[Experts consensus on the management of the right heart function in critically ill patients]

To establish the experts consensus on the right heart function management in critically ill patients. The panel of consensus was composed of 30 experts in critical care medicine who are all members of Critical Hemodynamic Therapy Collaboration Group (CHTC Group). Each statement was assessed based on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) principle. Then the Delphi method was adopted by 52 experts to reassess all the statements. (1) Right heart function is prone to be affected in critically illness, which will result in a auto-exaggerated vicious cycle. (2) Right heart function management is a key step of the hemodynamic therapy in critically ill patients. (3) Fluid resuscitation means the process of fluid therapy through rapid adjustment of intravascular volume aiming to improve tissue perfusion. Reversed fluid resuscitation means reducing volume. (4) The right ventricle afterload should be taken into consideration when using stroke volume variation (SVV) or pulse pressure variation (PPV) to assess fluid responsiveness.(5)Volume overload alone could lead to septal displacement and damage the diastolic function of the left ventricle. (6) The Starling curve of the right ventricle is not the same as the one applied to the left ventricle,the judgement of the different states for the right ventricle is the key of volume management. (7) The alteration of right heart function has its own characteristics, volume assessment and adjustment is an important part of the treatment of right ventricular dysfunction (8) Right ventricular enlargement is the prerequisite for increased cardiac output during reversed fluid resuscitation; Nonetheless, right heart enlargement does not mandate reversed fluid resuscitation.(9)Increased pulmonary vascular resistance induced by a variety of factors could affect right heart function by obstructing the blood flow. (10) When pulmonary hypertension was detected in clinical scenario, the differentiation of critical care-related pulmonary hypertension should be a priority. (11) Attention should be paid to the change of right heart function before and after implementation of mechanical ventilation and adjustment of ventilator parameter. (12) The pulmonary arterial pressure should be monitored timingly when dealing with critical care-related pulmonary hypertension accompanied with circulatory failure.(13) The elevation of pulmonary aterial pressure should be taken into account in critical patients with acute right heart dysfunction. (14) Prone position ventilation is an important measure to reduce pulmonary vascular resistance when treating acute respiratory distress syndrome patients accompanied with acute cor pulmonale. (15) Attention should be paid to right ventricle-pulmonary artery coupling during the management of right heart function. (16) Right ventricular diastolic function is more prone to be affected in critically ill patients, the application of critical ultrasound is more conducive to quantitative assessment of right ventricular diastolic function. (17) As one of the parameters to assess the filling pressure of right heart, central venous pressure can be used to assess right heart diastolic function. (18). The early and prominent manifestation of non-focal cardiac tamponade is right ventricular diastolic involvement, the elevated right atrial pressure should be noticed. (19) The effect of increased intrathoracic pressure on right heart diastolic function should be valued. (20) Ttricuspid annular plane systolic excursion (TAPSE) is an important parameter that reflects right ventricular systolic function, and it is recommended as a general indicator of critically ill patient. (21) Circulation management with right heart protection as the core strategy is the key point of the treatment of acute respiratory distress syndrome. (22) Right heart function involvement after cardiac surgery is very common and should be highly valued. (23) Right ventricular dysfunction should not be considered as a routine excuse for maintaining higher central venous pressure. (24) When left ventricular dilation, attention should be paid to the effect of left ventricle on right ventricular diastolic function. (25) The impact of left ventricular function should be excluded when the contractility of the right ventricle is decreased. (26) When the right heart load increases acutely, the shunt between the left and right heart should be monitored. (27) Attention should be paid to the increase of central venous pressure caused by right ventricular dysfunction and its influence on microcirculation blood flow. (28) When the vasoactive drugs was used to reduce the pressure of pulmonary circulation, different effects on pulmonary and systemic circulation should be evaluated. (29) Right atrial pressure is an important factor affecting venous return. Attention should be paid to the influence of the pressure composition of the right atrium on the venous return. (30) Attention should be paid to the role of the right ventricle in the acute pulmonary edema. (31) Monitoring the difference between the mean systemic filling pressure and the right atrial pressure is helpful to determine whether the infusion increases the venous return. (32) Venous return resistance is often considered to be a insignificant factor that affects venous return, but attention should be paid to the effect of the specific pathophysiological status, such as intrathoracic hypertension, intra-abdominal hypertension and so on. Consensus can promote right heart function management in critically ill patients, optimize hemodynamic therapy, and even affect prognosis.

Vitamin A maintains the airway epithelium in a murine model of asthma by suppressing glucocorticoid-induced leucine zipper

BACKGROUND

The effects of glucocorticoids (GCs) on the repair of the airway epithelium in asthma are controversial, and we previously reported that the GC dexamethasone (Dex) inhibits the repair of human airway epithelial cells and that this process is mediated by glucocorticoid-induced leucine zipper (GILZ) through MAPK-ERK signaling in vitro. Vitamin A (VA) is involved in the regulation of the MAPK-ERK pathway but has not been widely supplied during asthma treatment. It is unclear whether VA attenuates the negative regulation of GILZ on the MAPK-ERK pathway and maintains airway epithelium integrity during asthma treatment.

METHODS

Female BALB/c mice were sensitized and challenged with ovalbumin (OVA) and subsequently treated with Dex, VA or intranasal inhalation of adenovirus sh-GILZ vectors. Indexes of airway epithelium integrity, including pathological alterations, pulmonary EGFR expression and airway hyperresponsiveness (AHR), were then measured. The expression of GILZ and key components of activated MAPK-ERK signals (p-Raf-1, p-MEK, and p-Erk1/2) were also detected.

RESULTS

Dex failed to relieve OVA-induced asthma airway epithelium injury, as assessed through H&E staining, EGFR expression and AHR. Moreover, in the OVA-challenged mice treated with Dex, GLIZ expression was increased, whereas the ratios of p-Raf-1/Raf-1, p-MEK/MEK and p-Erk1/2/Erk1/2 were significantly decreased. Further study indicated that GILZ expression was decreased and that the ratios of p-Raf-1/Raf-1, p-MEK/MEK and p-Erk1/2/Erk1/2 were up-regulated in the GILZ-silenced OVA-challenged mice and VA-fed OVA-challenged mice, independent of Dex treatment. The airway epithelium integrity of the OVA-challenged mice was maintained by treatment with both VA and Dex.

CONCLUSIONS

Vitamin A maintained the Dex-treated asthma airway epithelium via the down-regulation of GILZ expression and the activation MAPK-ERK signaling, and these effects might contribute to improving the effects of GC therapeutics on asthma.

Effect of dietary fiber and diet particle size on nutrient digestibility and gastrointestinal secretory function in growing pigs

Reduction of diet particle size (PS) increases feed efficiency due to an increase in the apparent total tract (ATTD) of GE. However, other effects of PS on the gut secretory function are not known. Therefore, the objective of this experiment was to measure the effect of diet composition (DC) and PS on nutrient digestibility, gastrointestinal hormones, total bile acids (TBA), total cholesterol and glucose concentrations in plasma of finishing pigs ( = 8/diet). Pigs were fed finely (374 ± 29 µm) or coarsely (631 ± 35 µm) ground corn-soybean meal (CSB), CSB + 35% corn dried distillers' grains with solubles (DDGS), and CSB with 21% soybean hulls (SBH) diets for 49 d. Diet composition, nutrient digestibility, along with fasting plasma concentrations of gastrin, insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic peptide (GIP), TBA, cholesterol, and glucose were measured. Fine ground diets had greater ( < 0.05) ATTD of GE as well as greater ( < 0.05) ME than coarse ground diets independent on the DC. Fine ground diets also had greater ( < 0.05) ATTD of DM, N, ether extract, and NDF, independent of DC. A decrease in PS also caused an increase ( < 0.05) in ATTD of N, K, and S, but it did not affect ATTD of Ca, P, or Na. The DC and PS affected plasma gastrin, insulin and TBA but not GIP, GLP-1, glucose, and cholesterol. Gastrin concentration was greater ( < 0.05) in pigs fed coarse DDGS compared with feeding coarse CSB and SBH diets. Insulin concentration of pigs fed CSB was greater ( < 0.01) in pigs fed fine compared with coarse DDGS, and was greater ( < 0.05) in coarse compared with fine SBH diets. Pigs fed DDGS had greater ( < 0.05) TBA than those fed SBH and fine CSB diets. Gastrin, insulin, TBA and cholesterol tended ( < 0.10), or correlated ( < 0.05) with P, K and Fe intake. Insulin, TBA, and cholesterol were correlated ( < 0.05) with Na and S intake. In conclusion, a decrease in diet PS increases the ATTD of nutrients independently of DC, while mineral intake affects gastrointestinal secretion of hormones with potential metabolic impacts. Plasma insulin and glucose concentrations were correlated with DM intake, and glucose was associated with lipid and protein intake. Diet energy, nutrient digestibility, and plasma gastrin, insulin and TBA concentrations were affected by DC and PS.

High-flow Nasal Cannula Versus Noninvasive Ventilation for Treatment of Acute Hypoxemic Respiratory Failure in Renal Transplant Recipients

OBJECTIVE

This study aimed to evaluate the outcomes of high-flow nasal cannula (HFNC) oxygen therapy compared with noninvasive ventilation (NIV) for the treatment of acute hypoxemic respiratory failure in renal transplant recipients.

METHODS

Data were retrospectively collected from a tertiary intensive care unit (ICU) from July 1, 2011, to September 31, 2015. All renal recipients who had acute respiratory failure at that period of time were classified into the HFNC or NIV group depending on the initial form of respiratory support.

RESULTS

A total of 38 patients were enrolled in this study. Twenty patients received HFNC and the other 18 received NIV as the initial respiratory support. The ICU mortality in the HFNC group was 5% (1 patient), compared with 22.2% (4 patients) in the NIV group (P = .083). The median length of the ICU stay was 12 days in the HFNC group, compared with 14 days in the NIV group (P = .297). The number of ventilator-free days at day 28 was significantly higher in the HFNC group than in the NIV group (26 ± 3 vs 21 ± 3; P < .001). The incidences of both pneumothorax (0% vs 22.2%; P = .042) and skin breakdown (0% vs 22.2%; P = .042) were significantly lower in the HFNC group.

CONCLUSIONS

In renal transplant recipients with acute hypoxemic respiratory failure secondary to severe pneumonia, HFNC achieved outcomes similar to NIV. In addition, HFNC was associated with an increased number of ventilator-free days at day 28 and fewer complications.

An integrated analysis identifies STAT4 as a key regulator of ovarian cancer metastasis

Epithelial ovarian cancer (EOC) is one of the most common gynecological cancers, with diagnosis often at a late stage. Metastasis is a major cause of death in patients with EOC, but the underlying molecular mechanisms remain obscure. Here, we utilized an integrated approach to find potential key transcription factors involved in ovarian cancer metastasis and identified STAT4 as a critical player in ovarian cancer metastasis. We found that activated STAT4 was overexpressed in epithelial cells of ovarian cancer and STAT4 overexpression was associated with poor outcome of ovarian cancer patients, which promoted metastasis of ovarian cancer in both in vivo and in vitro. Although STAT4 mediated EOC metastasis via inducing epithelial-to-mesenchymal transition (EMT) of ovarian cancer cells in vivo, STAT4 failed to induce EMT directly in vitro, suggesting that STAT4 might mediate EMT process via cancer-stroma interactions. Further functional analysis revealed that STAT4 overexpression induced normal omental fibroblasts and adipose- and bone marrow-derived mesenchymal stem cells to obtain cancer-associated fibroblasts (CAF)-like features via induction of tumor-derived Wnt7a. Reciprocally, increased production of CAF-induced CXCL12, IL6 and VEGFA within tumor microenvironment could enable peritoneal metastasis of ovarian cancer via induction of EMT program. In summary, our study established a model that STAT4 promotes ovarian cancer metastasis via tumor-derived Wnt7a-induced activation of CAFs.

Discordance between patient and clinician reports of adverse reactions to MDR-TB treatment

SETTING

An urban out-patient clinic in Durban, South Africa, providing community-based treatment for drug-resistant tuberculosis (TB).

OBJECTIVE

To describe concordance between patient report and clinician documentation of adverse drug reactions (ADRs) to treatment for multidrug-resistant TB (MDR-TB).

DESIGN

ADRs were documented by interview using an 18-item symptom checklist and medical record data abstraction during a cross-sectional parent study with 121 MDR-TB patients, 75% of whom were co-infected with the human immunodeficiency virus. Concordance was analyzed using Cohen's κ statistic, Gwet's agreement coefficient (AC) 1, and McNemar's test.

RESULTS

ADRs were reported much more frequently in patient interviews (μ = 8.6) than in medical records (μ = 1.4). Insomnia was most common (67% vs. 2%), followed by peripheral neuropathy (65% vs. 18%), and confusion (61 vs. 4%). κ scores were very low, with the highest degree of concordance found in hearing loss (κ = 0.23), which was the only ADR not found to be significantly different between the two data sources (P = 0.34).

CONCLUSIONS

Our study showed a lack of concordance between patient report and clinician documentation of ADRs. These findings indicate the need for improved documentation of ADRs to better reflect patients' experiences during MDR-TB treatment. These data have important implications for country-level pharmacovigilance programs that rely on clinician documentation of ADRs for MDR-TB policy formation.

Identification of novel variants associated with warfarin stable dosage by use of a two-stage extreme phenotype strategy

Essentials Required warfarin doses for mechanical heart valves vary greatly. A two-stage extreme phenotype design was used to identify novel warfarin dose associated mutation. We identified a group of variants significantly associated with extreme warfarin dose. Four novel identified mutations account for 2.2% of warfarin dose discrepancies.

SUMMARY

Background The variation among patients in warfarin response complicates the management of warfarin therapy, and an improper therapeutic dose usually results in serious adverse events. Objective To use a two-stage extreme phenotype strategy in order to discover novel warfarin dose-associated mutations in heart valve replacement patients. Patients/method A total of 1617 stable-dose patients were enrolled and divided randomly into two cohorts. Stage I patients were genotyped into three groups on the basis of VKORC1-1639G>A and CYP2C9*3 polymorphisms; only patients with the therapeutic dose at the upper or lower 5% of each genotype group were selected as extreme-dose patients for resequencing of the targeted regions. Evaluation of the accuracy of the sequence data and the potential value of the stage I-identified significant mutations were conducted in a validation cohort of 420 subjects. Results A group of mutations were found to be significantly associated with the extreme warfarin dose. The validation work finally identified four novel mutations, i.e. DNMT3A rs2304429 (24.74%), CYP1A1 rs3826041 (47.35%), STX1B rs72800847 (7.01%), and NQO1 rs10517 (36.11%), which independently and significantly contributed to the overall variability in the warfarin dose. After addition of these four mutations, the estimated regression equation was able to account for 56.2% (R2Adj = 0.562) of the overall variability in the warfarin maintenance dose, with a predictive accuracy of 62.4%. Conclusion Our study provides evidence linking genetic variations in STX1B, DNMT3A and CYP1A1 to warfarin maintenance dose. The newly identified mutations together account for 2.2% of warfarin dose discrepancy.

Clinical efficacy of type-B ultrasound-guided intraperitoneal hyperthermic chemoperfusion combined with systemic chemotherapy in advanced gastric cancer patients with malignant ascites

OBJECTIVES

To evaluate the clinical efficacy of systemic chemotherapy combined with intraperitoneal hyperthermic perfusion in advanced gastric cancer patients with malignant ascites.

PATIENTS AND METHODS

Forty-eight gastric cancer patients with malignant ascites who were admitted to our hospital were selected and randomly divided into the hyperthermic perfusion and control groups. The control group only received systemic chemotherapy, and the hyperthermic perfusion group received systemic chemotherapy combined with intraperitoneal hyperthermic chemoperfusion. The therapeutic efficacy, the survival time and the associated toxicity were determined for the two groups.

RESULTS

The efficacy was significantly higher in the hyperthermic perfusion group (85.7%) than in the control group (30.0%) (P 0.05). The median progression-free survival (PFS) was significantly longer in the hyperthermic perfusion group (12 months) compared with the control group (6 months) (P < 0.05). The median overall survival (OS) was significantly longer in the hyperthermic perfusion group (21 months) compared with the control group (9 months) (P < 0.05). There was a significantly higher 1-year survival rate in the hyperthermic perfusion group (89.3%) than in the control group (36.4%) (P < 0.05); however, there was no significant difference in the 3-year survival rate (10.7% vs. 10.0%). The Karnofsky Performance Status (KPS) score in the hyperthermic perfusion group increased significantly from 62.8 ± 1.84 to 74.3 ± 5.0 after hyperthermic chemoperfusion (P < 0.05).

CONCLUSION

Systemic chemotherapy combined with intraperitoneal hyperthermic perfusion exhibited significant clinical efficacy in advanced gastric cancer patients with malignant ascites, helped control ascites, improved the quality of life and extended PFS and OS. This treatment regimen is worth promoting.

Antihyperglycemic and Antioxidant Activity of Fructus hordei Germinatus Extract on Streptozotocin-induced Diabetic Rats

Purpose: To explore the antihyperglycemic and antioxidant effects of Fructus Hordei Germinatus extract (FHGE) in diabetic rats.Methods: The aqueous extract of FHG was obtained by steeping the dried Fructus Hordei Germinatus in water at 60oC three times, each for 1 h before first drying in an oven and then freeze-drying the last extract thus obtained. Antihyperglycemic effect was measured by blood glucose and plasma insulin levels. Oxidative stress was evaluated in liver and kidney by antioxidant markers, viz, lipid peroxidation (LPO), superoxide dismutase (SOD), reduced glutathione (GSH), glutathione peroxidase (GPx) and catalase (CAT), while blood serum levels of creatinine and urea were also determined in both diabetic control and treated rats.Results: Compared with diabetic rats, oral administration of FHGE at a concentration of 20, 40 and 80 mg/kg daily for 45 days showed a significant decrease in fasting blood glucose (p < 0.05) and increased insulin (p < 0.05) level,. Furthermore, it significantly reduced biochemical parameters (serum creatinine and serum urea, p < 0.05)). The treatment also resulted in significant increase in GSH, GPx (p < 0.05), SOD and CAT (p < 0.05), as well as decreased LPO (p < 0.05) level in the liver and kidney of diabetic rats.Conclusion: The results suggest that FHGE may effectively normalize the impaired antioxidant status in streptozotocin-induced diabetes in a dose-dependent manner. FHGE has a protective effect against lipid peroxidation by scavenging free radicals and is thus capable of reducing the risk of diabetic complications.Keywords: Fructus hordei Germinatus, Diabetic, Antihyperglycemic, Lipid peroxidation, Antioxidant, Fasting blood glucose, Creatinine, Urea

CD147 interacts with NDUFS6 in regulating mitochondrial complex I activity and the mitochondrial apoptotic pathway in human malignant melanoma cells

Malignant melanoma (MM) is one of the most lethal tumors and is characterized by high invasiveness, frequent metastasis, and resistance to chemotherapy. The risk of metastatic MM is accompanied by disordered energy metabolism involving the oxidative phosphorylation (OXPHOS) process, which is largely carried out in mitochondrial complexes. Complex I is the first and largest mitochondrial enzyme complex associated with this process. CD147 is a transmembrane glycoprotein mainly expressed on the cell surface, and also appears in the cytoplasm in some tumors. We found that CD147 is often translocated to the cytoplasm in metastatic MM specimens as compared to primary MM. We also demonstrated high expression of CD147 in isolated mitochondrial fractions of A375 cells. The yeast two-hybrid (Y2H) assay identified NDUFS6 (which encodes a subunit of mitochondrial respiratory chain complex I) as a candidate that interacts with CD147 and depletion of CD147 in A375 cells significantly decreased complex I enzyme activity. We also showed that CD147 increased the viability of A375 cells exposed to berberine-induced mitochondrial damage, and protected them from apoptosis through a mitochondrial-dependent pathway. This finding was confirmed by adding exogenous Bcl-2 to A375 cell cultures. In summary, our results identify the existence of CD147 in human melanoma cell mitochondria. They indicate that CD147 appears to regulate complex I activity and apoptosis in MM by interacting with mitochondrial NDUFS6. Our findings provide new insight into the function of CD147 and identify it as a promising therapeutic target in melanoma through disruption of the energy metabolism.

The Role of αA-Crystallin in Experimental Autoimmune Uveitis

Uveitis refers to a group of ocular inflammatory diseases that can lead to blindness. For years, researchers have been trying to decipher the underlying mechanisms and develop therapeutic strategies using the model of experimental autoimmune uveitis (EAU). Recently, αA-crystallin has been found to be upregulated in EAU and can even ameliorate its severity through different mechanisms, suggesting its use as a potent therapeutic factor against uveitis. Here we review the protective role of αA-crystallin and discuss its functional mechanisms in EAU.

Sleep duration and snoring associate with hypertension and glycaemic control in patients with diabetes

AIMS

Few studies have analysed the effect of sleep duration and snoring on hypertension and glycaemic control in patients with diabetes. This study aims to investigate the relationship of sleep duration and snoring on prevalent hypertension and glycaemic control in people with diabetes.

METHODS

In the baseline survey of the REACTION study, 56 032 patients with diabetes were categorized into four groups according to self-reported sleep duration: < 6, 6-7.9, 8-8.9 and ≥ 9 h. Snoring frequency was evaluated as 'usually', 'occasionally' or 'never'. Hypertension was assessed by systolic blood pressure, diastolic blood pressure, self-reported previous diagnosis and antihypertensive medications. 'Good' glycaemic control was defined as HbA1c < 53 mmol/mol (7.0%) and 'poor' glycaemic control as HbA1c ≥ 53 mmol/mol (7.0%).

RESULTS

Controlling for potential confounders and intermediates, sleep ≥ 9 h relative to intermediate sleep (6-7.9 h) was significantly associated with prevalent hypertension (OR: 1.25, 95% CI: 1.18-1.32) and poor glycaemic control (OR: 1.11, 95% CI: 1.05-1.18), and a U-shaped association was found between sleep duration and prevalent hypertension (P for quadratic trend = 0.019). Usually snoring was positively associated with prevalent hypertension (OR: 1.30, 95% CI: 1.23-1.37), whereas the association between snoring and poor glycaemic control was only on the borderline of statistical significance.

CONCLUSIONS

Compared with a sleep duration of 6-7.9 h, longer sleep duration was associated with a higher prevalence of hypertension and poor glycaemic control in people with diabetes. Moreover, the relationship between sleep duration and prevalent hypertension was U-shaped. These findings may propose important public health implications for diabetes management.

A novel HLA-A allele, HLA-A*02:544

The novel allele HLA-A*02:544 has two nucleotide changes from its most closely related allele, HLA-A*02:148. Firstly at nucleotide 255 where C → T (codon 60 GAC → GAT), resulting in a non-coding change as GAC and GAT both code for the same amino acid aspartic acid. Secondly at nucleotide 368 where T → G (codon 98 TTT → TGT) resulting in a coding change, 98 phenylalanine is changed to cysteine.