Intestinal Complication With Myxomatous Mitral Valve Diseases in Chihuahuas

The effects of cardiac disease on the intestine have been reported in humans but not in dogs. We investigated the effects of myxomatous mitral valve disease (MMVD), which is capable of causing congestion and tissue hypoperfusion, on the intestine in Chihuahuas, a breed frequently encountered in clinical practice as the preferred breed for MMVD. In this study, 69 Chihuahuas were divided into four groups based on echocardiography and chest radiography: 19 healthy Chihuahuas (H) and 50 Chihuahuas with MMVD classified according to the ACVIM consensus (stage B1, B2, C/D). In all the cases, serum intestinal fatty acid-binding protein (I-FABP) and D/L-lactate concentrations, markers of intestinal mucosal injury, were measured. I-FABP was significantly higher in stage C/D Chihuahuas than in other groups (p < 0.05), and stage B2 was significantly higher than H (p < 0.05). D-lactate was significantly increased in stages B2 and C/D compared to H and stage B1 (p < 0.05). L-lactate was significantly higher in stage C/D Chihuahuas than in any other group (p < 0.05), and stage B2 was significantly higher than that in H and stage B1 (p < 0.05). Intestinal mucosal injury risk was significantly higher in Chihuahuas with heart failure due to MMVD, suggesting that the risk could increase with worsening heart disease. This is the first study to investigate the intestinal complications of MMVD, and further investigations a needed in the future.

A prospective study to assess serum level of soluble thrombomodulin as early marker of acute traumatic coagulopathy in polytrauma patients

Background: Coagulopathy following major trauma is conventionally attributed to activation of coagulation factors. We hypothesized that early coagulopathy is due to tissue hypoperfusion and investigated thrombomodulin (TM) as early marker of endothelial injury in poly trauma patient.Methods: This was a prospective cohort study of major trauma patients admitted to a single trauma center. Blood was drawn within 10 minutes of arrival for analysis of TM. We assess its association with blood transfusion, length of hospital stays and mortality.Results: A total of 90 patients were enrolled. An increasing lactate was associated with high soluble TM. High TM was significantly associated with increased mortality, blood transfusion requirements, hospital stay.Conclusions: Acute traumatic coagulopathy (ATC) occurs only in the presence of tissue hypoperfusion which we have measured in form of lactate and coagulopathy measured using international normalized ratio (INR) as standard. Admission serum TM can be predictive of clinical outcomes following major trauma.

The Value of Combining Carbon Dioxide Gap and Oxygen-Derived Variables with Lactate Clearance in Predicting Mortality after Resuscitation of Septic Shock Patients

Background. Achieving hemodynamic stabilization does not prevent progressive tissue hypoperfusion and organ dysfunction during resuscitation of septic shock patients. Many indicators have been proposed to judge the optimization of oxygen delivery to meet tissue oxygen consumption. Methods. A prospective observational study was conducted to evaluate and validate combining CO2 gap and oxygen-derived variables with lactate clearance during early hours of resuscitation of adults presenting with septic shock. Results. Our study included 456 adults with a mean age of 63.2 ± 6.9 years, with 71.9% being males. Respiratory and urinary infections were the origin of about 75% of sepsis. Mortality occurred in 164 (35.9%) patients. The APACHE II score was 18.2 ± 3.7 versus 34.3 ± 6.8 ( p < 0.001 ), the initial SOFA score was 5.8 ± 3.1 versus 7.3 ± 1.4 ( p = 0.001 ), while the SOFA score after 48 hours was 4.2 ± 1.8 versus 9.4 ± 3.1 ( p < 0.001 ) in the survivors and nonsurvivors, respectively. Hospital mortality was independently predicted by hyperlactatemia (OR: 2.47; 95% CI: 1.63–6.82, p = 0.004 ), PvaCO2 gap (OR: 2.62; 95% CI: 1.28–6.74, p = 0.026 ), PvaCO2/CavO2 ratio (OR: 2.16; 95% CI: 1.49–5.74, p = 0.006 ), and increased SOFA score after 48 hours of admission (OR: 1.86; 95% CI: 1.36–8.13, p = 0.02 ). A blood lactate cutoff of 40 mg/dl at the 6th hour of resuscitation (T6) had a 92.7% sensitivity and 75.3% specificity for predicting hospital mortality (AUROC = 0.902) with 81.6% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO2/CavO2 ratio cutoff of 1.4 increased the specificity to 93.2% with a sensitivity of 75.6% in predicting mortality and with 86.8% accuracy. Combining the lactate cutoff of 40 mg/dl and PvaCO2 gap of 6 mmHg increased the sensitivity to 93% and increased the specificity to 98% in predicting mortality with 91% accuracy. Conclusion. Combining the carbon dioxide gap and arteriovenous oxygen difference with lactate clearance during early hours of resuscitation of septic shock patients helps to predict hospital mortality more accurately.

Shock Cryptic, emerging diagnostic

Cryptic shock is a poorly identified clinical entity, and it still describes a patient with signs of tissue hypoperfusion without affecting blood pressure. In the emergency department, it is important to identify signs of hypoperfusion and evaluate various hidden sources of infection by taking a complete medical history, a thorough physical examination, and, if necessary advanced imaging. It is necessary to conclude that the importance of the timely diagnosis of this clinical entity helps to improve the prognosis significantly.

Renal Resistive Index on Intensive Care Unit Admission Correlates with Tissue Hypoperfusion Indices and Predicts Clinical Outcome

Background: Recent advancements in the context of shock pathophysiology, support ultrasound assessment of organ perfusion. Renal resistive index (RRI) has been used to evaluate renal blood flow. Our aim was to investigate the relation between RRI, and global tissue hypoperfusion indices, in mechanically ventilated critically ill patients and their association with clinical outcome.Methods: In this prospective observational study, RRI was measured within 24 hours of intensive care unit (ICU) admission. Clinical and laboratory data, routine hemodynamic variables and gas exchange at the time of RRI assessment were recorded. The ratio of central venous-to-arterial carbon dioxide partial pressure difference by arterial-to-central venous oxygen content difference (P(cv-a)CO2/C(a-cv)O2) and lactate were used as global tissue hypoperfusion indices. Results A total of 126 mechanically ventilated patients were included [median age 61 (IQR 28) years, 74% males]. Seventy-seven patients had RRI values >0.7. P(cv-a)CO2/C(a-cv)O2 ratio and arterial lactate, were significantly higher in patients with RRI > 0.7 compared to those with RRI ≤0.7 [2.4 (2.2) versus 1.2 (0.6) and 2.88 (3.39) versus 0.62 (0.57) mmol/l respectively, both p<0.001)]. RRI was significantly correlated with P(cv-a)CO2/C(a-cv)O2 ratio and arterial lactate for the whole patient population (rho=0.64, both p<0.0001) as well as for the subset of patients with shock (rho=0.47, p=0.001; and r=0.64, p<0.0001 respectively).All-cause ICU mortality was 27.8%. Compared to survivors, ICU non-survivors had a higher RRI [0.80 (0.10) versus 0.70 (0.10), p<0.001] and higher P(cv-a)CO2 / C(a-cv)O2 ratio [3.67 (3.8) versus 0.91 (1.4)] and lactate levels [2.80 (2.00) versus 1.50 (1.20)], both p <0.001). Logistic regression models showed a significant association between RRI and P(cv-a)CO2/C(a-cv)O2 ratio with clinical outcome. RRI showed good ability to predict ICU mortality (AUC 74.9% (95% CI 61% - 88.8%). The combination of RRI with P(cv-a)CO2)/(C(a-cv)O2 ratio and lactate better predicted mortality than RRI alone [AUC 84.8% (95% CI 5.1% - 94.4%)] versus 0.74.9%, respectively, p<0.001).Conclusions: In mechanically ventilated patients, renal blood flow impairment, assessed by the RRI on ICU admission, correlates with global tissue hypoperfusion indices. In addition, RRI in combination with tissue perfusion estimation is more valuable in predicting clinical outcome than RRI alone.

Alactic Base Excess, New Potential Marker Associated for Circulatory Stress Due to Hemodialysis, a Pilot Study

Indroduction: Circulatory stress increases mortality in patients with chronic kidney disease in renal replacement therapy by hemodialysis, the measurement of central venous saturation has been proposed as a useful tool for diagnosis but with limitations. We wanted to evaluate a new marker, the alactic base excess, to be applied in all types of hemodialysis patients to help diagnose this clinical condition.Methodology: An observational, analytical, prospective and longitudinal study was carried out in hemodialysis of the Instituto Mexicano del Seguro Social, in León, Guanajuato from May 2020 to June 2021 by determining the alactic base excess. The association of alactic base excess as a marker of circulatory stress in hemodialysis was proposed as a primary end point and mortality at 12 months was evaluated as a secondary end point.Results: An inverse association was found between the alactic base excess with the initial pH (r= -0.303, p= <0.05) and the final lactate (r= -0.297, p= <0.05), in addition to bicarbonate (r= 0.593, p= <0.05) and central venous saturation variability (r= 0.304, p= <0.05). In the analysis by subgroups, both lower tertiles had a higher risk of presenting the adverse event (HR= 0.817, [95% CI 0.21 to 3.05], p= 0.763). No association of mortality was found with the first (HR= 0.95, [95% CI= 0.73 to 1.2], p= 0.687) or final determination (HR= 1, [95% CI= 0.758 to 1.3], p= 0.99).Discussion: In this study we found that the alactic base excess proposed to diagnostic different types of acidosis is capable of identifying small changes related to circulatory stress, regardless of the chronicity of kidney failure, hemodynamic status or hemoglobin concentration, but not related to mortality.Conclusions: Alactic base excess is potentially useful to evaluate circulatory stress in conjunction with other tissue hypoperfusion markers, however it would be necessary to expand the sample size and introduce therapeutic variables to determine its clinical impact.

Genetics of Sirenomelia, the Mermaid Syndrome

Sirenomelia (SML) is a rare, almost universally fatal congenital malformation presenting pathognomically with fused lower extremities and absent or malformed perineum. The classic Sirenomelia sequence includes a uniform spectrum of caudal malformations, spinal defects, and a single umbilical artery. SML is postulated to be due to a genetic predisposition, unmasked by biochemical or environmental triggers. Primary developmental defects in the formation of caudal mesoderm or embryonic caudal vessels with resultant local tissue hypoperfusion are proposed hypotheses for its pathogenesis. SML occurs sporadically in humans, presumably due to a spontaneous mutation, and is speculated to have an autosomal dominant inheritance pattern. In mutant mice, specific defects in Cyp26a1 and Bmp 7 genes are demonstrated to produce offsprings with SML. Bmp 7 is a signaling protein, which belongs to the transforming growth factor-β (TGF β) superfamily. Tsg 1, a Bmp and chordin-binding protein, functions as an activator-inhibitor of Bmp signaling in the embryonic caudal region (ECR). Loss of Bmp7 genes combined with a complete loss or half-dose of Tsg 1 is demonstrated to produce an invariable SML phenotype. SML is also demonstrated to occur with increased Retinoic acid (RA) signaling in the ECR. The Cyp26a1 gene is involved in coding for an enzyme, which expresses in ECR and degrades RA. A specific defect in this gene leads to excess local RA concentration and SML generation with a reported 20% penetrance in mutant mice. However, the mutational screening of Cyp26a1 and Bmp 7genes has failed to confirm their involvement in mankind and the molecular defect and genetic inheritability of SML in humans remain undefined.

Low Hypoperfusion Intensity Ratio Is Associated with a Favorable Outcome Even in Large Ischemic Core and Delayed Recanalization Time

In ischemic brain tissue, hypoperfusion severity can be assessed using the hypoperfusion intensity ratio (HIR). We evaluated the link between HIR and clinical outcomes after successful recanalization by endovascular treatment. We retrospectively reviewed 162 consecutive patients who underwent endovascular treatment for intracranial large vessel occlusion. The HIR was calculated using an automated software program, with initial computed tomography perfusion images. The HIR was compared between patients with and without favorable outcomes. To observe the modifying effect of the HIR on the well-known major outcome determinants, regression analyses were performed in the low and high HIR groups. The median HIR value was significantly lower in patients with a favorable outcome, with an optimal cut-off point of 0.54. The HIR was an independent factor for a favorable outcome in a specific multivariable model and was significantly correlated with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). In contrast to the high HIR group, the low HIR group showed that ASPECTS and onset-to-recanalization time were not independently associated with a favorable outcome. Finally, the low HIR group had a more favorable outcome even in cases with an unfavorable ASPECTS and onset-to-recanalization time. The HIR could be useful in predicting outcomes after successful recanalization.

The pathophysiology of “happy” hypoglycemia

Background Hypoglycemia usually includes various neurological symptoms, which are the consequence of neuroglycopenia. When it is severe, it is associated with altered mental status, even coma. Case presentation We report the case of a patient with severe hypoglycemia, completely asymptomatic, due to the increase of lactate production in response to tissue hypoperfusion following a hemorrhagic shock. This illustrates that lactate can substitute glucose as an energy substrate for the brain. It is also a reminder that this metabolite, despite its bad reputation maintained by its role as a marker of severity in critical care patients, has a fundamental role in our metabolism. Conclusions Following the example of the “happy hypoxemia” recently reported in the literature describing asymptomatic hypoxemia in COVID-19 patients, we describe a case of “happy hypoglycemia.”