RESUMO
Point-of-care ultrasound (POCUS) involves the acquisition, interpretation, and immediate clinical integration of ultrasonographic imaging performed by a treating clinician. The current state of cardiac POCUS terminology is heterogeneous and ambiguous, in part because it evolved through siloed specialty practices. In particular, the medical literature and colloquial medical conversation contain a wide variety of terms that equate to cardiac POCUS. While diverse terminology aided in the development and dissemination of cardiac POCUS throughout multiple specialties, it also contributes to confusion and raises patient safety concerns. This statement is the product of a diverse and inclusive Writing Group from multiple specialties, including medical linguistics, that employed an iterative process to contextualize and standardize a nomenclature for cardiac POCUS. We sought to establish a deliberate vocabulary that is sufficiently unrelated to any specialty, ultrasound equipment, or clinical setting to enhance consistency throughout the academic literature and patient care settings. This statement (1) reviews the evolution of cardiac POCUS-related terms; (2) outlines specific recommendations, distinguishing between intrinsic and practical differences in terminology; (3) addresses the implications of these recommendations for current practice; and (4) discusses the implications for novel technologies and future research.
RESUMO
Objective: The lungs of patients with Systemic Sclerosis Associated Interstitial Lung Disease (SSc-ILD) contain inflammatory myofibroblasts arising in association with fibrotic stimuli and perturbed innate immunity. The innate immune DNA binding receptor Cyclic GMP-AMP synthase (cGAS) is implicated in inflammation and fibrosis, but its involvement in SSc-ILD remains unknown. We examined cGAS expression, activity, and therapeutic potential in SSc-ILD using cultured fibroblasts, precision cut lung slices (PCLS), and a well-accepted animal model. Methods: Expression and localization of cGAS, cytokines, and type 1 interferons were evaluated in SSc-ILD lung tissues, bronchoalveolar lavage (BAL), and isolated lung fibroblasts. CGAS activation was assessed in a publicly available SSc-ILD single cell RNA sequencing dataset. Production of cytokines, type 1 interferons, and αSMA elicited by TGFß1 or local substrate stiffness were measured in normal human lung fibroblasts (NHLFs) via qRT-PCR, ELISA, and immunofluorescence. Small molecule cGAS inhibition was tested in cultured fibroblasts, human PCLS, and the bleomycin pulmonary fibrosis model. Results: SSc-ILD lung tissue and BAL are enriched for cGAS, cytokines, and type 1 interferons. The cGAS pathway shows constitutive activation in SSc-ILD fibroblasts and is inducible in NHLFs by TGFß1 or mechanical stimuli. In these settings, and in human PCLS, cGAS expression is paralleled by the production of cytokines, type 1 interferons, and αSMA that are mitigated by a small molecule cGAS inhibitor. These findings are recapitulated in the bleomycin mouse model. Conclusion: cGAS signaling contributes to pathogenic inflammatory myofibroblast phenotypes in SSc-ILD. Inhibiting cGAS or its downstream effectors represents a novel therapeutic approach.
Assuntos
Suporte Vital Cardíaco Avançado , Ecocardiografia Transesofagiana , Humanos , Ecocardiografia Transesofagiana/métodos , Ecocardiografia Transesofagiana/normas , Suporte Vital Cardíaco Avançado/normas , Suporte Vital Cardíaco Avançado/métodos , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/normasRESUMO
PURPOSE: Despite the potential value of point-of-care ultrasonography (POCUS) in resource-limited environments, it is not widely used in low- and middle-income countries compared with high-income countries. We sought to evaluate the current POCUS practice of Ukrainian anesthesiologists who attended POCUS courses to guide future POCUS training in Ukraine. METHODS: We conducted a 25-question web-based survey. It was distributed to 255 participants of POCUS courses held in Ukraine in 2023. The survey sections described current POCUS practice, perception of POCUS value, POCUS skills self-assessment, and perceived barriers to implementing POCUS in clinical practice. RESULTS: Two hundred and forty-four out of 255 course participants completed the survey, representing 214 unique respondents. Those who self-rated their skills identified themselves as either novices or beginners in areas of POCUS knowledge (118/157, 75%), image acquisition (110/158, 70%), image interpretation (117/158, 74%), and integration into clinical decision-making (105/155, 68%). Among all survey responders, 55% (118/214) reported using POCUS for vascular access procedures, 45% (97/214) for trauma assessment, and 44% (93/214) for regional anesthesia. Reported barriers to POCUS implementation included lack of ultrasound devices (101/214, 47%) and lack of trained faculty (112/214, 52%). CONCLUSION: Among anesthesiologists who participated in POCUS courses in Ukraine, the majority were in early stages of ultrasound practice. Respondents identified POCUS applications not currently practiced and evaluated barriers to POCUS use. Based upon these survey findings, we propose the following measures in Ukraine: 1) developing a standardized national POCUS curriculum; 2) increasing the number of experienced instructors of POCUS; and 3) acquiring ultrasound devices to support clinical applications of POCUS, especially in the Central, Southern, and Eastern regions.
RéSUMé: OBJECTIF: Malgré la valeur potentielle de l'échographie ciblée (POCUS) dans les environnements à ressources limitées, cette modalité n'est pas très répandue dans les pays à revenu faible et intermédiaire par rapport aux pays à revenu élevé. Nous avons cherché à évaluer la pratique actuelle des anesthésiologistes en Ukraine qui ont suivi des cours d'échographie ciblée afin d'orienter la future formation en POCUS dans ce pays. MéTHODE: Nous avons mené un sondage en ligne de 25 questions. Il a été distribué à 255 personnes ayant suivi des cours de POCUS organisés en Ukraine en 2023. Les sections de l'enquête décrivaient la pratique actuelle en échographie ciblée, la perception de sa valeur, l'auto-évaluation des compétences en POCUS et les obstacles perçus à sa mise en Åuvre dans la pratique clinique. RéSULTATS: Deux cent quarante-quatre des 255 personnes ayant pris part au cours ont répondu au sondage, représentant 214 répondant·es uniques. Les personnes ayant auto-évalué leurs compétences se sont identifiées comme novices ou débutantes dans les domaines de la connaissance de l'échographie ciblée (118/157, 75 %), de l'acquisition d'images (110/158, 70 %), de l'interprétation d'images (117/158, 74 %) et de l'intégration dans la prise de décision clinique (105/155, 68 %). Parmi toutes les personnes ayant répondu à l'enquête, 55 % (118/214) ont déclaré utiliser l'échographie ciblée pour les procédures d'accès vasculaire, 45 % (97/214) pour l'évaluation des traumatismes et 44 % (93/214) pour l'anesthésie régionale. Les obstacles signalés à la mise en Åuvre de l'échographie ciblée comprenaient le manque d'appareils d'échographie (101/214, 47 %) et le manque de professeur·es formé·es (112/214, 52 %). CONCLUSION: Parmi les anesthésiologistes qui ont participé aux cours d'échographie ciblée en Ukraine, la majorité en étaient aux premiers stades de la pratique de l'échographie. Les répondant·es ont identifié les applications de l'échographie ciblée qui ne sont pas actuellement pratiquées et ont évalué les obstacles à son utilisation. Sur la base des résultats de cette enquête, nous proposons les mesures suivantes en Ukraine : 1) la création d'un programme national normalisé d'échographie ciblée; 2) l'augmentation du nombre d'instructrices et instructeurs expérimenté·es en échographie ciblée; et 3) l'acquisition d'appareils d'échographie pour soutenir les applications cliniques de cette modalité, en particulier dans les régions du Centre, du Sud et de l'Est du pays.
RESUMO
Rationale: Changes in peripheral blood cell populations have been observed, but not detailed, at single-cell resolution in idiopathic pulmonary fibrosis (IPF). Objectives: We sought to provide an atlas of the changes in the peripheral immune system in stable and progressive IPF. Methods: Peripheral blood mononuclear cells (PBMCs) from patients with IPF and control subjects were profiled using 10× chromium 5' single-cell RNA sequencing. Flow cytometry was used for validation. Protein concentrations of regulatory T cells (Tregs) and monocyte chemoattractants were measured in plasma and lung homogenates from patients with IPF and control subjects. Measurements and Main Results: Thirty-eight PBMC samples from 25 patients with IPF and 13 matched control subjects yielded 149,564 cells that segregated into 23 subpopulations. Classical monocytes were increased in patients with progressive and stable IPF compared with control subjects (32.1%, 25.2%, and 17.9%, respectively; P < 0.05). Total lymphocytes were decreased in patients with IPF versus control subjects and in progressive versus stable IPF (52.6% vs. 62.6%, P = 0.035). Tregs were increased in progressive versus stable IPF (1.8% vs. 1.1% of all PBMCs, P = 0.007), although not different than controls, and may be associated with decreased survival (P = 0.009 in Kaplan-Meier analysis; and P = 0.069 after adjusting for age, sex, and baseline FVC). Flow cytometry analysis confirmed this finding in an independent cohort of patients with IPF. The fraction of Tregs out of all T cells was also increased in two cohorts of lung single-cell RNA sequencing. CCL22 and CCL18, ligands for CCR4 and CCR8 Treg chemotaxis receptors, were increased in IPF. Conclusions: The single-cell atlas of the peripheral immune system in IPF reveals an outcome-predictive increase in classical monocytes and Tregs, as well as evidence for a lung-blood immune recruitment axis involving CCL7 (for classical monocytes) and CCL18/CCL22 (for Tregs).
Assuntos
Fibrose Pulmonar Idiopática , Leucócitos Mononucleares , Análise de Célula Única , Linfócitos T Reguladores , Humanos , Fibrose Pulmonar Idiopática/imunologia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Análise de Célula Única/métodos , Linfócitos T Reguladores/imunologia , Leucócitos Mononucleares/imunologia , Progressão da Doença , Estudos de Casos e Controles , Citometria de FluxoRESUMO
OBJECTIVES: Clinical practice guidelines are essential for promoting evidence-based healthcare. While diversification of panel members can reduce disparities in care, processes for panel selection lack transparency. We aim to share our approach in forming a diverse expert panel for the updated Adult Critical Care Ultrasound Guidelines. DESIGN: This process evaluation aims to understand whether the implementation of a transparent and intentional approach to guideline panel selection would result in the creation of a diverse expert guideline panel. SETTING: This study was conducted in the setting of creating a guideline panel for the updated Adult Critical Care Ultrasound Guidelines. PATIENTS: Understanding that family/patient advocacy in guideline creations can promote the impact of a clinical practice guideline, patient representation on the expert panel was prioritized. INTERVENTIONS: Interventions included creation of a clear definition of expertise, an open invitation to the Society of Critical Care Medicine membership to apply for the panel, additional panel nomination by guideline leadership, voluntary disclosure of pre-identified diversity criteria by potential candidates, and independent review of applications including diversity criteria. This resulted in an overall score per candidate per reviewer and an open forum for discussion and final consensus. MEASUREMENTS AND MAIN RESULTS: The variables of diversity were collected and analyzed after panel selection. These were compared with historical data on panel composition. The final guideline panel comprised of 33 panelists from six countries: 45% women and 79% historically excluded people and groups. The panel has representation from nonphysician professionals and patients advocates. Of the healthcare professionals, there is representation from early, mid, and late career stages. CONCLUSIONS: Our intentional and transparent approach resulted in a panel with improved gender parity and robust diversity along ethnic, racial, and professional lines. We hope it can serve as a starting point as we strive to become a more inclusive and diverse discipline that creates globally representative guidelines.
Assuntos
Cuidados Críticos , Guias de Prática Clínica como Assunto , Ultrassonografia , Humanos , Cuidados Críticos/normas , Ultrassonografia/normas , Adulto , Feminino , MasculinoRESUMO
The authors present a case of percutaneous closure of an incomplete surgical left atrial appendage (LAA) ligation with a new device LAmbre (Lifetech ScientificCo Ltd).
RESUMO
Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.
Assuntos
Fibrilação Atrial , Insuficiência Cardíaca , Insuficiência da Valva Tricúspide , Humanos , Feminino , Idoso , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/complicações , Átrios do Coração/diagnóstico por imagem , Valva Tricúspide/diagnóstico por imagem , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/etiologia , Fibrilação Atrial/terapiaRESUMO
To assess point-of-care ultrasound (POCUS) in 2024, we should start by defining its expanded scope and integration into general and specialty practice. Clinicians should abide by the evolving evidence for POCUS utilization and patient outcomes different from mortality and morbidity, especially as there are notable advancements in handheld ultrasound technology with a clear shift from capability to portability. To reduce diagnostic errors, POCUS practitioners need a holistic framework that accounts for known and new applications. Defining the POCUS scope of practices, proper training, and innovation, like artificial intelligence, can play a bigger role in mitigating diagnostic errors as we move forward.
Assuntos
Inteligência Artificial , Sistemas Automatizados de Assistência Junto ao Leito , Humanos , UltrassonografiaRESUMO
QUESTION: Severe asthma and COPD exacerbations requiring hospitalization are linked to increased disease morbidity and healthcare costs. We sought to identify Electronic Health Record (EHR) features of severe asthma and COPD exacerbations and evaluate the performance of four machine learning (ML) and one deep learning (DL) model in predicting readmissions using EHR data. STUDY DESIGN AND METHODS: Observational study between September 30, 2012, and December 31, 2017, of patients hospitalized with asthma and COPD exacerbations. RESULTS: This study included 5,794 patients, 1,893 with asthma and 3,901 with COPD. Patients with asthma were predominantly female (n = 1288 [68%]), 35% were Black (n = 669), and 25% (n = 479) were Hispanic. Black (44 vs. 33%, p = 0.01) and Hispanic patients (30 vs. 24%, p = 0.02) were more likely to be readmitted for asthma. Similarly, patients with COPD readmissions included a large percentage of Blacks (18 vs. 10%, p < 0.01) and Hispanics (8 vs. 5%, p < 0.01). To identify patients at high risk of readmission index hospitalization data of a subset of 2,682 patients, 777 with asthma and 1,905 with COPD, was analyzed with four ML models, and one DL model. We found that multilayer perceptron, the DL method, had the best sensitivity and specificity compared to the four ML methods implemented in the same dataset. INTERPRETATION: Multilayer perceptron, a deep learning method, had the best performance in predicting asthma and COPD readmissions, demonstrating that EHR and deep learning integration can improve high-risk patient detection.
Assuntos
Asma , Aprendizado Profundo , Doença Pulmonar Obstrutiva Crônica , Humanos , Feminino , Masculino , Readmissão do Paciente , Estudos Retrospectivos , Asma/diagnóstico , Asma/epidemiologia , Asma/terapia , Hospitalização , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/terapiaRESUMO
In the surgical field, the correct approach to the psychiatric patient represents a medical challenge, given the special considerations to be taken in the individualization of their diagnosis and treatment. We present an uncommon case of a 29-year-old patient with associated psychiatric pathology who presented to the emergency room after the introduction of two foreign bodies into the nasal cavity. After the endoscopic removal of one of the foreign bodies, the X-ray follow-up shows a second foreign body into the esophagus, which progressed to the vermiform appendix, causing the classical clinical signs of acute appendicitis as a complication. The importance of considering that events treated by the otorhinolaryngology area may have complications for urgent management by the general surgery service is denoted in this article.
RESUMO
This report highlights survival and the patient's perspective after prolonged venovenous extracorporeal membrane oxygenation (ECMO) for COVID-19-related respiratory failure. A 36-year-old man with COVID-19 presented with fever, anosmia, and hypoxia. After respiratory deterioration necessitating intubation and lung-protective ventilation, he was referred for ECMO. After 3 days of conventional venovenous ECMO, he required multiple creative cannulation configurations. Adequate sedation and recurrent bradycardia were persistent challenges. After 149 consecutive days of ECMO, he recovered native lung function and was weaned from mechanical ventilation. This represents the longest-duration ECMO support in a survivor of COVID-19 yet reported. Necessary strategies included unconventional cannulation and flexible anticoagulation.
Assuntos
COVID-19 , Oxigenação por Membrana Extracorpórea , Insuficiência Respiratória , Masculino , Humanos , Adulto , Respiração Artificial , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Pulmão/diagnóstico por imagemRESUMO
The clinical approach to undifferentiated shock in critically ill patients should be revised to use modern, point-of-care tools that are readily available. With the increasing availability of 2-dimensional ultrasonography and advanced Doppler capabilities, a quick, simplified, and integrated stepwise approach to shock using critical care echocardiography is proposed. Evidence supports the feasibility and usefulness of critical care echo-cardiography in enhancing diagnostic accuracy for shock, but there is a lack of systematic application of the technology in patients with undifferentiated shock. The proposed approach begins with the use of noninvasive ultrasonography with pulsed-wave Doppler capability to determine the flow state by measuring the velocity time integral of the left ventricular outflow tract. This narrative review explores the use left ventricular outflow tract velocity time integral, velocity time integral variation, limited visceral organ Doppler, and lung ultrasonography as a systematic approach for patients with undifferentiated shock.
Assuntos
Ecocardiografia , Choque , Humanos , Ecocardiografia/métodos , Coração , Choque/diagnóstico por imagem , Cuidados Críticos , Velocidade do Fluxo SanguíneoRESUMO
OBJECTIVES: A number of trials related to critical care pharmacotherapy were published in 2022. We aimed to summarize the most influential publications related to the pharmacotherapeutic care of critically ill patients in 2022. DATA SOURCES: PubMed/Medical Literature Analysis and Retrieval System Online and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update. STUDY SELECTION: Randomized controlled trials, prospective studies, or systematic review/meta-analyses of adult critically ill patients assessing a pharmacotherapeutic intervention and reporting clinical endpoints published between January 1, 2022, and December 31, 2022, were included in this article. DATA EXTRACTION: Articles from a systematic search and the Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update were included and stratified into clinical domains based upon consistent themes. Consensus was obtained on the most influential publication within each clinical domain utilizing an a priori defined three-round modified Delphi process with the following considerations: 1) overall contribution to scientific knowledge and 2) novelty to the literature. DATA SYNTHESIS: The systematic search and Clinical Pharmacy and Pharmacology Pharmacotherapy Literature Update yielded a total of 704 articles, of which 660 were excluded. The remaining 44 articles were stratified into the following clinical domains: emergency/neurology, cardiovascular, gastroenterology/fluids/nutrition, hematology, infectious diseases/immunomodulation, and endocrine/metabolic. The final article selected from each clinical domain was summarized following a three-round modified Delphi process and included three randomized controlled trials and three systematic review/meta-analyses. Article topics summarized included dexmedetomidine versus other sedatives during mechanical ventilation, beta-blocker treatment in the critically ill, restriction of IV fluids in septic shock, venous thromboembolism prophylaxis in critically ill adults, duration of antibiotic therapy for Pseudomonas aeruginosa ventilator-associated pneumonia, and low-dose methylprednisolone treatment in severe community-acquired pneumonia. CONCLUSIONS: This concise review provides a perspective on articles published in 2022 that are relevant to the pharmacotherapeutic care of critically ill patients and their potential impact on clinical practice.
RESUMO
Rationale: Asthma is a complex, heterogeneous disease strongly associated with type 2 inflammation, and blood eosinophil counts guide therapeutic interventions in moderate and severe asthma. Eosinophils are leukocytes involved in type 2 immune responses. Despite these critical associations between asthma and blood eosinophil counts, the shared genetic architecture of these two traits remains unknown. The objective of the present study was to characterise the genetic architecture of blood eosinophil counts and asthma in the UK Biobank. Methods: We performed genome-wide association studies (GWAS) of doctor-diagnosed asthma, blood eosinophil, neutrophil, lymphocyte and monocyte counts in the UK Biobank. Genetic correlation analysis was performed on GWAS results and validated in the Trans-National Asthma Genetic Consortium (TAGC) study of asthma. Results: GWAS of doctor-diagnosed asthma and blood eosinophil counts in the UK Biobank identified 585 and 3429 significant variants, respectively. STAT6, a transcription factor involved in interleukin-4 signalling, was a key shared pathway between asthma and blood eosinophil counts. Genetic correlation analysis demonstrated a positive correlation between doctor-diagnosed asthma and blood eosinophil counts (r=0.38±0.10, correlation±se; p=4.7×10-11). As a validation of this association, we found a similar correlation between TAGC and blood eosinophil counts in the UK Biobank (0.37±0.08, correlation±se; p=1.2×10-6). Conclusions: These findings define the shared genetic architecture between blood eosinophil counts and asthma risk in subjects of European ancestry and point to a genetic link to the STAT6 signalling pathway in these two traits.
RESUMO
The optimal duration of anticoagulation in patients with left ventricular thrombus (LVT) is unknown. The data package herein presented contains the information used to assess the effect of duration of anticoagulation in the incidence of stroke in patients with left ventricular thrombus (LVT) in a tertiary hospital. In order to collect the required data, all transthoracic echocardiography studies at our institution from January 1st 2014 to December 31st 2021 with LVT were retrieved using dedicated software (Phillips Intellispace Cardiovascular; Koninklijke Phillips N.V., 2004-2020). Second, a dataset was designed ad hoc for this study in which the recruited data for the predefined objectives were obtained from electronic medical records. These data included clinical and demographic information including treatment choices (vitamin K antagonists [VKA] versus direct oral anticoagulants [DOAC]), duration of treatment, reason for interruption of treatment, occurrence of stroke, acute myocardial infarction, bleeding events, thrombus resolution, recurrence, and death. Retrieved data were stored in an excel sheet for analysis using the statistical package STATA (StataCorp v. 15.0, College station, TX). This methodology allows the reuse of these data for further analysis, in the context of the present study and also for future recruitment of additional patients from other institutions to increase statistical power.
RESUMO
Rationale: Changes in peripheral blood cell populations have been observed but not detailed at single-cell resolution in idiopathic pulmonary fibrosis (IPF). Objectives: To provide an atlas of the changes in the peripheral immune system in stable and progressive IPF. Methods: Peripheral blood mononuclear cells (PBMCs) from IPF patients and controls were profiled using 10x Chromium 5' single-cell RNA sequencing (scRNA-seq). Flow cytometry was used for validation. Protein concentrations of Regulatory T-cells (Tregs) and Monocytes chemoattractants were measured in plasma and lung homogenates from patients and controls. Measurements and Main Results: Thirty-eight PBMC samples from 25 patients with IPF and 13 matched controls yielded 149,564 cells that segregated into 23 subpopulations, corresponding to all expected peripheral blood cell populations. Classical monocytes were increased in progressive and stable IPF compared to controls (32.1%, 25.2%, 17.9%, respectively, p<0.05). Total lymphocytes were decreased in IPF vs controls, and in progressive vs stable IPF (52.6% vs 62.6%, p=0.035). Tregs were increased in progressive IPF (1.8% vs 1.1%, p=0.007), and were associated with decreased survival (P=0.009 in Kaplan-Meier analysis). Flow cytometry analysis confirmed this finding in an independent cohort of IPF patients. Tregs were also increased in two cohorts of lung scRNA-seq. CCL22 and CCL18, ligands for CCR4 and CCR8 Treg chemotaxis receptors, were increased in IPF. Conclusions: The single-cell atlas of the peripheral immune system in IPF, reveals an outcome-predictive increase in classical monocytes and Tregs, as well as evidence for a lung-blood immune recruitment axis involving CCL7 (for classical monocytes) and CCL18/CCL22 (for Tregs).
RESUMO
The nearby radio galaxy M87 is a prime target for studying black hole accretion and jet formation1,2. Event Horizon Telescope observations of M87 in 2017, at a wavelength of 1.3 mm, revealed a ring-like structure, which was interpreted as gravitationally lensed emission around a central black hole3. Here we report images of M87 obtained in 2018, at a wavelength of 3.5 mm, showing that the compact radio core is spatially resolved. High-resolution imaging shows a ring-like structure of [Formula: see text] Schwarzschild radii in diameter, approximately 50% larger than that seen at 1.3 mm. The outer edge at 3.5 mm is also larger than that at 1.3 mm. This larger and thicker ring indicates a substantial contribution from the accretion flow with absorption effects, in addition to the gravitationally lensed ring-like emission. The images show that the edge-brightened jet connects to the accretion flow of the black hole. Close to the black hole, the emission profile of the jet-launching region is wider than the expected profile of a black-hole-driven jet, suggesting the possible presence of a wind associated with the accretion flow.