Severe postpartum hemorrhage occurs in 1/1000 women giving birth. This condition is often dramatic and may be life threatening. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has ...in recent years been introduced as a novel treatment for hemorrhagic shock. We present a series of fluoroscopy-free REBOA for controlling life threatening postpartum hemorrhage.
In 2008 an 'aortic occlusion kit' was assembled and used in three Norwegian university hospitals. The on-call interventional radiologist (IR) was to be contacted with a response time < 30 minutes in case of life threatening PPH. Demographics and characteristics were noted from the medical records.
This retrospective study includes 36 patients treated with fluoroscopy-free REBOA for controlling severe postpartum hemorrhage in the years 2008-2015. The REBOA success rate was 100% and no patients died from REBOA related complications. Uterine artery embolization was performed in 17 (47%) patients and a hysterectomy in 16 (44%) patients. A short (11cm) introducer length was strongly associated with iliac artery thrombus formation (ρ = 0.50, P = 0.002). In addition, there was a strong negative correlation between uterine artery embolization and hysterectomy (ρ = -0.50, P = 0.002).
Our Norwegian experience indicates the clinical safety and feasibility of REBOA in life threatening PPH. Also, REBOA can be used in an emergency situation without the use of fluoroscopy with a high degree of technical success. It is important that safety implementation of REBOA is established, especially through limited aortic balloon occlusion time and a thorough balloon deflation regime.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Carotid intima-media thickness (cIMT) holds prognostic information for future cardiovascular disease and is associated with the extent of coronary atherosclerosis. We investigated the effect of ...exercise on cIMT progression in patients with both type 2 diabetes and coronary artery disease (CAD).
Patients with type 2 diabetes and CAD (n = 137) were randomized to exercise training or standard follow-up. The 12 month exercise program contained 150 min weekly of combined aerobic and resistance training. High-resolution ultrasonography of the distal part of the common carotid artery (CCA) was performed to measure cIMT before and after the intervention. The CCA and the carotid bulb were scanned for the presence of atherosclerotic plaques. Differences in changes between the randomized groups were calculated by one-way ANCOVA.
In the total population no difference in changes of cIMT from baseline to 12 months was observed between the exercise group and controls -0.016 mm (95 % CI -0.037 to 0.006) vs. -0.007 mm (95 % CI -0.029 to 0.015), p = 0.57. However, there was a significant interaction between the effect of exercise training and the presence of carotid plaques (p = 0.013), and significant reduced cIMT was demonstrated in the exercise group compared with controls in patients without identified carotid plaques (n = 65) -0.034 mm (95 % CI -0.060 to 0.008) vs. 0.013 mm (95 % CI -0.011 to 0.038), p = 0.010.
One year of exercise training in patients with type 2 diabetes and CAD did not significantly change cIMT progression. However, in patients without identified carotid plaques, beneficial effect of exercise training on cIMT progression was demonstrated.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
In vivo characterization of intracardiac blood velocity vector fields may provide new clinical information but is currently not available for bedside evaluation. In this paper, 4-D vector flow ...imaging for intracardiac flow assessment is demonstrated using a clinical ultrasound (US) system and a matrix array transducer, without the use of contrast agent. Two acquisition schemes were developed, one for full volumetric coverage of the left ventricle (LA) at 50 vps and a 3-D thick-slice setup with continuous frame acquisition (4000 vps), both utilizing ECG-gating. The 3-D vector velocity estimates were obtained using a novel method combining phase and envelope information. In vitro validation in a rotating tissue-mimicking phantom revealed velocity estimates in compliance with the ground truth, with a linear regression slope of 0.80, 0.77, and 1.03 for the x, y, and z velocity components, and with standard deviations of 2.53, 3.19, and 0.95 cm/s, respectively. In vivo measurements in a healthy LV showed good agreement with PC-MRI. Quantitative analysis of energy loss (EL) and kinetic energy (KE) further showed similar trends, with peak KE at 1.5 and 2.4 mJ during systole and 3.6 and 3.1 mJ for diastole for US and PC-MRI. Similar for EL, 0.15-0.2 and 0.7 mW was found during systole and 0.6 and 0.7 mW during diastole, for US and PC-MRI, respectively. Overall, a potential for US as a future modality for 4D cardiac vector flow imaging was demonstrated, which will be further evaluated in clinical studies.
Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). ...However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response.
This study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI.
The ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days.
We randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 95% confidence interval: 0.2 to 11.3 percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups.
Tocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction ASSAIL-MI; NCT03004703)
Display omitted
Introduction
Postpartum hemorrhage (PPH) remains a global health problem. The introduction of resuscitative endovascular balloon occlusion of the aorta (REBOA) in 2008 sought to enhance the ...management of hemorrhagic shock during PPH. In this study, we present a single Norwegian center's experience with REBOA as a supportive treatment in combating life threatening PPH.
Material and methods
This is a historical cohort study from St Olav's University Hospital, with data from period 2008–2021. It includes all patients who underwent REBOA as an adjunct treatment due to life threatening PPH, analyzing the outcomes and trends over a 14‐year period.
Results
A total of 37 patients received REBOA as an adjunct treatment. All procedures were technically successful, achieving hemodynamic stability with an immediate average increase in systolic blood pressure of 36 ± 22 mmHg upon initial balloon inflation. Additionally, a downward trend was noted in the frequency of hysterectomies and the volume of blood transfusions required over time. No thromboembolic complications were observed.
Conclusions
Our 14 years of experience at St Olav's Hospital suggests that REBOA serves as a safe and effective adjunct interventional technique for managing life‐threatening PPH. Furthermore, the findings indicate that incorporating a multidisciplinary approach to enable rapid aortic occlusion can potentially reduce the necessity for blood transfusions and hysterectomies.
A total of 14 years of experience at St Olav's Hospital suggests that REBOA serves as a safe and effective adjunct interventional technique for managing life‐threatening postpartum hemorrhage. Furthermore, the findings indicate that incorporating a multidisciplinary approach to enable rapid aortic occlusion can potentially reduce the necessity for blood transfusions and hysterectomies.
Reduced diastolic function is an early sign of diabetes cardiomyopathy in adults and is associated with elevated levels of HbA1c and advanced glycation end products (AGEs).
To assess the associations ...between early reduced diastolic function and elevated levels of HbA1c and AGEs in children and adolescents with type 1 diabetes (T1D).
One hundred fourty six T1D patients (age 8-18 years) without known diabetic complications were examined with tissue Doppler imaging and stratified into two groups according to diastolic function. A clinical examination and ultrasound of the common carotid arteries were performed. Methylglyoxal-derived hydroimidazolone-1 (MG-H1) was measured by immunoassay.
At inclusion, 36 (25%) participants were stratified into a low diastolic function group (E'/A'-ratio < 2.0). Compared to the rest of the T1D children, these participants had higher body mass index (BMI), 22.8 (SD = 4.0) vs. 20.1 (SD = 3.4) kg/m
, p < 0.001, higher systolic blood pressure 104.2 (SD = 8.7) vs. 99.7 (SD = 9.3) mmHg, p = 0.010, and higher diastolic blood pressure, 63.6 (SD = 8.3) vs. 59.9 (SD = 7.9) mmHg, p = 0.016. The distensibility coefficient was lower, 0.035 (SD = 0.010) vs. 0.042 (SD = 0.02) kPa
, p = 0.013, Young's modulus higher, 429 (SD = 106) vs. 365 (SD = 143), p = 0.009, and MG-H1 higher, 163.9 (SD = 39.2) vs. 150.3 (SD = 33.4) U/ml, p = 0.046. There was no difference in carotid intima-media thickness between the groups. There were no associations between reduced diastolic function and years from diagnosis, HBA1c, mean HBA1c, CRP or calculated glycemic burden. Logistic regression analysis showed that BMI was an independent risk factor for E'/A'-ratio as well as a non-significant, but relatively large effect size for MG-H1, indicating a possible role for AGEs.
Early signs of reduced diastolic function in children and adolescents with T1D had higher BMI, but not higher HbA1c. They also had elevated serum levels of the advanced glycation end product MG-H1, higher blood pressure and increased stiffness of the common carotid artery, but these associations did not reach statistical significance when tested in a logistic regression model.
We recently showed that interleukin (IL)-6 inhibition by tocilizumab improves myocardial salvage in ST-elevation myocardial infarction (STEMI). However, the mechanisms for this effect are not clear.
...In this exploratory sub-study of the ASSAIL-MI trial, we examined leukocyte differential counts and their relation to myocardial salvage and peak troponin T (TnT) in STEMI patients randomised to tocilizumab (n = 101) or placebo (n = 98). We performed RNA-sequencing on whole blood (n = 40) and T cells (n = 20). B and T cell subpopulations were examined by flow cytometry (n = 69).
(i) STEMI patients had higher neutrophil counts at hospitalisation compared with stable angina patients. (ii) After percutaneous coronary intervention there was a gradual decline in neutrophils, which was significantly more pronounced in the tocilizumab group. (iii) The decrease in neutrophils in the tocilizumab group was associated with improved myocardial salvage and lower peak TnT. (iv) RNA-sequencing suggested that neutrophil function was also attenuated by tocilizumab. (v) B and T cell sub-populations changed only minimally after STEMI with minor effects of tocilizumab, supported as well by RNA-sequencing analyses of T cells. (vi) However, a low CD8+ count was associated with improved myocardial salvage in patients admitted to the hospital > 3 h after symptom onset.
Tocilizumab induced a rapid reduction in neutrophils and seemed to attenuate neutrophil function in STEMI patients potentially related to the beneficial effects of tocilizumab on myocardial salvage.
South-Eastern Norway Regional Health Authority (Nos. 2019067, 2017084), the Central Norway Regional Health Authority and Norwegian Research Council (No. 283867).
Using magnetic resonance imaging (MRI) to relate cardiovascular structures to surface anatomy in a population relevant to cardiac arrest victims, relate the external thoracic anterior-posterior (AP) ...diameter (APEXTERNAL) and blood-filled structures to recommended chest compression depths, and define an optimal compression point (OCP).
MRI axial scans of referred patients were analysed. We defined origo as the skin surface of the centre of sternum in the internipple line. The blood-filled structures beneath origo were identified and the sum of their inner diameters (APBLOOD) and APEXTERNAL were measured. We defined OCP based on the image with maximum compressible left and right ventricle and where LVOT was not present. We measured the distance from origo to OCP.
Consecutive patients, mean (SD), age 52 (17) years, 110 (76 %) males, were categorized: cardiac disease (n = 74), aortic disease (n = 13), no findings/study patient (included in another study) (n = 57). The structure LVOT/aortic valve (AV)/aortic root was present in 46 % of patients with cardiac disease vs. 19 % of patients with no findings. APEXTERNAL for males and females was 25 (2) cm and 22 (2) cm, and APBLOOD 6.5 cm (2) and 4.7 cm (2), respectively. Distance from origo to OCP was 32 (11) mm to the left and 16 (21) mm caudally.
LVOT/AV/aortic root was present beneath the origo in almost half the patients with cardiac disease. Recommended chest compression depths exceeded the anterior-posterior diameter of blood-filled structures in more than half of the females. OCP was found 3 cm left of the origo.
Based on our study, individualized compression point and depth could be further studied in a prospective, clinical study.
Abstract
Aims
Arterial stiffness is a strong predictor of cardiovascular events. We aimed to assess the impact of type 1 diabetes (T1D) on arterial stiffness and cardiac function in young adults.
...Methods and results
Aortic pulse wave velocity (PWV), distensibility, left ventricular (LV) function and LV mass were measured by cardiovascular magnetic resonance imaging (CMR) in 47 T1D patients and 33 healthy controls. All were participants in the Atherosclerosis and Childhood Diabetes study, with baseline values registered 5 years previously. The patients had a mean age of 20.8 years and a median duration of diabetes of 10.0 years. PWV was significantly higher in the diabetes group compared with controls, mean 4.10 (SD = 4.58) vs. 3.90 (SD = 4.04) m/s, P = 0.045. In the diabetes group, insulin pump users at baseline had lower PWV than multiple injection users, mean 3.94 (SD = 0.38) vs. 4.23 (SD = 0.48) m/s, P = 0.028. Also in the diabetes group, multiple regression analysis identified C-reactive protein (CRP), female gender and insulin pump use as independent baseline risk factors for PWV 5 years later. There was no difference in cardiac function or LV mass between the diabetes and control groups.
Conclusion
In this prospective study, we found increased PWV assessed by CMR in young adults with T1D compared with controls. Also, CRP, female gender and insulin pump use emerged as independent baseline risk factors for PWV 5 years later.
Background:
Advanced protein glycation is an important mechanism for the development of late diabetic complications including atherosclerosis. Methylglyoxal-derived hydroimidazolone-1 is the most ...abundant advanced glycation end product in human plasma.
Aim:
To investigate the relationship between methylglyoxal-derived hydroimidazolone-1 and early signs of atherosclerosis in children and adolescents with type 1 diabetes and healthy controls.
Methods:
A total of 314 diabetes patients aged 8–18 years were compared with 120 healthy controls. Serum methylglyoxal-derived hydroimidazolone-1 was measured by immunoassay. Atherosclerosis was evaluated by assessing carotid intima-media thickness by ultrasound, arterial stiffness by Young’s modulus and inflammation by C-reactive protein.
Results:
Methylglyoxal-derived hydroimidazolone-1 was significantly increased in the diabetes group compared with controls, 155.3 (standard deviation (SD) = 41.0) versus 143.0 (SD = 35.1) U/mL, p = 0.003, as was C-reactive protein, median 0.51 (0.27, 1.83) versus 0.31 (0.19, 0.67) mg/L, p < 0.001. There was no significant difference between the groups regarding carotid intima-media thickness or Young’s modulus. Multiple regression analysis showed a significant positive association between methylglyoxal-derived hydroimidazolone-1 and C-reactive protein in the diabetes group.
Conclusion:
Serum levels of methylglyoxal-derived hydroimidazolone-1 in diabetes patients are increased and associated with low-grade inflammation, but not yet arterial stiffness or wall thickness. This indicates that methylglyoxal-derived hydroimidazolone-1 may be important in the early phase of the accelerated atherosclerotic process in diabetes.
PDF
