Volume 103 ·  Issue 10 ·  2023

Heparin resistance is becoming a hot issue of clinical concern. In critically ill patients, heparin resistance can lead to failure of anticoagulation therapy or increase the risk of major bleeding. Prompt recognition of heparin resistance can help to precisely adjust heparin dosage and avoid deterioration and adverse events. Heparin resistance can be mechanistically classified into the antithrombin-mediated and the non-antithrombin-mediated. Common etiologies include heparin-induced thrombocytopenia, severe infections such as severe COVID-19, treatment with extracorporeal circulation or extracorporeal membrane oxygenation (ECMO), and use of factor Xa reversal agents; heparin resistance is now often identified by the concordance of activated partial thromboplastin time (APTT) ratio with anti-FXa. Common clinical management strategies include antithrombin supplementation and replacement of anticoagulant drugs (e.g., direct thrombin inhibitors), but their safety and efficacy still need to be further validated.

To explore the clinical efficacy of a modified no-touch technique (MNTT) in establishing autogenous arteriovenous fistulas (AVF) in hemodialysis patients.

A total of 63 patients with AVF which was first established by MNTT in the Department of Nephrology, Suzhou Science and Technology Town Hospital from January 2021 to August 2022 were retrospectively included. The clinical data, ultrasound evaluation data of AVF, AVF maturity rate and AVF patency rate were collected. Subsequently, the AVF rate of patients in the MNTT group was compared with the patency rate of patients in the conventional operation group in the same hospital from January 2019 to December 2020. The Kaplan-Meier method was used to draw the survival curve, and the log-rank test was used to compare the difference in postoperative patency rate between the two groups.

There were 63 cases in the MNTT group, with 39 males and 24 females, and aged (60±17) years. Meanwhile, there were 40 cases in the conventional operation group, including 23 males and 17 females, and aged (60±13) years. In the MNTT group, the immediate patency rate was 100% (63/63) after surgery, and the AVF maturation rate at 2, 4 and 8 weeks postoperatively were 54.0% (34/63), 85.7% (54/63), and 90.5% (57/63), respectively. The primary patency rate was 90.0% (45/50), 85.0% (34/40), 82.9% (29/35), and 81.0% (17/21) at 3, 6, 9 months, and 1 year after the operation, respectively, and the assisted patency rates were all 100.0%. The one-year primary patency rate in the MNTT group was higher than that in the conventional surgery group (81.0% versus 63.5%, log-rank χ²=5.12, P=0.023). Ultrasound results showed that in the MNTT group, AVF veins were evenly dilated, the vascular wall gradually thickened, the brachial artery blood flow gradually increased, and spiral laminar flow occurred in the cephalic vein and radial artery.

AVF established by MNTT features with fast maturity and a high patency rate, which is worthy of clinical promotion.

To explore the predictive value of controlling nutritional status (CONUT) score and dialysis age for peritoneal dialysis-associated peritonitis (PDAP).

This study was a follow-up study. Patients with end-stage renal disease who received peritoneal dialysis (PD) for the first time in the Department of Nephrology, the Third Affiliated Hospital of Suzhou University from January 2010 to December 2020 were enrolled in the study. Patients were divided into non-peritonitis group, mono group (only once PDAP occurred in one year) and frequent group (twice or more PDAP occurred in one year) according to the occurrence and frequency of PDAP during follow-up. The demographic, clinical and laboratory data of patients were collected, and the body mass index and CONUT score were recorded after half a year. Cox regression analysis was used to screen the relevant factors, and receiver operating characteristic (ROC) curve was used to analyze the predictive value of CONUT score and dialysis age for PDAP.

A total of 324 PD patients were included, with 188 males (58.0%) and 136 females (42.0%), and aged［M（Q₁，Q₃）］48 (37, 60) years old. The follow-up time was 33 (19, 56) months. PDAP occurred in 112 patients (34.6%), including 63 patients (19.4%) in mono group and 49 patients (15.1%) in frequent group. Multivariate Cox regression analysis showed that half-year CONUT score (HR=1.159, 95%CI: 1.047-1.283, P=0.004) was a risk factor for PDAP, and the baseline CONUT score (HR=1.194, 95%CI: 1.012-1.408, P=0.036) was a risk factor for frequent peritonitis. The area under ROC curve of baseline CONUT score combined with dialysis age in predicting PDAP and frequent peritonitis was 0.682 (95%CI: 0.628-0.733) and 0.676 (95%CI: 0.622-0.727), respectively.

CONUT score and dialysis age have certain predictive value for PDAP, and the predictive value of combined diagnosis is higher, which may be used as a potential predictor for PDAP in PD patients.

To investigate the relationship between different serum potassium levels at admission and discharge and all-cause mortality in patients with acute heart failure (HF).

A total of 2 621 patients with acute HF who were hospitalized in the Heart Failure Center of Fuwai Hospital from October 2008 to October 2017 were analyzed. Patients were divided into three groups according to the different serum potassium levels at admission: hypokalemia with serum potassium<3.5 mmol/L (n=329), normokalemia with 3.5-5.5 mmol/L (n=2 270), and hyperkalemia with serum potassium>5.5 mmol/L (n=22). Clinical data such as patient history, comorbidities, clinical examination and drug use were collected, and systematic outpatient review or telephone follow-up was performed after patients were discharged from the hospital until January 2020. The primary outcome was all-cause death at 90 days, 2 years, and 5 years of follow-up. We compared the clinical characteristics of patients with different serum potassium levels at admission and discharge, and used a multivariate Cox proportional hazards regression model to analyze the association between serum potassium levels at admission and discharge and all-cause mortality.

The age of all patients was (58.0±15.3) years old, and 1 877 patients (71.6%) were male. There were 329 (12.6%) and 22 (0.8%) patients with hypokalemia and hyperkalemia at admission, and 38 (1.4%) and 18 (0.7%) at discharge, respectively. The serum potassium levels of all patients were (4.01±0.50) and (4.25±0.44) mmol/L at admission and discharge, respectively. The follow-up time[M(Q₁,Q₃)] of this study was 2.63(1.00,4.42)years, and a total of 1 076 all-cause deaths were recorded at the last follow-up. Compared with patients with normokalemia at discharge, discharged patients with hypokalemia and hyperkalemia were followed up for 90 days (90.3% vs 76.3% vs 38.9%), 2 years (73.8% vs 60.5% vs 33.3%) and 5 years (63.4% vs 44.7% vs 22.2%), respectively, and the difference of which in cumulative survival rates were statistically significant (all P values<0.001). The multivariate-adjusted Cox regression analysis showed that hypokalemia (HR=0.979, 95%CI: 0.812-1.179, P=0.820) and hyperkalemia (HR=1.368, 95%CI: 0.805-2.325, P=0.247) at admission were not associated with all-cause mortality risk, however, hypokalemia (HR=1.668, 95%CI: 1.081-2.574, P=0.021) and hyperkalemia (HR=3.787, 95%CI: 2.264-6.336, P<0.001) at discharge were associated with increased all-cause mortality risk.

Both hypokalemia and hyperkalemia at discharge in hospitalized patients with acute HF were associated with increased short-and long-term all-cause mortality, and serum potassium levels should be closely monitored.

To compare the improvement in quality of life (QoL) after implantation of leadless pacemakers (L-PM) with that of conventional pacemakers (C-PM) in patients with slow-onset arrhythmias.

A total of 112 patients who received pacemaker implantation for the first time at Beijing Anzhen Hospital from January 2020 to July 2021 were selected, including 50 leadless pacemakers (L-PM) and 62 conventional pacemakers (C-PM). Clinical baseline data were collected, pacemaker-related complications and SF-36 scores were recorded and followed up at 1, 3, and 12 months post-operatively; SF-36 questionnaires and additional questionnaires were completed to compare the quality of life of the 2 groups; and factors associated with the change in QoL from baseline to 1, 3 and 12 months post-operatively were analyzed using multiple linear regression models.

The age of the 112 patients was (70.3±10.5) years, and 69 patients (61.6%) were male. The age of patients with L-PM and C-PM was (75.8±8.5) years and (67.5±10.4) years, respectively (P=0.004). In the L-PM group, 50 patients completed 1-, 3-, and 12-month follow-up. In the C-PM group, 62 patients completed the 1-month and 3-month follow-up, and 60 completed the 12-month follow-up. The C-PM group had a higher incidence of discomfort in the surgical area, impact of daily activities for the discomfort in the surgical area, and concern about heart or overall condition than the L-PM group on the additional questionnaire (all P values<0.05). After adjusting for age and SF-36 scores at baseline, at 12^th month of follow-up, patients implanted with C-PM had lower values for quality of life PF, RP, SF, RE, and MH scores compared to patients implanted with L-PM, with beta values (95%CI) of -24.500 (-30.010--18.981), -27.118 (-32.997--21.239), -8.085 (-12.536--3.633), -4.839 (-9.437--0.241), -12.430 (-18.558--6.301), respectively (all P values<0.05).

L-PM is associated with better QoL in slow arrhythmias patients, and patients who received L-PM reported less activity limitations due to surgical discomfort and less emotional distress.

To investigate the efficacy and safety of a new endoscopic anastomosis clip in the treatment of defects after endoscopic full-thickness resection (EFTR).

Retrospective cohort study. Fourteen patients [4 males and 10 females, aged (55.9±8.2) years (45-69 years)] with gastric submucosal tumors underwent EFTR at the First Affiliated Hospital of Soochow University were included from December 2018 to January 2021. Patients were divided into new anastomotic clamp group (n=6) and nylon ring combined with metal clips group (n=8). Preoperative endoscopic ultrasound examinations were required to all patients to evaluate the wound condition. The size of the defect, operation time required for wound closure, success rate of closure, postoperative gastric tube placement time, postoperative hospital stay, incidence of complications, preoperative and postoperative serological indexes were compared between the two groups. All patients were followed up after the operation, among which the general endoscopy was reviewed in the first month after the operation, and the telephone and questionnaire follow-up were used in the second, third, sixth month and one year after the operation to evaluate the therapeutic effect of the new endoscopic anastomosis clip and nylon rope combined with metal clip after the EFTR operation.

Both groups successfully completed EFTR and were successfully closed. There was no significant difference between the age, tumor diameter and defect diameter of the two groups (all P>0.05). Compared with the nylon ring combined with metal clip group, the operation time of the new anastomotic clip group was shortened [(5.0±1.8) minutes vs (35.6±10.2) minutes, P<0.001]. The operation time was shortened [(62.2±12.5) minutes vs (92.5±0.2) minutes, P=0.007]. Postoperative fasting time decreased [(2.8±0.8) days vs (4.9±1.1) days, P=0.002]. The hospital stay after operation was also shortened [(5.2±0.8) days vs (6.9±1.5) days, P=0.023]. The total intraoperative bleeding volume decreased [(20.00±5.48) ml vs (35.63±14.75) ml, P=0.031]. The patients in both groups received endoscopic examination 1 month after operation, and there was no delayed perforation and bleeding after operation. There was no obvious symptoms of discomfort.

The new anastomotic clamp is suitable for the treatment of full-thickness gastric wall defects after EFTR, and shows advantages of shorter operation, less bleeding, and fewer postoperative complications.

To investigate the role of caspase recruitment domain protein 9 (CARD9) in airway injury and inflammation of steroid resistant asthma in C57BL/6 mice.

C57BL/6 mice were divided into A group (control group), B group (model group) and C group (dexamethasone treatment group), with 6 mouse in each group using random number table. The mouse asthma model was established in B and C group by subcutaneous injection of ovalbumin (OVA)/complete Freund adjuvant (CFA) in the abdomen and OVA aerosol challenge, the pathological change and cell count in broncho alveolar lavage fluid (BALF) were detected in order to confirm the model as steroid resistant asthma, and the lung tissue inflammatory infiltration was scored. Western blot was used to detect the changes of CARD9 protein between the group A and B; then wild-type and CARD9 knockout mice were divided into D group (wild-type control group), E group (wild-type model group), F group (CARD9 knockout control group) and G group (CARD9 knockout model group), the following indicators were observed and compared after establishing steroid resistant asthma model separately: HE staining was used to observe the pathological changes of lung tissue, ELISA was used to detect the protein levels of interleukin-4 (IL-4), interleukin-5 (IL-5) and interleukin-17(IL-17) in BALF, and RT-PCR was used to detect the mRNA levels of CXC motif chemokine ligand-10 (CXCL-10) and IL-17 in lung.

The inflammatory score (3.33±0.82 vs 0.67±0.52) and BALF total cell count [(10.13±4.83) ×10⁵/ml vs (3.76±0.84) ×10⁵/ml] in B group were higher than those in the A group with statistical significance (P<0.05). There was no significant difference between group C and group B in inflammatory infiltration score (2.83±0.75 vs 3.33±0.82) and BALF total cell count [(9.80±3.19) ×10⁵/ml vs (10.13±4.83) ×10⁵/ml] (P>0.05). Moreover the protein level of CARD9 was increased in the B group than A group (0.245±0.090 vs 0.047±0.014, P=0.004). Compared to E group and F group, more obviously inflammatory cells, neutrophils, eosinophils infiltration and tissue injury were observed in G group (P<0.05), so did the expression of IL-4 (P<0.05), IL-5 and IL-17. Meanwhile the mRNA expression levels of IL-17 and CXCL-10 also increased in lung tissue (P<0.05) of G group.

CARD9 gene deletion may aggravate the steroid resistant of asthma by increasing neutrophil chemokines, such as IL-17 and CXCL-10, therefore increasing infiltration of neutrophils in C57BL/6 mice asthma model.

The study aimed to evaluate whether an intra-aortic balloon pump (IABP) could improve the prognosis of patients with cardiogenic shock (CS) of Stage C (Classic), Stage D (Deteriorating), and Stage E (Extremis) based on Society for Cardiovascular Angiography and Interventions (SCAI) classification. The hospital information database was searched, and the patients who met the diagnostic criteria of CS were included and treated following the same protocol. The association between IABP and the survival of patients at 1 month and 6 months were analyzed separately in SCAI stage C of CS, and stages D and E of CS. The multiple logistic regression models were used to separately evaluate whether IABP was independently associated with increased survival in stage C of CS, and stages D and E of CS. A total of 141 patients with stage C of CS and 267 patients with stages D and E of CS were included. In stage C of CS, IABP was significantly associated with improved survival of patients at 1 month [adjusted OR (95%CI)=0.372 (0.171-0.809), P=0.013] and survival at 6 months [adjusted OR (95%CI)=0.401 (0.190-0.850), P=0.017]. However, when percutaneous coronary intervention or coronary artery bypass grafting (PCI/CABG) was introduced as an adjusted factor, there was a significant association between survival rates and PCI/CABG rather than IABP. In stages D and E of CS, IABP was significantly associated with an improved survival at 1 month [adjusted OR (95%CI)=0.053 (0.012-0.236), P=0.001]. Therefore, IABP could assist patients with stage C of CS in the perioperative period of PCI/CABG and improve survival rates, and IABP might prolong short-term prognosis of patients with stages D and E of CS.

IgG4-associated disease (IgG4-RD) is an immune-mediated systemic disease characterized by tissue lymphocyte infiltration, fibrosis. There are few reports of IgG4-RD combined with connective tissue disease (CTD). This article reports the clinical manifestations, imaging features and pathological features of a patient with IgG4-RD combined with CTD, in order to provide reference for the diagnosis and treatment of IgG4-RD combined with CTD.

Patient, male, 85 years old. The main reason for "conscious penis retraction discomfort for more than 1 year" was to see a doctor. In the past year, the patient has gradually developed penis retraction with severe discomfort without obvious inducement. Only a little penis head and penis body can be exposed during the attack, and he feels extreme pain, accompanied by general fatigue, low mood, irritability and insomnia. The patient was obese (waist circumference 110 cm, body mass index 27.7 kg/m²), with a past history of diabetes, atherosclerosis, hyperlipidemia, etc. Auxiliary examination: Peripheral blood testosterone (T) 2.46 μ g/L. The patients were treated with testosterone supplementation therapy (TST) and type 5 phosphodiesterase inhibitor (PDE5-I). After multiple follow-ups within 3 months after treatment, the above symptoms were significantly improved.

Bilateral renal cancer has a low incidence and unknown etiology. Clear cell renal carcinoma is the main pathological type of bilateral sporadic renal carcinoma, and the histological agreement between bilateral renal carcinomas is high. Surgery is the preferred treatment for double renal cancer, including partial nephrectomy and radical nephrectomy. The formulation of treatment plan should comprehensively consider the patient's age, clinical manifestations, tumor size, number and location, lymph node involvement status and subjective willingness, etc. The factors affecting the prognosis of patients include age, pathological characteristics of tumor, growth rate, treatment mode, surgical margin, etc. The prognosis of patients with double renal cancer is generally similar to that of patients with unilateral renal cancer.

The incidence of metabolic cardiovascular disease is increasing rapidly worldwide, and how to comprehensively manage and intervene in its early stage is the focus of clinical attention. The concept of chronic diseases based on cardiovascular metabolism helps to divide the stages of diagnosis and treatment and fine management of metabolic cardiovascular diseases. In terms of specific prevention and treatment methods, evidence-based medical evidence of new hypoglycemic drugs, lipid-lowering drugs and mineralocorticoid antagonists continues to emerge, and the benefits of lifestyle and bariatric surgery have been confirmed in high-quality studies. In addition, there are new advances and breakthroughs in the treatment of cardiovascular residual risk. This review reviews important research advances published in the field of metabolic cardiovascular diseases in 2022 and looks forward to future directions.

The novel coronavirus infection (COVID-19) is caused by the novel coronavirus (SARS-CoV-2) infection, which brings tremendous prevention and control pressure to the world. AZD7442 adopts antibody cocktail therapy, and two long-acting neutralizing antibodies, Tixagevimab and Cilgavimab, synergistically play a neutralizing role, which has both preventive and therapeutic value. This review summarizes the structural characteristics and pharmacodynamic studies of AZD742's effective neutralization of SARS-CoV-2, with a view to gaining a deeper understanding of the neutralizing effect of AZD7442 on SARS-CoV-2. AZD7442 has also shown a positive role in post-exposure prevention and treatment, and is currently the only neutralizing antibody approved for pre-exposure prevention of COVID-19. Given the dual application prospects of AZD7442 in COVID-19 prevention and treatment, AZD7442 is expected to provide a new option for the current prevention and treatment of SARS-COV-2 infection, and at the same time provide reference significance for the prevention and treatment of other viral infections.

Takayasu arteritis is a rare nonspecific autoimmune vascular inflammatory disease. In recent years, studies on the mechanism of Takayasu arteritis have increased year by year, but there are still few studies on cell function and various signaling pathways within cells. In order to further enhance the systematic understanding of the research on cell signaling pathways in Takayasu arteritis, this paper focuses on the research on cell signaling pathways in recent five years, including mammalian rapamycin target protein (mTOR), Janus kinase (JAK), mononuclear macrophage pathway and fibroblast pathway, and introduces the possible interactions between different signaling pathways and possible research directions in the future.

Simultaneous bilateral renal tumor is a rare and complicated condition of renal tumor, with an incidence of 1.8% ~11.0%. For patients with bilateral renal tumors, surgical treatment requires comprehensive consideration of tumor location, size and anatomical complexity, patient's physical condition and current underlying diseases, perioperative risk, surgeon's professional knowledge and skills and other factors. Nephron-sparing surgery (NSS) should be the first choice for patients who are evaluated to be operatively treated to protect renal function as much as possible and to reduce cardiovascular morbidity and all-cause mortality. However, at present, international guidelines have not put forward formal recommendations for the treatment of such patients, and academic circles have not yet formed a clear and consistent consensus on the ideal treatment method for bilateral kidney tumors in the same period, especially whether to perform kidney biopsy before operation, whether to perform simultaneous surgery or staged surgery, and which side of the tumor to treat first. There are still many controversies. In order to solve the above controversial issues and optimize the management and surgical treatment strategies of patients with bilateral renal tumors, the study collected and retrospectively analyzed the data of 41 patients who underwent partial nephrectomy (PN) or radical nephrectomy (RN) for bilateral renal tumors between June 2008 and June 2019, and analyzed the demographic and oncology-related characteristics of patients, surgical modalities (contemporaneous or staged, open surgery or robotic surgery), etc. Of 41 patients, 37 (90.2%) underwent bilateral PN, 3 (7.3%) underwent PN + RN, and 1 (2.5%) underwent bilateral RN. The most common tumor histological type was clear cell renal cell carcinoma (62.1%), and the bilateral tumor histological agreement rate was 81.5%. Seventeen patients (41.4%) and 24 patients (58.6%) underwent simultaneous and staged surgery, respectively. Median operative time for staged surgical patients (310 vs 240 min,P=0.01), thermal ischemia time (18 vs. 10 min,P=0.01) and length of hospital stay (10 versus 6 d,P=0.01) was significantly longer than that of contemporaneous surgical patients. There were no statistically significant differences in the median estimated glomerular filtration rate (eGFR) at baseline, 3 months after surgery, and last follow-up for contemporaneous and staged surgery patients (P>0.05）。 Survival analysis showed no statistically significant difference in disease-free survival between the two groups (82.4% vs 95.8%,P=0.14）。 The results of this study suggest that simultaneous and staged surgical treatment is feasible and safe for patients with simultaneous bilateral renal tumors.

Bilateral renal cell carcinoma (RCC) accounts for approximately 5% of all RCC patients, including simultaneous RCC (diagnosed simultaneously with or within 3 months after the original tumor was discovered) and metachronous RCC (diagnosed 3 months after the original tumor was discovered). Because the incidence of bilateral RCC is relatively rare, so far, there is a lack of reports in the literature on patients undergoing bilateral renal surgery. Only a few literatures have studied the influence of tumor characteristics, surgical method choice and patient-related risk factors on the functional prognosis of patients. Recent studies have reported the results of renal function after different bilateral renal surgeries in patients with simultaneous bilateral renal tumors. Bilateral partial nephrectomy (PN) was associated with a significant improvement in estimated glomerular filtration rate (eGFR) compared to radical nephrectomy (RN). Compared with staged PN, patients with nonmetastatic synchronous bilateral tumors who received contemporaneous PN had lower mean eGFR at 3 months and 12 months after surgery. However, the current guidelines still lack recommendations for the optimal surgical sequence, and few studies compare the long-term functional prognosis of patients undergoing different surgical sequences. Therefore, in order to evaluate the long-term renal function prognosis of patients with bilateral RCC after receiving different sequences of PN and RN and further optimize the treatment regimen of patients with bilateral renal tumors, this study retrospectively analyzed the demographic information, oncological data and prognostic outcome data of 267 patients with bilateral RCC from Seoul University Hospital (SNUH), Bonton Seoul University Hospital (SNUBH), Seoul, Korea. The results showed that bilateral PN (n=48), RN after PN (n=8) and PN after RN (n=25) patients had postoperative eGFR of 79.4, 41.4, and 61.2 ml/ (min 1.73 m, respectively²）（P=0.003）。 There were statistically significant differences in the degree of eGFR decline from baseline and the incidence of chronic kidney disease (CKD ≥ stage Ⅲ) between the groups (bothP<0.05), with the worst functional outcome in patients undergoing PN after RN. In addition, the incidence of postoperative CKD in bilateral RCC was significantly higher in the bilateral PN group than in the unilateral RCC group (13.8% vs. 6.9%,P=0.016）。 Multivariate analysis indicated that hypertension (P=0.010) and sequence of surgery (RN after PN,P<0.001) was a significant predictor of new postoperative CKD. Therefore, the most ideal surgical method for patients with bilateral renal tumors is PN, but when the combination of RN and PN is inevitable, the surgical sequence should be decided carefully. PN after RN is not beneficial to the renal function protection of patients.