenous phosphocreatine (creatine phosphate, CP) on them. METHODS: A total of 32 male adult Sprague-Dawley rats were randomly divided into 4 groups: control group (group A), CPR group (group B), low-dose CP group (group C, CP 0.5 g/kg at beginning of CPR and 1.0 g/kg at 2 hours after CPR) and high-dose CP group (group D, CP 1.0 g/kg at beginning of CPR and 2.0 g/kg at 2 hours after CPR). Cardiac arrest was induced by asphyxiation and CPR started at 7 minutes after asphyxiation in groups B, C and D. Myocardium samples were taken at 24 hours after CPR. Cardiomycytic apoptosis was detected by the TdT-mediated dUTP-biotin nick end labeling (TUNEL) method. The expression of Bcl-2 and Bax protein was measured by immunohistochemistry. RESULTS: Cardiomyocytic apoptosis index (AI) and expression of Bcl-2 and Bax protein increased more significantly in groups B, C and D than in group A (P<0.01), but Bcl-2/Bax ratio significantly decreased (P<0.01). Cardiomyocytic AI and expression of Bcl-2 and Bax protein decreased more significantly in groups C and D than in group B (P<0.01), but Bcl-2/Bax ratio increased more significantly (P<0.01). Cardiomyocytic AI and expression of Bcl-2 and Bax protein decreased more significantly in group D than in group C (P<0.05), but Bcl-2/Bax ratio increased more significantly (P<0.05). CONCLUSION: Exogenous phosphocreatine, especially at a large dose, could inhibit cardiomyocytic apoptosis and alleviate myocardial injury after CPR in rats.

[Protective effect of ulinastatin on myocardium after cardiopulmonary resuscitation in rats].

OBJECTIVE: To investigate the changes in serum creatine kinase isoenzyme (CK-MB) and cardiac troponin I (cTnI) levels and the ultrastructure of myocardium, and the effect of ulinastatin after cardiopulmonary resuscitation (CPR) in rats. METHODS: One hundred and twenty Sprague-Dawley (SD) rats were randomly divided into sham operation group, CPR group and ulinastatin group. And each group was divided into five subgroups (n=8) according to time points of 0.5, 3, 6, 12, 24 hours after tracheostomy in sham operation group or after restoration of spontaneous circulation (ROSC) in CPR group and ulinastatin group. Cardiac arrest (CA) and CPR models were reproduced by asphyxia in CPR group and ulinastatin group, with injection of ulinastatin 100 kU/kg via carotid 2 minutes after ROSC in ulinastatin group. Normal saline was given in the same dosage as ulinastatin in CPR group. Serum samples was taken at each time point of subgroups for measuring serum levels of CK-MB and cTnI. The ultrastructure changes in myocardium were observed under the electron microscope. RESULTS: The serum levels of CK-MB and cTnI were increased from 0.5 hours after ROSC in CPR group and ulinastatin group compared with sham operation group ( all P<0.01), and CK-MB peaked at 12 hours, then decreased. The serum CK-MB or cTnI levels started to decreased from 3 hours or 0.5 hours after ROSC in ulinastatin group compared with CPR group (P<0.05 or P<0.01). There were milder pathological changes of ultrastructure of myocardium in ulinastatin group than in CPR group. CONCLUSION: Ulinastatin could decrease serum levels of CK-MB and cTnI, and alleviate myocardial injury after CPR in rats.

[Expression of mRNA of matrix metalloproteinase and tissue inhibitor of matrix metalloproteinase after cardiopulmonary resuscitation for asphyxial cardiac arrest in rat].

OBJECTIVE: To study the change in mRNA expression of matrix metalloproteinase (MMPs) and tissue inhibitor-1 of matrix metalloproteinase (TIMP-1) in brain after cardiopulmonary resuscitation (CPR) for asphyxial cardiac arrest in rat. METHODS: The animal model of cardiac arrest was reproduced by clamping endotracheal tube at the expiration. Eighty male SD rats were randomly divided into two groups: control group and resuscitation group, and they were again divided into 0, 0.5, 3, 6, 9 hours subgroups (n=8). Evans blue content and mRNA expressions of MMPs and TIMP-1 in the brain after CPR were determined respectively. RESULTS: The mRNA expression of MMP-9 and TIMP-1 was up-regulated 3 hours after restoration of spontaneous circulation (ROSC). At 6 hours after ROSC, they were markedly high, and the ratio of MMP-9/TIMP-1 was higher too. The mRNA expression of MMP-2 showed no significant change at 9 hours after ROSC. CONCLUSION: The mRNA expression of MMP-9 and TIMP-1 and MMP-9/TIMP-1 are increased at early stage after CPR, but the mRNA expression of MMP-2 shows no significant change.

Changes of tumor necrosis factor-alpha and the effects of ulinastatin injection during cardiopulmonary cerebral resuscitation.

The changes of tumor necrosis factor-alpha (TNF-alpha) and brain ultrastructure during cardiopulmonary resuscitation and the effects of ulinastation injection were observed, and the mechanism was investigated. Twenty-four adult healthy Sprague-Dawley rats were randomly divided into control group (8 rats), resuscitation group (8 rats) and ulinastatin (UTI) group (8 rats). Rats in control group underwent tracheotomy without clipping the trachea to induce circulatory and respiratory standstill. Rats in resuscitation and ulinastatin group were subjected to the procedure of establishing the model of cardiopulmonary cerebral resuscitation (CPCR). Rats in ulinastatin group were given with UTI 104 U/kg once after CPCR. In the control group, the plasma was collected immediate, 30 min, 2 h, 4 h, and 6 h after tracheotomy. In resuscitation group and UTI group, plasma was collected immediate after tracheotomy, 30 min, 2 h, 4 h and 6 h after successful resuscitation. The plasma levels of TNF-alpha were determined by radioimmunoassay (RIA). At the end of the experiment, 2 rats were randomly selected from each group and were decapitated. The cortex of the brain was taken out immediately to observe the ultrastructure changes. In control group, there were no significant differences in the level of TNF-alpha among different time points (P>0.05). In resuscitation group, the level of TNF-alpha was increased obviously after resuscitation (P<0.01) and reached its peak 2 h later after resuscitation. An increasing trend of TNF-alpha showed in UTI group. There were no differences in TNF-alpha among each sample taken after successful resuscitation and that after tracheotomy. The utrastructure of brains showed the injury in UTI group was ameliorated as compared with that in resuscitation group. In early period of CPCR, TNF-alpha was expressed rapidly and kept increasing. It indicated that TNF-alpha might take part in the tissue injury after CPCR. The administration of UTI during CACR could depress TNF-alpha and ameliorate brain injury. By regulating the expression of damaging mediator, UTI might provide a protective effect on the tissue injury after CPCR.