Background and aims: Hyperuricemia is a known risk factor for cardiovascular diseases, but little is known on whether the association between hyperuricemia and poor outcomes in ST-segment elevation myocardial infarction (STEMI) is modified by low-density lipoprotein cholesterol (LDL-c). This study aimed to investigate the effect of the interaction between hyperuricemia and LDL-c on the risk of 1-year post-discharge all-cause mortality in STEMI patients.Methods and results: A total of 1396 STEMI patients were included. Cox proportional hazards models were used to determine the association between hyperuricemia and 1-year all-cause mortality in the overall population and subgroups stratified based on LDL-c levels (<3.0 mmol/L or >3.0 mmol/L). Multivariate analysis indicated that hyperuricemia was associated with 1-year mortality (HR: 2.66; 95% CI: 1.30-5.47; p = 0.008). However, the prognostic effect of hyperuricemia was only observed in patients with LDL-c level >3.0 mmol/L (HR: 12.90; 95% CI: 2.98-55.77; p < 0.001), but not in those with LDL-c level <3.0 mmol/L (HR: 0.91, 95% CI: 0.30-2.79, p = 0.875). The interaction between hyperuricemia and LDL-c levels had a significant effect on 1-year mortality.Conclusion: Hyperuricemia was associated with increased 1-year post-discharge mortality in patients with LDL-c level> 3.0 mmol/L, but not in those with LDL-c level< 3.0 mmol/L.& COPY; 2022 Published by Elsevier B.V. on behalf of The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University.

Background Fulminant myocarditis is a clinical syndrome associated with threatening dysrhythmia which temporary pacemaker can be used for life-saving support. As a method of physiological pacing, His bundle pacing (HBP) maintain better cardiac synchronization than traditional right ventricular (RV) pacing. Case presentation It’s a severe case of fulminant myocarditis in a 41-year-old patient who presented for recurrent arrhythmias with hemodynamic instability. Temporary His bundle pacing combined with optimal medical therapy and extracorporeal membrane oxygenators (ECMO) supported him through his critical period of hospitalization. Conclusions During 1-year follow up, the cardiac function recovery was obvious without any pacing related complications. Echocardiography showed better atrioventricular and intra-ventricular synchronization during HBP in DDD mode. This is the first reported case of temporary His-purkinje conduction system pacing used for severe fulminant myocarditis.

Background: Mineralocorticoid receptor antagonists (MRA) improve outcomes in chronic kidney disease (CKD) and acute myocardial infarction (AMI) patients. However, the lack of evidence regarding long-term clinical outcomes in the use of MRA, including spironolactone, in patients with AMI combined with CKD. Objectives: This study aimed to investigate whether spironolactone could significantly reduce the risk of all-cause mortality and re-admission in patients with AMI and CKD. Methods: In this single center, observational, retrospective, registry based clinical study, a total of 2,465 AMI patients were initially screened; after excluding patients with estimated glomerular filtration rate more than 60 ml/min/1.73 m 2 , 360 patients in the standard treatment group and 200 patients in the spironolactone group met the criteria. All enrolled patients follow-up for 30 months. The primary outcomes were all-cause mortality and re-admission. The key safety outcome was hyperkalemia rates during the 30 months follow-up period. Results: 160 (44.4%) and 41 (20.5%) patients in the standard treatment and spironolactone groups died, respectively [hazard ratio (HR): 0.389; 95% confidence interval (CI): 0.276–0.548; p < 0.001]. Re-admission occurred in 217 (60.3%) and 95 (47.5%) patients in the standard treatment and spironolactone groups, respectively (HR: 0.664; 95% CI: 0.522–0.846; p = 0.004). The spironolactone group was divided into two based on the daily dose, low dose group (no more than 40 mg) and high dose group (more than 40 mg); the differences in the mortality rate between low dose group (16.7%) and the standard treatment group (44.4%) (HR: 0.309; 95% CI: 0.228–0.418; p < 0.001) and high dose group (34.1%) (HR: 0.429; 95% CI: 0.199–0.925; p = 0.007) were significant. The differences in re-hospitalization rate between low dose group (43.6%) and the standard treatment group (60.3%) (HR: 0.583; 95% CI: 0.457–0.744; p < 0.001) and high dose group (61.4%) (HR: 0.551; 95% CI: 0.326–0.930; p = 0.007) was significant. Hyperkalemia occurred in 18 (9.0%) and 18 (5.0%) patients in the spironolactone group and standard treatment group, respectively (HR: 1.879; 95% CI: 0.954–3.700; p = 0.068). Whereas, Hyperkalemia occurred in high dose group (20.5%) significantly more often than in the standard treatment group ( p < 0.001) and low dose group (5.8%) ( p = 0.003). Conclusion: Using MRA, such as spironolactone, may substantially reduce the risk of both all-cause mortality and re-admission in patients with AMI and CKD; the use of low-dose spironolactone has the best efficacy and safety. However, this was a relatively small sample size, single center, observational, retrospective, registry based clinical study and further prospective evaluation in adequately powered randomized trials were needed before further use of spironolactone in AMI with CKD population.

BACKGROUND:Mycobacterium chimaera infections subsequent to cardiac surgery are related to contaminated heater-cooler devices, with high mortality. Nevertheless, few studies have been reported in Asia.CASE PRESENTATION:We described the case of a 55-year-old man with Mycobacterium chimaera infection following cardiac surgery in the mainland of China. He was diagnosed with endocarditis caused by Mycobacterium chimaera subsequent to open heart surgery. Metagenomic next-generation sequencing (mNGS) and 16S rRNA gene PCR analysis were used to identify potential pathogens. The patient underwent redo valve replacement surgery and received combination therapy with azithromycin, ethambutol, linezolid, and amikacin. No signs of relapse were observed during the 11-month follow-up visit.CONCLUSIONS:This is the first documented case of Mycobacterium chimaera infection following cardiac surgery in the mainland of China and the first documented transnational imported case worldwide. Moreover, mNGS is a novel diagnostic technology that can guide antimicrobial therapy prior to obtaining fluid/tissue culture results for Mycobacterium chimaera, providing a new approach for the detection of potential Mycobacterium chimaera infection.

Objective Lymphocyte-to-monocyte ratio (LMR), a novel systemic inflammatory factor, correlates with adverse outcomes in patients with cardiovascular disease. However, data are limited regarding the prognostic value of LMR in patients with ST-elevation myocardial infarction (STEMI) after hospital discharge. Therefore, the aim of our study was to evaluate the prognostic impact of admission LMR in hospital survivors of STEMI. Methods This retrospective observational study enrolled 1369 STEMI patients between 2014 and 2017. The study population was divided into three groups according to tertiles (T) of LMR (T1: ≥2.84; T2: 1.85–2.83; T3: <1.85). The primary outcomes were long-term outcomes after discharge including major adverse cardiac events (MACE) and all-cause mortality. The associations between LMR and long-term outcomes were assessed using Cox regression analysis. Results The median follow-up period was 556 days (interquartile range, 342–864 days). Independent correlations were observed between LMR and both long-term MACE and all-cause mortality. For long-term MACE, the T3 (adjusted hazard ratio [HR], 1.74; 95% confidence interval [CI]: 1.12–2.70; P = 0.013) and T2 groups (adjusted HR, 1.65; CI: 1.07–2.54; P = 0.024) showed significantly higher risk of MACE than did the T1 group. For long-term all-cause mortality, the adjusted HR was 3.07 (CI: 1.10–8.54; P = 0.032) in the T3 group and 2.35 (CI: 0.82–6.76; P = 0.112) in the T2 group compared with that of the T1 group. Conclusion Decreased admission LMR was independently associated with long-term all-cause mortality and MACE after discharge in patients with STEMI.

Objective Hyperlactatemia at admission is associated with poor outcome in critically ill patients. However, data on the prognostic value of blood lactate level in patients with acute coronary syndrome (ACS) are limited. The present study assessed the prognostic effect of admission lactate level in a large population of patients with ACS. Materials and methods This was a retrospective observational study including patients with ACS who were admitted to the Coronary Care Unit of the First Affiliated Hospital of Wenzhou Medical University between 2014 and 2017. Patients were divided into tertiles of lactate level (T1: <1.8; T2: 1.8-2.6; T3: >= 2.7 mmol/l). The clinical outcomes were 30-day and 180-day mortality from hospital admission. Cox proportional hazards models were used to evaluate the association between lactate level and survival. Results A total of 1865 consecutive patients with ACS were enrolled. Significant positive associations were observed between admission lactate level and both 180-day and 30-day mortality, with highest risk for lactate greater than or equal to 2.7 mmol/l. The adjusted hazard ratio for 180-day mortality was 2.09 [ 95% confidence interval (CI): 1.18-3.71, P=0.011] for T3 and 1.53 (95% CI: 0.86-2.72, P=0.147) for T2 compared with T1 (P for trend=0.006), and 1.10 (95% CI: 1.02-1.18, P=0.010) for each unit increase in lactate level. Similar trends were observed for 30-day mortality. The association was highly consistent across all subgroups studied (all P for interaction > 0.05). Conclusion In patients with ACS, elevated admission lactate level is an independent predictor of 30-day and 180-day all-cause mortality. Copyright (c) 2018 Wolters Kluwer Health, Inc. All rights reserved.

1 临床资料 男性,63岁,有高血压病史5年余,近来未服药,自述血压控制可.有糖尿病病史5年余,服用"二甲双胍、格列齐特缓释片(达美康)".否认心脏病病史、脑卒中史、既往大出血史、手术外伤史及食物药物过敏史.此次因"心悸半年余"于2018年10月4日入院 ,查动态心电图提示阵发性心房颤动.查体:体温:36.4℃, 心率:47 次/min,血压:131/74 mmHg(1 mmHg=0.133 kPa),呼吸:20次/min.无颈静脉怒张,两肺呼吸音清,未闻及干、湿啰音.腹软,无压痛.专科查体:心前区无隆起,未见异常搏动.触诊心尖搏动位于左第V肋间,锁骨中线内0.5 cm,力量强,无抬举感、无摩擦感及震颤.心相对浊音界大小正常.心音正常,心律齐,各瓣膜区未闻及杂音,双下肢无浮肿,足背动脉搏动好.入院诊断:阵发性心房颤动,高血压病,2型糖尿病.入院后超声心动图示:左心房增大,轻度二尖瓣反流,主动脉窦部及升部增宽,主动脉瓣局部钙化,轻度主动脉瓣反流,轻度三尖瓣反流,左心室舒张功能轻度减退.计算机断层摄影术(CT):左心房及两肺静脉主干未见明确血栓,予以完善相关术前检查.

Title: Risk scores for predicting dysphagia in critically ill patients after cardiac surgery Authors: Xiaodong Zhou (836585998@qq.com) Weihua Dong (15158542480@163.com) Chuhuan Zhao (2367683071@qq.com) Xiafei Feng (343217782@qq.com) Weiwei Wen (wenww88@163.com) Wenyi Tu (15858580535@163.com) Mengxing Cai (654517050@qq.com) Tiancheng Xu (464179111@qq.com) Qiangli Xie (xieqiangli@163.com) Version: 3 Date: 27 Dec 2018 Author’s response to reviews: Re: Revision for “Risk scores for predicting dysphagia in critically ill patients after cardiac surgery” (BMC Anesthesiology BANE-D-18-00188)

This study aimed at developing and validating a scoring model to stratify critically ill patients after cardiac surgery based on risk for dysphagia, a common but often neglected complication.

目的 探讨急性心肌梗死(AMI)后并发室间隔穿孔(VSR)的临床表现及VSR修补术效果. 方法 收集AMI后并发VSR的病例共21例,行VSR修补手术(手术组)7例,未行手术患者(非手术组)14例.比较患者一般情况、基础疾病、梗死部位、心功能、发现VSR时间、血肌钙蛋白水平、肝功能、肾功能、代谢性酸中毒、血乳酸水平、是否行室间隔修补手术、心超表现、是否行连续肾脏替代治疗(CRRT)、主动脉内球囊反搏治疗(IABP)、30d病死率等数据. 结果 手术组患者术前肺动脉收缩压45～108(54.2±11.4)mmHg,手术后肺动脉收缩压24～45(31.4±8.7)mmHg,较术前明显下降(P＜0.01);手术组患者30d内无一例死亡,非手术组患者30d无一例幸存,平均存活时间为3.5～11(6.4±1.7)d,术后30d两组病死率差异有统计学意义(P＜0.05). 结论 AMI后继发VSR心功能差,保守治疗预后差,手术是积极有效的治疗手段.

目的 探讨人工机械瓣功能障碍早期诊断及治疗,提高对人工机械瓣膜置换术后机械瓣膜功能障碍的认识.方法 回顾性分析27例手术治疗人工机械主动脉瓣、二尖瓣功能障碍患者的临床资料,并复习相关文献资料.结果 27例患者确诊为人工机械瓣膜功能障碍,其中二尖瓣置换术后11例、主动脉瓣置换术后12例、双瓣置换术后4例.通过急诊或限期行人工瓣膜再次置换手术治疗,死亡2例(7.4％),其余恢复良好,术后心功能状况改善明显.结论 对于人工机械瓣置换术后的患者远期出现类似于瓣膜狭窄的病理生理改变及相关的临床症状时,应高度怀疑人工机械瓣膜功能障碍可能,其合并出现急性功能障碍时常表现危重,应争取时间尽快再手术,这是挽救患者生命的重要手段.

目的 观察封闭负压引流在治疗心脏手术后胸骨裂开创面中的临床应用效果.方法 选择2012年5月～2016年5月本院收治的心脏手术后出现胸骨裂开患者18例(冠状动脉搭桥术10例,心脏瓣膜置换术8例),采用单纯持续封闭负压引流方式治疗胸骨裂开创面,3～10 d病房更换一次负压引流敷料,至创面完全愈合;回顾分析创面愈合情况、愈合时间、更换负压引流敷料次数、随访出院后创面情况.结果 18例患者心脏术后胸骨裂开感染创面经持续封闭负压引流方式治疗21～88 d,更换负压引流敷料3～12次,创面均完全愈合,无死亡病例,随访2个月～2年,创面均无再次裂开、感染.结论 封闭负压引流是心脏术后胸骨裂开感染创面理想治疗方式,安全有效,操作简单易行.

Pheochromocytoma associated with pregnancy is not common. Caesarean section may induce pheochromocytoma crisis, resulting in a lethal condition. The clinical picture of pheochromocytoma crisis is extremely variable. In this report, we describe a case of severe pheochromocytoma crisis induced by caesarean section presenting with hyperpyrexia, haemodynamic collapse, muscle weakness, heart failure, and acute kidney injury. Furthermore, we report that the muscle weakness was a manifestation of rhabdomyolysis, resulting from the pheochromocytoma crisis. Standard medical therapy failed to halt the patient's rapidly deteriorating condition. Continuous renal replacement therapy removed catecholamines from the circulation, resulting in improvement of haemodynamics and abrogation of rhabdomyolysis.

Objective To analyze risk factors of Swan-Ganz catheter-related bloodstream infections ( CRBSI) in patients with severe heart disease in Cardiac Care Unit ( CCU) . Methods A total of 768 patients undergoing indwelling Swan-Ganz catheterization in CCU between January 2013 to December 2014 were enrolled in this study. Bacterial culture of blood in catheter and catheter tip that 5 cm distance from distal end were performed if the patients were suspected of intravascular catheter-related infections or the catheter was removed from the patients for more than 7 days. Results During 3050 catheter days, 23 of 768 patients were diagnosed of CRBSI(7. 5 ‰), and the infection rate was about 3%. The top 5 pathogenic bacteria were staphylococcus aureus, staphylococcus haemolyticus, staphylococcus epidermidis, albicans saccharomyces and klebsiella pneumoniae. The patient′s gender, ages, with diabetes or not, and usage of antibiotic during catheterization had no correlation with catheter related infection (P >0. 05), but the skin of whole body clean or not before catheterization, the length of catheterization had correlation with catheter related infection ( P < 0. 05 ). Multivariate logistic regression analysis showed that the whole bode skin clean before catheterization was the protective factor for CRBSI, and long catheter indwelling time and combined antibiotic treatment during catheterization were the risk factors for CRBSI (P<0. 05). Conclusions The incidence of CRBSI in patients with severe heart disease is related to the catheter indwelling time, and skin clean before indwelling which are able to effectively reduce the incidence of CRBSI. Antibiotic treatment during catheterization is not beneficial for decreasing the incidence of CRBSI.

目的：探讨运用不同足浴疗法促进食管癌术后患者胃肠功能恢复的效果。方法：将食管癌术后患者120例，随机分成4组（每组30例）。对照组采用常规治疗护理，实验组共3组分别为：单纯温水足浴组（实验1组）、中药足浴组（实验2组）、中药汤加穴位按摩组（实验3组）。4组患者以拔除胃管作为实验结束时间，实验结束后比较各组首次肛门排气时间、胃管引流液量、胃管拔除时间。结果：实验2组和实验3组术后首次肛门排气时间较对照组缩短，差异均有统计学意义（均P＜0.01），且实验3组的术后首次肛门排气时间短于实验2组（P＜0.05）；实验2组和实验3组术后胃管引流液量较对照组减少，差异均有统计学意义（均P＜0.01）；实验1组、实验2组和实验3组术后胃管拔除时间均较对照组提前，差异均有统计学意义（均P＜0.01）。结论：中药足浴能够促进食管癌术后患者胃肠功能的恢复，其中中药汤足浴加穴位按摩对患者胃肠功能恢复的作用效果最明显。

目的:探讨急性A型主动脉壁间血肿合并心包积液的急诊治疗策略选择。方法:7例A型主动脉壁间血肿伴心包积液患者,心包积液CT值为(38.6±5.8)HU,怀疑为心包积血,其中3例行急诊外科手术治疗,其余4例予内科药物保守治疗。结果:急诊外科手术治疗的3例患者均存活,内科药物保守治疗3例患者死亡,1例存活。结论:对急性A型主动脉壁间血肿合并心包积液患者,当确认心包积液为心包积血时应立即行急诊手术治疗,药物保守治疗病死率高。

Objective To explore the influence of cardiopulmonary bypass(CPB) on platelet and its relationship with postoperative acute lung injury.Methods The retrospective analysis was performed on 20 patients undergoing cardiac surgery under CPB.The platelet count(PLT) and thromboxane B2(TXB2)value were measured before heparinization,at 30 min after CPB,end of CPB and postoperative 24 h.After surgery,ulinastatin injection 200 000 U was added into normal saline 100 mL and Shenmai injection 30 mL was added into 5%glucose solution 250 mL for intravenous drip,once daily for successive 14 d.The arterial blood gas analysis,lung dynamic com1served at different postoperative time points.Results The PLT count during CPB and after CPB was lower than that before surgery.The TXB2 value during CPB was significantly increased compared with before surgery,decreased very rapidly after CPB,but was significantly higher than that before surgery,which showing statistical difference(P < 0.05 or P < 0.01).The lung dynamic compliance and the oxygenation index were reduced after CPB(P < 0.05 or P < 0.01).Conclusion CPB can lead to changes of platelet count and activation index,which plays an important role to lung injury in the CPB-induced PLT change.

Objective To explore cardiopulmonary bypass's influence on platelet and megakaryocytes.Methods Megakaryocytes and platelet count(PLT)in 20 patients before and after cardiopulmonary bypass(CPB)were measured.To explore cardiopulmonary bypass's influence on platelet and megakaryocytes.Results The total number of megakaryocytes and 4-type of megakaryocytes in venous blood were higher than the same arterial blood.The total number of megakaryocytes and 4-type of megakaryocytes in venous blood within CPB were higher than before and after CPB.PLT within CPB were lower than before and after CPB(P<0.01).Conclusion CPB can lead to changes of platelet count and megakaryocytes.Platelets and megakaryocytes were destructed in lung by CPB.Injury in acute lung may affect the quantity of platelet.

急性Stanford A型主动脉夹层一旦确诊,应予急诊手术治疗.但手术风险大,术后并发症高,急诊手术死亡率为20%左右[1-2].我院于2006年2月至2009年8月,对17例该病患者行升主动脉及主动脉弓替换加降主动脉支架植入术,效果满意,现将围术期并发症及其治疗体会总结如下.

目的探讨急性主动脉夹层(Aortic dissection AD)的患病危险因素、临床特点及治疗方法,以提高临床救治率,改善预后。方法对67例AD住院患者临床资料进行回顾性系统分析。结果病因:高血压占81.0%,马凡综合征占10.5%,临床表现:90%患者为剧烈胸痛,5%无疼痛的表现。56.4%需4种以上降压药物治疗;内科药物治疗34例,好转27例,死亡7例;外科大血管手术治疗17例,死亡1例;主动脉夹层腔内隔绝术治疗16例,无1例死亡。结论高血压和马凡综合征是AD的主要危险因素,AD临床表现变化多端,但仍以突发剧烈胸痛为主要临床症状;多种影像学检查结合有助于病情综合评估;药物治疗中血压控制多需降压药物联合应用,外科手术、介入治疗是安全有效治疗手段。