FOXO1 reshapes neutrophils to aggravate acute brain damage and promote late depression after traumatic brain injury

Background:Neutrophils are traditionally viewed as first responders but have a short onset of action in response to traumatic brain injury(TBI).However,the heterogeneity,multifunctionality,and time-dependent modulation of brain damage and outcome mediated by neutrophils after TBI remain poorly understood.Methods:Using the combined single-cell transcriptomics,metabolomics,and proteomics analysis from TBI patients and the TBI mouse model,we investigate a novel neutrophil phenotype and its associated effects on TBI outcome by neurological deficit scoring and behavioral tests.We also characterized the underlying mechanisms both invitro and invivo through molecular simulations,signaling detections,gene expression regulation assessments[including dual-luciferase reporter and chromatin immunoprecipitation(ChIP)assays],primary cultures or co-cultures of neutrophils and oligodendrocytes,intracellular iron,and lipid hydroperoxide concentration measurements,as well as forkhead box protein O1(FOXO1)conditional knockout mice.Results:We identified that high expression of the FOXO1 protein was induced in neutrophils after TBI both in TBI patients and the TBI mouse model.Infiltration of these FOXO1high neutrophils in the brain was detected not only in the acute phase but also in the chronic phase post-TBI,aggravating acute brain inflammatory damage and promoting late TBI-induced depression.In the acute stage,FOXO1 upregulated cytoplasmic Versican(VCAN)to interact with the apoptosis regulator B-cell lymphoma-2(BCL-2)-associated X protein(BAX),suppressing the mitochondrial translocation of BAX,which mediated the antiapoptotic effect companied with enhancing interleukin-6(IL-6)production of FOXO1high neutrophils.In the chronic stage,the“FOXO1-transferrin receptor(TFRC)”mechanism contributes to FOXO1high neutrophil ferroptosis,disturbing the iron homeostasis of oligodendrocytes and inducing a reduction in myelin basic protein,which contributes to the progression of late depression after TBI.Conclusions:FOXO1high neutrophils represent a novel neutrophil phenotype that emerges in response to acute and chronic TBI,which provides insight into the heterogeneity,reprogramming activity,and versatility of neutrophils in TBI.

Pain management in acute musculoskeletal injury: Effect of opioid vs nonopioid medications

BACKGROUND The use of opioids for pain is linked to an increased risk of developing opioid use disorder,and has resulted in the emergence of the opioid crisis over the last few years.AIM The systematic review question is“How does the use of opioid medications in pain management,compared with non-opioid medications,affect pain intensity over the short,intermediate,and long-term in adults with acute traumatic pain?”.METHODS The protocol was prospectively registered on the International Prospective Re-gister of Systematic Reviews:CRD42021279639.Medline and Google Scholar were electronically searched for controlled peer-reviewed studies published in full,with the PICO framework:P:Adult patients with traumatic injuries,I:Opioid medications,C:Non-opioid medi-cations,O:A minimum clinically important difference(MCID)in pain.RESULTS After full-text screening,we included 14 studies in the qualitative synthesis.Of these 14 studies,12 were rando-mized clinical trials(RCTs)and 2 were pseudo-RCTs with a total of 2347 patients enrolled.There was heteroge-neity in both medication utilized and outcome in these studies;only two studies were homogeneous regarding the type of study conducted,the opioid used,its comparator,and the outcome explored.The MCID was evaluated in 8 studies,while in 6 studies,any measured pain reduction was considered as an outcome.In 11 cases,the setting of care was the Emergency Department;in 2 cases,care occurred out-of-hospital;and in one case,the setting was not well-specified.The included studies were found to have a low-moderate risk of bias.CONCLUSION Non-opioids can be considered an alternative to opioids for short-term pain management of acute musculoskeletal injury.Intravenous ketamine may cause more adverse events than other routes of administration.

Acute drivers of neuroinflammation in traumatic brain injury

Neuroinflammation is initiated as a result of traumatic brain injury and can exacerbate evolving tissue pathology.Immune cells respond to acute signals from damaged cells,initiate neuroinflammation,and drive the pathological consequences over time.Importantly,the mechanism(s)of injury,the location of the immune cells within the brain,and the animal species all contribute to immune cell behavior following traumatic brain injury.Understanding the signals that initiate neuroinflammation and the context in which they appear may be critical for understanding immune cell contributions to pathology and regeneration.Within this paper,we review a number of factors that could affect immune cell behavior acutely following traumatic brain injury.

Predictors and in-hospital outcomes of preoperative acute kidney injury in patients with type A acute aortic dissection

Background Acute kidney injury （AKI） is common after surgery for acute aortic dissection （AAD） and increases in-hospital and long-term mortality. However, few data exist on the clinical and prognostic relevance of early preoperative AKI in patients with type A AAD We aimed to determine the incidence and predictors of preoperative AKI and the impact of AKI on in-hospital outcomes in patients with type A AAD. Methods From May 2009 to June 2014, we retrospectively enrolled 178 patients admitted to our hospital within 48 h from symp- tom onset and receiving open surgery for type A AAD. The patients were divided into no AKI and AKI groups and staged with AKI severity according to the KDIGO criteria before surgery. Results AKI occurred in 41 patients （23.0%）. The incidence of in-hospital complications was significantly higher in patients with preoperative AKI compared to no AKI （41.5% vs. 9.5%, P 〈 0.001）, including renal infarction （7.3% vs. 0, P = 0.012）, and it increased with AKI severity （Ptrend〈 0.001）. Patients with AKI had higher in-hospital mortality compared with pa- tients without AKI, although no significant difference was found （14.6% vs. 5.1%, P = 0.079）. Multivariate analysis indicated that male gender, diastolic blood pressure on admission and bilateral renal artery involvement were independent predictors of preoperative AKI in patients with type A AAD. Conclusions Early AKI before surgery was common in patients with type A AAD, and was associated with increased in-hospital complications. Male gender, diastolic blood pressure on admission and bilateral renal artery involvement were major predictors for preoperative AKI.

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

Objective Acute kidney injury （AKI） frequently occurs after catheter-based interventional procedures and increases mortality. However, the implications of AKI before thoracic endovascular aneurysm repair （TEVAR） of type B acute aortic dissection （AAD） remain unclear. This study evaluated the incidence, predictors, and in-hospital outcomes of AKI before TEVAR in patients with type B AAD. Methods Between 2009 and 2013, 76 patients were retrospectively evaluated who received TEVAR for type B AAD within 36 h from symptom onset. The patients were classified into no-AKI vs. AKI groups, and the severity of AKI was further staged according to kidney disease： im- proving global outcomes criteria before TEVAR. Results The incidence of preoperative AKI was 36.8%. In-hospital complications was significantly higher in patients with preoperative AKI compared with no-AKI （50.0% vs. 4.2%, respectively; P 〈 0.001）, including acute renal failure （21.4% vs. O, respectively; P 〈 0.001）, and they increased with severity of AKI （P 〈 0.001）. The maximum levels of body tem- perature and white blood cell count were significantly related to maximum serum creatinine level before TEVAR. Multivariate analysis showed that systolic blood pressure on admission （OR： 1.023; 95% CI： 1.003-1.044; P ： 0.0238） and bilateral renal artery involvement （OR： 19.076; 95% CI： 1.914 190.164; P = 0.0120） were strong predictors of preoperative AKI. Conclusions Preoperative AKI frequently occurred in patients with type B AAD, and correlated with higher in-hospital complications and enhanced inflammatory reaction. Systolic blood pressure on admission and bilateral renal artery involvement were major risk factors for AKI before TEVAR.

Acute kidney injury in traumatic brain injury intensive care unit patients

BACKGROUND The exact definition of Acute kidney injury(AKI)for patients with traumatic brain injury(TBI)is unknown.AIM To compare the power of the“Risk,Injury,Failure,Loss of kidney function,and End-stage kidney disease”(RIFLE),Acute Kidney Injury Network(AKIN),Creatinine kinetics(CK),and Kidney Disease Improving Global Outcomes(KDIGO)to determine AKI incidence/stage and their association with the inhospital mortality rate of patients with TBI.METHODS This retrospective study collected the data of patients admitted to the intensive care unit for neurotrauma from 2001 to 2012,and 1648 patients were included.The subjects in this study were assessed for the presence and stage of AKI using RIFLE,AKIN,CK,and KDIGO.In addition,the propensity score matching method was used.RESULTS Among the 1648 patients,291(17.7%)had AKI,according to KDIGO.The highest incidence of AKI was found by KDIGO(17.7%),followed by AKIN(17.1%),RIFLE(12.7%),and CK(11.5%)(P=0.97).Concordance between KDIGO and RIFLE/AKIN/CK was 99.3%/99.1%/99.3%for stage 0,36.0%/91.5%/44.5%for stage 1,35.9%/90.6%/11.3%for stage 2,and 47.4%/89.5%/36.8%for stage 3.The in-hospital mortality rates increased with the AKI stage in all four definitions.The severity of AKI by all definitions and stages was not associated with inhospital mortality in the multivariable analyses(all P>0.05).CONCLUSION Differences are seen in AKI diagnosis and in-hospital mortality among the four AKI definitions or stages.This study revealed that KDIGO is the best method to define AKI in patients with TBI.

Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury

BACKGROUND: Rapid and effective pain relief in acute traumatic limb injuries(ATLI) is one of the most important roles of emergency physicians. In these situations, opioid addiction is an important concern because of the dependency on opioids. The study aims to compare the effectiveness of intravenous(IV) fentanyl versus morphine in reducing pain in patients with opioid addiction who suffered from ATLI.METHODS: In this double-blind randomized clinical trial, 320 patients with ATLI, who presented to the emergency department(ED) from February 2016 to April 2016, were randomly divided into two groups. One group(160 patients) received 0.1 mg/kg IV morphine. The other group(160 patients) received 1 mcg/kg IV fentanyl. Patients' demographic data, pain score at specif ic intervals, vital signs, side effects, satisfaction and the need for rescue analgesia were recorded.RESULTS: Eight patients in the morphine group and five patients in the fentanyl group were excluded. Pain score in the fentanyl group had a significant decrease at 5-minute follow-up(P value=0.00). However, at 10, 30, and 60-minute follow-ups no signifi cant differences were observed between the two groups in terms of pain score reduction. The rescue analgesia was required in 12(7.7%) patients in the fentanyl group and in 48(31.6%) patients in the morphine group(P value=0.00). No signifi cant difference was observed regarding side effects, vital signs and patients' satisfaction between the two groups.CONCLUSION: Fentanyl might be an effective and safe drug in opioid addicts suffering from ATLI.

Veno-Venous Extracorporeal Membrane Oxygenation for Acute Lung Injury after Surgery for Aortic Dissection: A Case Report

Acute respiratory failure after surgery for aortic dissection is a serious complication that has been associated with increased mortality and morbidity. Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is reported as one of the treatments for this life-threatening complication. A 78-year-old male patient was admitted to our hospital for Stanford type A acute aortic dissection. He underwent emergency replacement of the ascending aorta, after which he developed acute lung injury. It was difficult to maintain oxygenation with a respirator mask. Therefore, VV-ECMO was initiated on postoperative day 1. The oxygenation gradually improved, and VV-ECMO was continued until postoperative day 13. On postoperative day 25, mechanical ventilation was withdrawn. The patient was discharged from the hospital on postoperative day 149. We report a case of successful treatment of acute lung injury with VV-ECMO initiated after surgery for aortic dissection. VV-ECMO can be considered as a treatment option for severe acute lung injury after surgery for aortic dissection.

Association of blood transfusion with acute kidney injury after transcatheter aortic valve replacement: A metaanalysis

AIM To assess red blood cell(RBC) transfusion effects on acute kidney injury(AKI) after transcatheter aortic valve replacement(TAVR). METHODS A literature search was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and clinicaltrials.gov from the inception of the databases through December 2015. Studies that reported relative risk, odds ratio or hazard ratio comparing the risks of AKI following TAVR in patients who received periprocedural RBC transfusion were included. Pooled risk ratio(RR) and 95%CI were calculated using a random-effect, generic inverse variance method. RESULTS Sixteen cohort studies with 4690 patients were included in the analyses to assess the risk of AKI after TAVR in patients who received a periprocedural RBC transfusion. The pooled RR of AKI after TAVR in patients who received a periprocedural RBC transfusion was 1.95(95%CI: 1.56-2.43) when compared with the patients who did not receive a RBC transfusion. The meta-analysis wasthen limited to only studies with adjusted analysis for confounders assessing the risk of AKI after TAVR; the pooled RR of AKI in patients who received periprocedural RBC transfusion was 1.85(95%CI: 1.29-2.67). CONCLUSION Our meta-analysis demonstrates an association between periprocedural RBC transfusion and a higher risk of AKI after TAVR. Future studies are required to assess the risks of severe AKI after TAVR requiring renal replacement therapy and mortality in the patients who received periprocedural RBC transfusion.

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

Introduction:Blunt thoracic aortic injury(BTAI)is rare in elderly patients.As the population ages and life expectancy increases,the frequency of this injury will increase,while the treatment and outcomes remain unclear.Methods:We retrospectively analyzed the collected data of patients>60 years old with BTAI to investigate the mechanism of trauma;time interval from injury to diagnosis;type and timing of surgical intervention;aortic arch pattern;choice of left subclavian artery reconstruction;endograft to treat BTAI;length of the endovascular procedure;endoleaks;complications including stroke,paraplegia,and renal failure;length of hospital stay(LOS)and intensive care unit stay(L.ICUS);and 30-day mortality.Results:Five elderly trauma patients were found to have BTAI.Four(80%)were males,the cohort mean age was68 years,the major mechanism of trauma was fall injury,and the associated injury was thoracic trauma.All patients were transferred to our hospital,and emergency computed tomography angiography showed BTAI in each patient.The average time interval from injury to diagnosis was 2.7 days.Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair,while 3 patients underwent delayed endovascular repair.The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery;the aortic arch pattern was II(80.0%)in 4 cases and III in 1 case(20.0%).The choice of left subclavian artery reconstruction included chimney,double chimney,prefenestration,and chimney combined with in situ fenestration.Endografts to treat BTAI included the Ankura(Lifetech Scientific,Shenzhen,China)and the C-TAG(W.L.Gore&Associates,Flagstaff,AZ USA).The length of the endovascular procedure was 75.4 min;there were no endoleaks and no complications including stroke,paraplegia,or renal failure.The average LOS was25 days,and the average L.ICUS of 2 patients was 15 days,with no 30-day mortality.Conclusion:Elderly patients with fall injury should promptly exclude BTAI.Thoracic endovascular aortic repair(TEVAR)with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications.Because of the low incidence of this type of injury,we are unable to provide any evidence to guide the treatment option for this life-threatening condition.

Management of acute spinal cord injury:A summary of the evidence pertaining to the acute management,operative and non-operative management

Acute traumatic spinal cord injury is often a lifechanging and devastating event with considerable mortality and morbidity.Over half a million people suffer from traumatic spinal cord injury annually with the majority resulting from road traffic accidents or falls.The Individual,societal and economic costs are enormous.Initial recognition and treatment of acute traumatic spinal cord injury are crucial to limit secondary injury to the spinal cord and to provide patients with the best chance of some functional recovery.This article is an overview of the management of the acute traumatic spinal cord injury patient presenting to the emergency department.We review the initial assessment,criteria for imaging and clearing the spine,and evaluate the literature to determine the optimum timing of surgery and the role of non-surgical treatment in patients presenting with acute spinal cord injury.

Hydroxyethylstarch revisited for acute brain injury treatment

Infusion of the colloid hydroxyethylstarch has been used for volume substitution to maintain hemodynamics and microcirculation after e.g., severe blood loss.In the last decade it was revealed that hydroxyethylstarch can aggravate acute kidney injury, especially in septic patients.Because of the serious risk for critically ill patients, the administration of hydroxyethylstarch was restricted for clinical use.Animal studies and recently published in vitro experiments showed that hydroxyethylstarch might exert protective effects on the blood-brain barrier.Since the prevention of blood-brain barrier disruption was shown to go along with the reduction of brain damage after several kinds of insults, we revisit the topic hydroxyethylstarch and discuss a possible niche for the application of hydroxyethylstarch in acute brain injury treatment.

Electroacupuncture in Treatment of Acute Gastrointestinal Injury in Patients with Severe Traumatic Brain Injury:A Multicenter Randomized Controlled Trial

Objective: To evaluate whether electroacupuncture(EA) would improve gastrointestinal function and clinical prognosis in patients with severe traumatic brain injury(TBI) complicocted by acute gastrointestinal injury(AGI). Methods: This multicenter, single-blind trial included patients with TBI and AGI admitted to 5Chinese hospitals from September 2018 to December 2019. A total of 500 patients were randomized to the control or acupuncture groups using a random number table, 250 cases in each group. Patients in the control group received conventional treatment, including mannitol, nutritional support, epilepsy and infection prevention, and maintenance of water, electrolytes, and acid-base balance. While patients in the acupuncture group received EA intervention at bilateral Zusanli(ST 36), Shangjuxu(ST 37), Xiajuxu(ST 39), Tianshu(ST 25), and Zhongwan(RN 12) acupoints in addition to the conventional treatment, 30 min per time, twice daily,for 7 d. The primary endpoint was 28-d mortality. The secondary endpoints were serum levels of D-lactic acid(D-lac), diamine oxidase(DAO), lipopolysaccharide(LPS), motilin(MTL) and gastrin(GAS), intra-abdominal pressure(IAP), bowel sounds, abdominal circumference, AGI grade, scores of gastrointestinal failure(GIF),Glasgow Coma Scale(GCS), Acute Physiology and Chronic Health Evaluation(APACHE Ⅱ), Sequential Organ Failure Assessment(SOFA), and Multiple Organ Dysfunction Syndrome(MODS), mechanical ventilation time,intense care unit(ICU) stay, and the incidence of hospital-acquired pneumonia. Results: The 28-d mortality in the acupuncture group was lower than that in the control group(22.80% vs. 33.20%, P<0.05). Compared with the control group, the acupuncture group at 7 d showed lower GIF, APACHE Ⅱ, SOFA, MODS scores, D-lac,DAO, LPS, IAP, and abdominal circumference and higher GCS score, MTL, GAS, and bowel sound frequency(all P<0.05). In addition, the above indices showed simillar changes at 7 d compared with days 1 and 3 in the EA group(all P<0.05). Conclusion: Early EA can improve gastrointestinal function and clinical prognosis in patients with severe TBI complicated by AGI.(Registration No. ChiCTR2000032276)

Management and Outcome of Acute Subdural Hematoma in Gabriel TouréHospital

Background: Traumatic Brain Injury (TBI) is a major health problem worldwide. It is the main cause of trauma mortality. Acute subdural hematoma (ASDH) has a reputation for being the most serious of all posttraumatic head injuries. Its frequency is estimated to be 1% to 5% of all head injuries and 22% of severe head injuries. The aim of this study was to assess the epidemiological, clinical and prognosis aspects of ASDH in our department. Material and Methods: This prospective study, from January to December 2019, included 57 patients admitted to the Gabriel Touré Teaching Hospital for ASDH. Patients underwent detailed clinical and radiological evaluation and ASDH was diagnosed by non-contrast computed tomography (CT) scan. Functional outcome was evaluated 6 months after injury by Glasgow Outcome Scale. Results: During the study period, 662 patients were admitted for TBI including 57 (8.61%) cases of ASDH. The mean age was 34 years with extremes of 2 and 77 years. There was a male predominance with 52 (91.2%). The main cause of trauma was motor vehicle accidents in 38 (66.6%) patients. According to the Glasgow coma scale (GCS), 33 (57.9%) patients were classified mild (Table 2). The thickness of the hematoma was more than 1 cm in 13 (22.8%) patients and less than 1 cm in 44 (77%) patients. Surgical treatment was performed in 13 (22.8%) patients. The outcome was favorable in 30 (52.6%) patients and the mortality rate was 33.3%. Conclusion: ASDH remains a difficult challenge because of the high mortality. The mortality rate remains high particularly in patient with poor GCS score at admission.

Evaluation of acute kidney injury as defined by the risk, injury, failure, loss, and end-stage criteria in critically ill patients undergoing abdominal aortic aneurysm repair

Background Acute kidney injury （AKI） is considered as a common and significant complication following abdominal aortic aneurysm （AAA） repair. This study aimed to assess the associated risk factors of AKI in the critically ill patients undergoing AAA repair and to evaluate the appropriate AKI management in the specific population. Methods We retrospectively examined data from all critically ill patients undergoing AAA repairs at our institution from April 2007 to March 2012. Multivariable analysis was used to identify factors associated with postoperative AKI, which was defined by risk, injury, failure, loss and end-stage （RIFLE） kidney disease criteria. The goal-directed hemodynamic optimization （maintenance of optimal hemodynamics and neutral or negative fluid balance） and renal outcomes were also reviewed. Results Of the 71 patients enrolled, 32 （45.1%） developed AKI, with 30 （93.8%） cases diagnosed on admission to surgical intensive care unit （SICU）. Risk factors for AKI were ruptured AAA （odds ratio （OR）=5.846, 95% confidence interval （CI）： 1.346-25.390）, intraoperative hypotension （OR=6.008, 95% CI： 1.176 to 30.683）, and perioperative blood transfusion （OR=4.611, 95% CI： 1.307-16.276）. Goal-directed hemodynamic optimization resulted in 75.0% complete and 18.8% partial renal recovery. Overall in-hospital mortality was 2.8%. AKI was associated with significantly increased length of stay （（136.9±24.5） hours vs. （70.4±11.3） hours） in Surgical Intensive Care Unit. Conclusions Critically ill patients undergoing AAA repair have a high incidence of AKI, which can be early recognized by RIFLE criteria. Rupture, hypotension, and blood transfusion are the significant associated risk factors. Application of goal-directed hemodynamic optimization in this cohort appeared to be effective in improving renal outcome.

Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers increases the risk of postoperative acute kidney injury after elective endovascular abdominal aortic aneurysm repair

Background: Endovascular abdominal aortic aneurysm repair (EVAR) is the major treatment for abdominal aortic aneurysm (AAA);however, EVAR still carries a considerable risk of acute kidney injury (AKI). The present study aimed to investigate the risk factors for AKI after elective EVAR procedures.Methods: This was a retrospective observational study. Eligible patients who underwent EVAR from September 2011 to March 2019 in West China Hospital were included. The primary outcome was the occurrence of AKI within two days after EVAR, which was defined by the Kidney Disease Improving Global Outcomes Clinical Practice Guideline. Demographics, comorbidities, medications, laboratory tests, anatomical parameters of AAA, and relative operative details were collected as variables. Univariable and multivariable logistic regression analyses were applied to identify the risk factors among variables, and covariate interactions were further assessed.Results: A total of 679 eligible patients were included. The incidence of postoperative AKI was 8.2% (56/679) in the whole cohort, and it was associated with a lower 5-year survival rate (63.5%vs. 80.9%;χ^(2) = 4.10;P = 0.043). The multivariable logistic regression showed that chronic kidney disease (OR, 5.06;95% CI: 1.43-17.95;P = 0.012), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) (OR, 2.60;95% CI: 1.17-5.76;P = 0.019), and short neck (OR, 2.85;95% CI: 1.08-7.52;P = 0.035) were independent risk factors for postoperative AKI. In the covariate interaction analysis, the effect of ACEIs/ARBs use on postoperative AKI was similar across all subgroups (P > 0.05), thereby suggesting a robust effect of ACEIs/ARBs use in all patients undergoing elective endovascular abdominal aortic aneurysm repair.Conclusions: Postoperative AKI was associated with lower survival rate, and the use of ACEIs/ARBs was the only adjustable independent risk factor. Clinicians should consider withdrawing ACEIs/ARBs in high-risk patients undergoing elective endovascular abdominal aortic aneurysm repair to prevent postoperative AKI.

Acute kidney injury after isolated aortic valve replacement surgery according to risk/injury/failure/loss/end-stage and acute kidney injury network criteria

Background The epidemiology of acute kidney injury after cardiac surgery depends on the definition used. Limited study reports the incidence of acute kidney injury after isolated aortic valve replacement. Methods We retrospectively analyzed clinical data of 165 adults who had isolated aortic valve replacement between Jan- uary 2010 and June 2011 and compared the maximum acute kidney injury stage according to the RIFLE （risk, injury, failure, loss of function, end-stage kidney disease） and AKIN （Acute Kidney Injury Network） criteri- a. Receiver operating curves were used to compare the predictive ability of each AKI definition for the occur- rence of renal replacement therapy. Results The incidence of AKI using the RIFLE and AKIN criteria was 82.4% and 71.5% respectively, but individual patients were classified differently. The area under the receiver operating characteristic curve for renal replacement therapy showed no difference between the RIFLE and AKIN criteria （0.710 vs. 0.703, P 〉 0.05）. Conclusion There is a high incidence of acute kidney injury after isolated aortic valve replacement, and there is no difference between the RIFLE and AKIN criteria for predict- ing renal replacement therapy.

Combined fenestrated/chimney thoracic endovascular repair for the treatment of blunt traumatic aortic injury:A case report

Blunt traumatic thoracic aortic injury(BTAI)is an extremely serious medical condition with a high rate of associated mortality.Recent advances in techniques such as thoracic endovascular repair offer new opportunities to manage the critical BTAI patients in an efficacious yet less invasive manner.A 65 year-old-male suffered from multiple injuries after a fall,including BTAI in the aortic arch,which resulted in dissection of the descending thoracic-abdominal aorta and iliac artery,development of an intimal flap in the left common carotid artery,and dissection of the left subclavian artery.Based on the imaging information of this patient and our clinical experience,the combined treatment of fenestrated thoracic endovascular repair and a chimney technique was immediately planned to fully repair these dissections and moreover prevent further dissection of the branching vessels,additionally to ensure sufficient blood flow in the left subclavian artery and left common carotid artery.The intervention yielded satisfactory early outcomes.Follow-up assessment at six months reported no symptoms or complications associated with the stent-graft.Computed tomography angiography further confirmed adequate stent-graft coverage of the aortic injury.

Blunt aortic injury-traumatic aortic isthmus pseudoaneurysm with right iliac artery dissection aneurysm:A case report

BACKGROUND Blunt aortic injury is a special type of aortic disease.Due to its low incidence,high prehospital mortality and high probability of leakage diagnosis,the timely identification of patients with blunt aortic injury who survive the initial injury has always been a clinical challenge.CASE SUMMARY We report a case of traumatic aortic pseudoaneurysm with right iliac artery dissection aneurysm that was diagnosed 3 mo after a traffic accident.The patient is a 76-year-old male who was knocked down by a fast-moving four-wheel motor vehicle while crossing the road(the damage mechanism was side impact).He received chest,cranial computed tomography(CT)and whole abdomen enhanced CT in the local hospital.The images suggested subarachnoid hemorrhage,right frontoparietal scalp hematoma,fracture of the right clavicle and second rib,lumpshaped mediastinal shadow outside the anterior descending thoracic aorta(mediastinal hematoma),mesenteric vascular injury with hematoma formation,pelvic fracture,and subluxation of the left sacroiliac joint.After the pelvic fracture was fixed with an external stent,he was sent to our hospital for further treatment.In our hospital,he successfully underwent partial resection of the small intestine and CT-guided screw internal fixation of the left sacroiliac joint and returned to the local hospital for rehabilitation treatment.However,since the accident,the patient has been suffering from mild chest pain,which has not aroused the attention of clinicians.During rehabilitation,his chest pain gradually worsened,and the thoracic aorta computed tomography angiography performed in the local hospital showed a pseudoaneurysm in the initial descending segment of the aortic arch.After transfer to our hospital,a dissecting aneurysm of the right external iliac artery was incidentally found in the preoperative evaluation.Finally,endovascular stent graft repair was performed,and he was discharged on the 10th day after the operation.No obvious endo-leak was found after 4 years of follow-up.CONCLUSION We highlight that emergency trauma centers should consider the possibility of aortic injury in patients with severe motor vehicle crashes and repeat the examination when necessary to avoid missed diagnoses.

Dynamic changes in growth factor levels over a 7-day period predict the functional outcomes of traumatic brain injury

Traumatic brain injury（TBI） can result in poor functional outcomes and death, and overall outcomes are varied. Growth factors, such as angiopoietin-1（Ang-1）, vascular endothelial growth factor（VEGF）, and granulocyte-colony stimulating factor（G-CSF）, play important roles in the neurological functions. This study investigated the relationship between serum growth factor levels and long-term outcomes after TBI. Blood samples from 55 patients were collected at 1, 3 and 7 days after TBI. Blood samples from 39 healthy controls were collected as a control group. Serum Ang-1, G-CSF, and VEGF levels were measured using ELISA. Patients were monitored for 3 months using the Glasgow Outcome Scale-Extended（GOSE）. Patients having a GOSE score of 〉 5 at 3 months were categorized as a good outcome, and patients with a GOSE score of 1-5 were categorized as a bad outcome. Our data demonstrated that TBI patients showed significantly increased growth factor levels within 7 days compared with healthy controls. Serum levels of Ang-1 at 1 and 7 days and G-CSF levels at 7 days were significantly higher in patients with good outcomes than in patients with poor outcomes. VEGF levels at 7 days were remarkably higher in patients with poor outcomes than in patients with good outcomes. Receiver operating characteristic analysis showed that the best cut-off points of serum growth factor levels at 7 days to predict functional outcome were 1,333 pg/mL for VEGF, 447.2 pg/mL for G-CSF, and 90.6 ng/mL for Ang-1. These data suggest that patients with elevated levels of serum Ang-1, G-CSF, and decreased VEGF levels had a better prognosis in the acute phase of TBI（within 7 days）. This study was registered with the Chinese Clinical Trial Registry（registration number： ChiCTR1800018251） on September 7, 2018.