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Effect of Focused Cardiac Ultrasound in Combination with Lung Ultrasound on Critically Ill Patients: A Multicenter Observational Study in China

Zhang Hongmin, Zhang Lina, Liu Lixia, Zhu Ying, Yin Wanhong, He Wei, Shang Xiuling, Chao Yangong, Lv Liwen, Wang Xiaoting, Liu Dawei, Chinese Critical Ultrasound Study Group

Vol. 36, Issue 4, Pages: 257-264(2021) DOI: 10.24920/003874

Abstract：Objective Focused cardiac ultrasound (FCU) and lung ultrasound (LU) are increasingly being used in critically ill patients. This study aimed to investigate the effect of FCU in combination with LU on these patients and to determine if the timing of ultrasound examination was associated with treatment change. Methods This is a multicenter cross-sectional observational study. Consecutive patients admitted to the intensive care unit (ICU) were screened for enrollment. FCU and LU were performed within the first 24 h, and treatment change was proposed by the performer based on the ultrasound results and other clinical conditions. Results Among the 992 patients included, 502 were examined within 6 h of ICU admission (early phase group), and 490 were examined after 6 h of admission (later phase group). The early phase group and the later phase group had similar proportions of treatment change (48.8% vs. 49.0%, χ ²=0.003, P=0.956). In the multivariable analysis, admission for respiratory failure was an independent variable associated with treatment change, with an odds ratio (OR) of 2.357 [95% confidence interval (CI): 1.284-4.326, P=0.006]; the timing of examination was not associated with treatment change (OR=0.725, 95%CI: 0.407-1.291, P=0.275). Conclusions FCU in combination with LU, whether performed during the early phase or later phase, had a significant impact on the treatment of critically ill patients. Patients with respiratory failure were more likely to experience treatment change after the ultrasound examination.  

Keywords：cardiac ultrasound;lung ultrasound;critically ill;point-of-care   

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BAG3-Related Myofibrillar Myopathy Presenting as Hypercapnia: A Case Report and Literature Review

Xu Yan, Liu Shixuan, Xu Wenbing, Luo Jinmei, Niu Jingwen, Liu Zhi, Gao Jinming, Wang Jinglan, Dai Yi, Wang Mengzhao

Vol. 36, Issue 4, Pages: 265-278(2021) DOI: 10.24920/003883

Abstract：Objective BAG3-related myopathy is a rare condition so far reported in twenty patients worldwide. The purpose of this study was to draw attention to this rare disease and to the fact that BAG3-related myopathy should be considered as a rare differential diagnosis of hypercapnia. Methods We report a sporadic case of a 14-year-old Chinese girl with a de novo p.Pro209Leu mutation in BAG3 and reviewed the literatures for reported cases related to this mutation. Results We described a 14-year-old Chinese girl who presented with gradually appearing symptoms of hypercapnia that required assisted ventilation. The muscle biopsy and the blood whole-exome sequencing results confirmed the diagnosis of myofibrillar myopathy with a de novo p.Pro209Leu mutation in BAG3. Totally twenty-one patients from twenty families with a confirmed diagnosis of BAG3-related myopathy were reported to date, including this patient and literature review. The male to female ratio was 11:10 and most showed initial symptoms in the first decade of life. Most patients presented toe/clumsy walking or running as the onset symptom, followed by muscle weakness or atrophy. Creatine kinase levels were elevated in fourteen patients and were normal in three. Eighteen patients developed respiratory insufficiency during the disease course and thirteen (one could not tolerate non-invasive assisted ventilation) required non-invasive assisted ventilation for treatment. Except for one not reported, heart involvement was found in seventeen patients during the disease course and seven underwent heart transplantation. Z-disk streaming and aggregation could be observed in most of the patients’ muscle histology. In the long-term follow-up, five patients died of cardiac or respiratory failure. Conclusion BAG3-associated myopathy is a rare type of myofibrillar myopathy. It should be considered as a rare differential diagnosis of hypercapnia.  

Keywords：myofibrillar myopathy;BAG3;respiratory insufficiency;hypercapnia   

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The Great Imitator: Atypical Cutaneous Manifestations of Primary Syphilitic Chancre

Gong Huizi, Wu Mengyin, Li Jun, Zheng Heyi

Vol. 36, Issue 4, Pages: 279-283(2021) DOI: 10.24920/003842

Abstract：Objective To analyze the reasons of misdiagnosis of primary syphilitic chancre and strengthen the understanding of atypical features of this disease. Methods A case series of twenty-seven challenging primary syphilis patients who were not immediately recognized as chancre was included in our study. The clinical data including the patients’ age, sex, skin lesions, HIV status, syphilis serologic test results, treatment, and follow-up results were collected. Hematoxylin-eosin and immunohistochemistry staining of skin biopsy sections were reviewed. Results Four female cases with extragenital chancres presenting as erythema or erosive skin lesions on the nipple were misdiagnosed as Paget’s disease or eczema. The disorder of missed or misdiagnosed male cases manifested as syphilitic balanitis or multiple chancres on the penis root and adjacent pubis rather than coronal sulcus or frenum. Patients with nonreactive nontreponemal tests at initial presentation were also easily missed or misdiagnosed. Conclusion Primary syphilis presenting as multiple lesions rather than a single chancre, at atypical locations, or with a nonreactive nontreponemal test result, tends to be missed or misdiagnosed.  

Keywords：primary syphilis;chancre;misdiagnosis   

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Does Prior Cancer Have an Influence on the Survival Outcomes of Patients with Localized Pancreatic Neuroendocrine Tumors?

Wang Liang, Li Gang, Bing Yun-tao, Tian Mao-lin, Wang Hangyan, Yuan Chunhui, Xiu Dianrong

Vol. 36, Issue 4, Pages: 284-294(2021) DOI: 10.24920/003803

Abstract：Objective To investigate the impact of prior non-pancreatic cancer on the survival outcomes of patients with localized pancreatic neuroendocrine tumors (PanNETs). Methods We reviewed the Surveillance, Epidemiology, and End Results database and selected patients with localized PanNETs diagnosed between 1973 and 2015. We divided the patients into two groups according to the presence or absence of prior non-pancreatic malignancy. Before and after propensity score matching, we compared the clinicopathological characteristics and studied the overall survival and cancer-specific survival. Results A total of 357 (12.9%) of 2778 patients with localized PanNETs had prior cancer. A total of 1211 cases with only a localized PanNET and 133 cases with a localized PanNET and prior cancer had complete data and met the inclusion criteria of the current study. Patients with prior cancer were associated with advanced age (>65 years, 57.9% prior cancer vs. 31.0% no prior cancer, P<0.001), later year of diagnosis (87.2% vs. 80.2%, P=0.049), a higher proportion of poorly differentiated/undifferentiated grade tumors (4.5% vs. 1.5%, P=0.025), and a higher proportion of no primary site surgery (19.5% vs. 10.4%, P=0.003). Prostate (29.32%), breast (18.05%), other genitourinary and retroperitoneal (16.54%), and gastrointestinal (12.78%) cancers were the most common prior cancer types. Most of the prior cancers (95.49%) were localized and regional, and only 4.51% of the prior cancers were distant. Patients with interval periods between the prior cancer and PanNET of ≤36 months, 36-60 months, 60-120 months, and >120 months accounted for 33.08%, 13.53%, 24.06%, and 29.32% of all cases with prior cancers, respectively. Univariate and multivariate Cox proportional hazards analyses were performed. The presence/absence of prior cancers did not impact survival outcomes of patients with localized PanNETs before and after propensity score matching (PSM). Further subgroups analysis showed that, patients with localized PanNETs and prior distant cancer had worse cancer-specific survival than patients with prior local/regional cancer or patients without prior cancer (P<0.001). No significant differences in cancer-specific survival were observed in terms of the different sites of the prior cancers and the different interval periods of prior cancers and PanNETs (P<0.05). Conclusions Patients with localized PanNETs and a history of prior cancer had survival outcomes that were comparable to those of patients with no history of prior cancer. Patients with localized PanNETs and prior cancer could be candidates for clinical trials if they satisfy all other conditions; aggressive and potentially curative therapies should be offered to these patients.  

Keywords：pancreatic neuroendocrine tumor;prior cancer;propensity score matching   

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Aortic Valve Replacement for Patients with Heyde Syndrome: A Literature Review

Li Huili, Lin Peishuang, Yao Yuntai

Vol. 36, Issue 4, Pages: 307-315(2021) DOI: 10.24920/003881

Abstract：Objective To explore the characteristics and clinical outcomes of patients with Heyde syndrome (HS) who undergo aortic valve replacement (AVR). Methods Electronic databases including PubMed, Embase, Ovid, WANFANG, VIP and CNKI were searched to identify all case reports of HS patients undergoing AVR surgery, using different combinations of search terms “Heyde syndrome”, “gastrointestinal bleeding”, “aortic stenosis”, and “surgery”. Three authors independently extracted the clinical data including the patients’ characteristics, aortic stenosis severity, gastrointestinal bleeding sites, surgical treatments and prognosis. Results Finally, 46 case reports with 55 patients aging from 46 to 87 years, were determined eligible and included. Of them, 1 patient had mild aortic stenosis, 1 had moderate aortic stenosis, 42 had severe aortic stenosis, and 11 were not mentioned. Gastrointestinal bleeding was detected in colon (n=8), jejunum (n=6), ileum (n=4), cecum (n=3), duodenal (n=3) and multiple sites (n=8). No specific bleeding site was identified in 23 patients. Preoperative hemoglobin level ranged from 43 to 117 g/L. All but one of 16 patients showed decreased level of high molecule weight von Willebrand factor. Of the 55 patients, 43 underwent AVR, and 12 received transcatheter AVR. Aortic valves of 14 cases were replaced by mechanical valves, and 33 cases by biological valves. All patients recovered well during the follow-up, except 5 patients. One patient who had perivalvular leakage and gastrointestinal bleeding after AVR underwent the second AVR. Two patients had recurrent gastrointestinal bleeding. Two patients died of life-threatening acute subdural hematoma and multiple organ failure, respectively. Conclusions HS is a rare syndrome characterized by aortic stenosis and gastrointestinal bleeding. AVR is an effective treatment for HS.  

Keywords：Heyde syndrome;gastrointestinal bleeding;aortic valve stenosis   

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Reviews

Substitution for In Vitro and In Vivo Tests: Computational Models from Cell Attachment to Tissue Regeneration

Huang Hao, Liu Chaozong, Yi Teng, Tamaddon Maryam, Yuan Shanshan, Shi Zhenyun, Liu Ziyu

Vol. 36, Issue 4, Pages: 323-332(2021) DOI: 10.24920/004007

Abstract：To get an optimal product of orthopaedic implant or regenerative medicine needs to follow trial-and-error analyses to investigate suitable product’s material, structure, mechanical properites etc. The whole process from in vivo tests to clinical trials is expensive and time-consuming. Computational model is seen as a useful analysis tool to make the product development. A series of models for simulating tissue engineering process from cell attachment to tissue regeneration are reviewed. The challenging is that models for simulating tissue engineering processes are developed separately. From cell to tissue regeneration, it would go through blood injection after moving out the defect; to cell disperse and attach on the scaffold; to proliferation, migration and differentiation; and to the final part—becoming mature tissues. This paper reviewed models that related to tissue engineering process, aiming to provide an opportunity for researchers to develop a mature model for whole tissue engineering process. This article focuses on the model analysis methods of cell adhesion, nutrient transport and cell proliferation, differentiation and migration in tissue engineering. In cell adhesion model, one of the most accurate method is to use discrete phase model to govern cell movement and use Stanton-Rutland model for simulating cell attachment. As for nutrient transport model, numerical model coupling with volume of fluid model and species transport model together is suitable for predicting nutrient transport process. For cell proliferation, differentiation and migration, finite element method with random-walk algorithm is one the most advanced way to simulate these processes. Most of the model analysis methods require further experiments to verify the accuracy and effectiveness. Due to the lack of technology to detect the rate of nutrient diffusion, there are especially few researches on model analysis methods in the area of blood coagulation. Therefore, there is still a lot of work to be done in the research of the whole process model method of tissue engineering. In the future, the numerical model would be seen as an optimal way to investigate tissue engineering products bioperformance and also enable to optimize the parameters and material types of the tissue engineering products.  

Keywords：tissue engineering;scaffold;computer aided design;computational fluid dynamics;finite element models   

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Case Report

Severe Pulmonary Embolism, Thrombosis of Lower Extremity, Unexpected Mild Renal Disorder in MPO-ANCA Associated Vasculitis: A Case Report

Liao Zhonghua, Feng Juntao, Tang Jiale, Luo Liying, Li Xiaozhao

Vol. 36, Issue 4, Pages: 342-345(2021) DOI: 10.24920/003871

Abstract：Myeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA) associated vasculitis is an autoimmune disease usually with severe multiple dysfunction syndrome, especially prominent acute renal failure. A 65-year-old woman was admitted with progressive dyspnoea for six months and fever, sputum with blood, pain of the lower extremities and intermittent claudication for two days, indicating multiple organ involvement (respiratory system, blood vessels). The renal involvement was relatively mild, presenting with microscopic haematuria. The chest computed tomography demonstrated multiple pulmonary embolisms. Ultrasound and computed tomography angiography for the lower extremity vessels showed venous and arterial thrombosis. Exclusion of other diseases that can cause multiple organ damage and thrombosis, the positive perinuclear ANCA and MPO-ANCA strongly support the diagnosis of MPO-ANAC-associated vasculitis. The patient’s physical condition has been greatly improved by treatment with corticosteroids and anticoagulation.  

Keywords：antineutrophil cytoplasmic antibody-associated vasculitis;myeloperoxidase;pulmonary embolism;arterial embolism   

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Special Report