Conjoined twins are one of the most intriguing malformations in human beings. This report describes the anesthetic management of a two-day-old pretermomphalopagus conjoined twins posted for an emergency diverting colostomy for imperforate anus. These conjoined twins were born to a primigravid via cesarean section for fetal indication. They were born preterm at 36 weeks age of gestation with a collective birth weight of4.1 kg and an APGAR score 89. Computerized tomography scan of the chest and abdomen revealed Omphalopagus twins with left lower lobe atelectasis for Twin 2, fused liver, separate stomach and small intestines with distal fusion, imperforate anus, horseshoe kidney, bladder fistula, and the shared lower extremity appears to derive its blood supply from Twin 1. Evaluation of cross-circulation between the twins was done pre-induction by giving atropine IV to Twin 1. Atropine flush and increase in heart rate were noted in Twin 1, however, were not appreciated in Twin 2. Anesthesia for conjoined twins can be the most daunting and intimidating procedure that an anesthesiologist can handle in his lifetime. We highlight the challenges encountered with anesthesia preparation, preoperative planning, positioning, airway management, preservation of hemodynamic stability, as well as monitoring in an emergency setting.
Twins, Conjoined ; Cross Circulation

In the first paper of this experiment, the author reported no significant changes in NPN, urea nitrogen and creatinine blood levels resulting from cross circulation between normal dogs. In this experiment cross circulations between Nephrectemized dogs and normal ones were performed and the rate of removal of waste products from the blood of bilaterally nephrectomized dogs through the kidneys of normal dogs as well as the state of improvement of a general condition were observed. Blood levels of NPN, urea nitrogen and creatinine were determined. Sixty to seventy-two hours after both kidneys were removed, the dogs developed anorexia, nausea, vomiting and apathy. Cross circulation as previously described was instituted when blood concentration of NPN varied from 139.2 to 193 mg%; urea nitrogen, from 86.7 to 137.8 mg; and creatinine, from 4.8 to 6.8 mg%. All procedures were carried out under an aseptic technique and penicillin or streptomycin were given to prevent infection. Using the indirect cross circulation in two pairs of dogs, 2080 cc and 3520 cc of blood was cross transfused for periods of 100 minutes and 5 hours respectively. Blood was exchanged by the direct cross circulation in four pairs of dogs for periods ranging from four hours 35 minutes to eight hours. The results obtained are as follows: During cross circulation between the nephrectomized dogs and the normal ones, the former exhibited improvement in their vitality, ceased nausea and vomiting and began to eat. During the indirect cross circulation the NPN of the nephrectomized dogs was lowered 13.8 mg% and 27.2 mg; whereas when using the direct cross circulation a decrease of 57.6 mg% to 84.6mg% and obtained. Decreases in urea nitrogen and creatinine blood concentrations were observed to be 10.2 mg% to 22.6 mg% and O.6 mg% respectively by the indirect cross circulation. whereas 32.7mg% to 65.1 mg% and 2.2 mg% to 3.O mg% respectively by the direct method. The lowered blood concentrations of the waste products, however, rose again and the general condition of the nephrectomized dogs became worse one or two days after the completion of the experiment. The normal dogs receiving blood from the nephrectomized dogs developed a rapid pulse, frequent and irregular respirations, a weakened general condition and elevation of blood concentrations of NPN. urea nitrogen and creatinine. The general condition and the blood concentrations, however, returned to normal one to four days after the completion of the experiments. The direct method of cross circulation between bilaterally nephrectomized dogs and healthy ones is superior to the indirect method in respect to the animals general condition and to the removal of waste products from the blood of the nephrectomized animal.
Animals ; Anorexia ; Apathy ; Creatinine* ; Cross Circulation* ; Dogs* ; Kidney* ; Nausea ; Nitrogen* ; Penicillins ; Streptomycin ; Urea* ; Vomiting ; Waste Products

BACKGROUND: The cerebral blood flow velocity (CBFV) has been known to increase in response to acute hypoxia. However, how CBFV might respond to exercise in hypoxic conditions and be associated with electroencephalogram (EEG) remains unclear. The purpose of this study was to evaluate the effect of exercise in hypoxic conditions corresponding to altitudes of 4,000 m on CBFV and EEG. METHODS: In a randomized, double-blind, balanced crossover study, ten healthy volunteers (19.8±0.4 years) were asked to perform the incremental bicycle ergometer exercise twice in hypoxic and control (sea level) conditions with a 1-week interval, respectively. Exercise intensity was set initially at 50 W and increased by 25 W every 2 minutes to 125 W. Acute normobaric hypoxic condition was maintained for 45 minutes using low oxygen gas mixture. CBFV in the middle cerebral artery (MCA) and EEG were measured at rest 5 minutes, rest 15 minutes, immediately after exercise, and 15 minutes recovery using transcranial-Doppler sonography and EEG signal was recorded from 6 scalp sites leading to analysis of alpha and beta wave relative activities. All data were analyzed using two-way repeated-measures analysis of variance and Pearson's correlation. RESULTS: CBFV in the MCA in the hypoxic condition was significantly higher than that in the control condition at rest 5 minutes (83±9 vs. 69±9 cm/s, P<0.01), rest 15 minutes (87±8 vs. 67±7 cm/s, P<0.001), immediately after exercise (112±9 vs. 97±9 cm/s, P<0.01), and 15 minutes recovery (91±11 vs. 74±7 cm/s, P<0.01). However, no significant correlation was found between the changes of CBFV and EEG wave activities. CONCLUSIONS: These results suggest that the drastic change of CBFV observed during exercise with hypoxia might appear independently with EEG wave activities.
Altitude ; Anoxia ; Cerebrovascular Circulation ; Cross-Over Studies ; Electroencephalography ; Healthy Volunteers ; Middle Cerebral Artery ; Oxygen ; Scalp

BACKGROUND: The cerebral blood flow velocity (CBFV) and rate pressure product (RPP) have been reported to benefit hemodynamics more during exercise in the recumbent position than during that in the upright position. However, it is unclear which angle is of the greatest benefit to hemodynamics during exercise in the recumbent position. This study aimed to evaluate the effect of the recumbent angle on CBFV and RPP during exercise. METHODS: In a balanced crossover study, 15 healthy volunteers (age, 18.7±1.1 years) were asked to perform the bicycle exercise four times in the upright and at recumbent angles of 67° (R), 47°R, and 15°R, with weekly intervals between each condition. The exercise intensity was set initially at 50 W and increased by 25 W every 2 minutes up to 150 W. CBFV in the middle cerebral artery (MCA) was measured using transcranial doppler sonography. All data were analyzed using two-way repeated-measures analysis of variance. RESULTS: CBFV at 15°R was significantly higher than that in the upright position and at 67°R at 10 minutes recovery (69±16 vs. 56±7 and 58±10 cm/s, respectively; P<0.05). The RPP was significantly lower at 67°R, 47°R, and 15°R than in the upright position immediately after exercise (176±23, 177±22, and 173±26, respectively, vs. 241±42 mmHg×beats/min×10⁻²; P<0.001). CONCLUSIONS: At an angle of less than 67°R, exercise increases CBFV and reduces RPP, relative to those during exercise in the upright position. This hemodynamic effect was most prominent at 15°R, where cerebral circulation was further increased in the recovery phase.
Cerebrovascular Circulation ; Cross-Over Studies ; Healthy Volunteers ; Hemodynamics ; Middle Cerebral Artery ; Posture ; Ultrasonography, Doppler, Transcranial

Normal adult Korean dogs (Mongrel) were used for these experiments. Operations and cross circulations were performed under sterile conditions and anesthesia with intravenous sodium pentothal injection. Heparin was used as the anticoagulant before and during cross circulation. Two dogs were placed on operating tables so that their legs were together. The femoral arteries and veins in adjacent legs were isolated and cannulated with tubes of 1.0mm inside diameter. The arterial cannule of each animal was connected to the venous cannule of the other dog, and cross circulation was started and continued for 2 to 13 hours. This method is referred as direct cross circulation. A second method, indirect cross circulation, was devised to connect the arterial cannule of each dog to the venous cannule of the other dog through a glass bottle containing 20cc of ACD solution elevated one meter above the animals. With the venous tubing clamped, arterial blood flowed into the bottles. When 100cc of arterial blood had been collected, blood flow was reversed by clamping the arterial tubings and removing the venous clamps. The procedures were repeated for 5 hours. General condition, pulse, respiration, NPN. BUN and creatinine of blood content were observed and determined before, during and after cross circulation. The experiments were done in 7 pairs of animals by the direct method, and in 2 pairs by the indirect method. During the experiment, pulse and respiration became frequent and irregular. They showed sign of weakness. But dogs returned to normal in 1 to 3 days after the experiment. No significant differences were noted in the amount of blood NPN, BUN and creatinine content during and after cross circulation by both animals. However, the indirect method appears safer for the animals but less blood volume can be exchanged than in using the direct method.
Adult ; Anesthesia ; Animals ; Blood Volume ; Constriction ; Creatinine ; Cross Circulation* ; Dogs* ; Femoral Artery ; Glass ; Heparin ; Humans ; Kidney* ; Leg ; Operating Tables ; Respiration ; Sodium ; Thiopental ; Veins

Objectives: To evaluate microvascular perfusion and left ventricular function in patients with acute ST-segment elevation myocardial infarction after revascularization using myocardial contrast echocardiography (MCE), and to explore clinical influencing factors of abnormal microvascular perfusion in these patients. Methods: This is a cross-sectional study. The analysis was performed among patients admitted to Peking University People's Hospital for acute ST-segment elevation myocardial infarction (STEMI) from June 2018 to July 2021. All patients underwent percutaneous coronary intervention (PCI) and completed MCE within 48 hours after PCI. Patients were divided into normal myocardial perfusion group and abnormal perfusion group according to the myocardial perfusion score. The echocardiographic indexes within 48 hours after PCI, including peak mitral valve flow velocity (E), mean value of early diastolic velocity of left ventricular septum and lateral mitral annulus (Em), left ventricular global longitudinal strain (GLS) and so on, were analyzed and compared between the two groups. Multivariate logistic regression analysis was used to evaluate the influencing factors of myocardial perfusion abnormalities. Results: A total of 123 STEMI patients, aged 59±13 years with 93 (75.6%) males, were enrolled. There were 50 cases in the normal myocardial perfusion group, and 73 cases in the abnormal myocardial perfusion group. The incidence of abnormal myocardial perfusion was 59.3% (73/123). The left ventricular volume index ((62.3±18.4)ml/m² vs. (55.1±15.2)ml/m², P=0.018), wall motion score index (WMSI) (1.59 (1.44, 2.00) vs. 1.24(1.00, 1.47), P<0.001) and mitral E/Em (17.8(12.0, 24.3) vs. 12.2(9.2, 15.7), P<0.001) were significantly higher whereas left ventricular global longitudinal strain (GLS) ((-10.8±3.4)% vs. (-13.8±3.5)%, P<0.001) was significantly lower in the abnormal myocardial perfusion group than those in the normal myocardial perfusion group. Multivariate logistic regression analysis showed that left anterior descending (LAD) as culprit vessel (OR=3.733, 95%CI 1.282-10.873, P=0.016), intraoperative no/low-reflow (OR=6.125, 95%CI 1.299-28.872, P=0.022), and peak troponin I (TnI) (OR=1.018, 95%CI 1.008-1.029, P=0.001) were independent risk factors of abnormal myocardial perfusion. As for ultrasonic indexes, deceleration time of mitral E wave (OR=0.979, 95%CI 0.965-0.993, P=0.003), mitral E/Em (OR=1.100, 95%CI 1.014-1.194, P=0.022) and WMSI (OR=7.470, 95%CI 2.630-21.222, P<0.001) were independently related to abnormal myocardial perfusion. Conclusions: The incidence of abnormal myocardial perfusion after PCI is high in patients with acute STEMI. Abnormal myocardial perfusion is related to worse left ventricular systolic and diastolic function. LAD as culprit vessel, intraoperative no/low-reflow and peak TnI are independent risk factors of abnormal myocardial perfusion.
Male ; Humans ; Female ; ST Elevation Myocardial Infarction/diagnostic imaging* ; Percutaneous Coronary Intervention ; Cross-Sectional Studies ; Coronary Circulation ; Echocardiography ; Anterior Wall Myocardial Infarction/etiology* ; Ventricular Function, Left ; Perfusion

BACKGROUND AND PURPOSE: Although sleep disturbances are common and considered a major burden for patients with Alzheimer's disease (AD), the fundamental mechanisms underlying the development and maintenance of sleep disturbance in AD patients have yet to be elucidated. The aim of this study was to examine the correlation between regional cerebral blood flow (rCBF) and sleep disturbance in AD patients using technetium-99m hexamethylpropylene amine oxime single-photon emission computed tomography (SPECT). METHODS: A total of 140 AD patients were included in this cross-sectional study. Seventy patients were assigned to the AD with sleep loss (SL) group and the rest were assigned to the AD without SL group. SL was measured using the sleep subscale of the Neuropsychiatric Inventory. A whole-brain voxel-wise analysis of brain SPECT data was conducted to compare the rCBF between the two groups. RESULTS: The two groups did not differ in demographic characteristics, severity of dementia, general cognitive function, and neuropsychiatric symptoms, with the exception of sleep disturbances. The SPECT imaging analysis displayed decreased perfusion in the bilateral inferior frontal gyrus, bilateral temporal pole, and right precentral gyrus in the AD patients with SL group compared with the AD patients without SL group. It also revealed increased perfusion in the right precuneus, right occipital pole, and left middle occipital gyrus in the AD with SL group compared with the AD without SL group. CONCLUSIONS: The AD patients who experienced sleep disturbance had notably decreased perfusion in the frontal and temporal lobes and increased rCBF in the parietal and occipital regions. The findings of this study suggest that functional alterations in these brain areas may be the underlying neural correlates of sleep disturbance in AD patients.
Alzheimer Disease* ; Brain* ; Cerebrovascular Circulation ; Cognition ; Cross-Sectional Studies ; Dementia ; Frontal Lobe ; Humans ; Occipital Lobe ; Parietal Lobe ; Perfusion* ; Prefrontal Cortex ; Rabeprazole ; Temporal Lobe ; Tomography, Emission-Computed ; Tomography, Emission-Computed, Single-Photon

In Part II, the authors have reported that cross circulation between normal dogs and bilaterally nephrectomized dogs resulted in decreased blood concentrations of non-protein nitrogen, urea nitrogen and creatinine in the bilaterally nephrectomized dogs and improvement of the dogs' general condition for a short time. In this study the renal arteries of normal dogs were occluded by clamping for varied periods of time to cause reversible renal insufficiency. After renal insufficiency developed cross criculation with untreated normal dogs was instituted to investigate the effects of cross circulation on blood concentrations of NPN, urea nitrogen and creatinine, urinary out-put and in the general condition of the dogs.As a control experiment, renal arteries of dogs were clamped bilaterally for 1, 2, 3, 4, 5 and 6 hours and blood concentrations of NPN, urea nitrogen and creatinine, general condition and urinary out-put of these dogs were studied.In the oliguric phase caused by bilateral clamping of the renal arteries of dogs for 3, 4, 5, and 6 hours, cross circulation between these dogs and normal dogs was performed. One to three cross circulations were done on each dog and one cross circulation lasted for 2 to 4 hours. Changes in the blood concentration of NPN, urea nitrogen and creatinine, the general condition of the dogs and urinary out-put were studied.In the control and cross circulation studies 5 dogs were studied in each of the groups designated by the time interval of clamping renal arteries except one dog was used for the 1 and 2 hour groups. Using normal Korea mongrels weighing 12kg. or more, the kidneys were exposed through a flank incision under pentothal anesthesia. Perirenal fat tissue was freed and vessels supplying the renal capsule were severed and ligated. The upper ureters were freed of abarrent vessels. The right kidney was first exposed and then the left. Clamping of both renal arteries was instituted at the same time. The renal arteries were lightly clamped using a rubber shod clamp to interrrupt the blood stream but bot to damage the arterial wall. Clamping of both renal arteries were released simultaneously and the operative wounds were closed. Direct cross circulation as described previously was used in this study and all procedures were done under aseptic technic. Prophylactic penicillin and streptomycin were also given pre- and postoperatively. All observation and determination of experimental items were done before clamping the arteries and at 12 hours after clamping. Daily determinaton for 5 days followed thereafter. Hourly determinatons were performed during the cross circulation. The results of the experiment are summarized as follows: When bilateral renal arteries of normal dogs were clamped for 1, 2, 3, 4, 5 and 6 hours, oliuria or anuria was observed immediately after clamping. Blood levels of NPN, urea nitrogen and creatinine were increased at 12 hours after clamping. A poor general condition was observed in most dogs one to two days post-experimentally in these and there was gradual exacerbation in the induced kidney insufficiency during oliguric phase. Most experimental animals died except a few did recover after regaining enough renal unction to produce diuresis. During cross circulation, urinary out-put was not altered and the general condition of the dogs was remarkedly improved. A decrease in the blood concentrations of NPN, urea nitrogen and creatinine was observed in all the dogs. For one to seven days after the circulation the condition of these dogs became slightly worse but a diuretic phase soon developed and most dogs in these experimental groups survived except for the few which died during or after the cross circulaton.In each of the six control groups in which the renal arteries were clamped for 1 to 6 hours as described above, 1, 1, 2, 2, 0 and 0 dogs survived. With cross circulation, experimental groups in which the renal arteries were clamped for 3, 4, 5 and 6 hours, had a survival of 4, 3, 3 and 2 dogs, respectively. Of 20 dogs, 12 survived and 8 died.Cross circulation increased the survival rate of dogs with induced renal insufficieney, but it is unlikely that pathological changes and function in these kidneys were changed during the curculation. It, however, is clear that the toxic state of renal insufficiency was relieved markedly during the cross circulation, although temporarily, but long enough to provide better survival condition. Most dogs were supported adequately to overcome the oliguric crisis and return to the diuretic phase.In normal dogs used in the cross circulation the development of an apathetic state, and elevation in blood concentrations of NPN, urea nitrogen and creatinine were observed. These dogs urinated several times during the experiment and experienced frequent pulse and respiratory rates. Arrhythmias of a temporary nature were observed. These dogs returned to normal in one to three days after the cross circulation.
Anesthesia ; Animals ; Anuria ; Arrhythmias, Cardiac ; Arteries ; Constriction ; Creatinine* ; Cross Circulation* ; Diuresis ; Dogs* ; Kidney* ; Korea ; Nitrogen* ; Penicillins ; Renal Artery* ; Renal Insufficiency ; Respiratory Rate ; Rivers ; Rubber ; Streptomycin ; Survival Rate ; Thiopental ; Urea* ; Ureter ; Wounds and Injuries

Objective: To describe the current status and trends in the treatment of patent ductus arteriosus (PDA) among very preterm infants (VPI) admitted to the neonatal intensive care units (NICU) of the Chinese Neonatal Network (CHNN) from 2019 to 2021, and to compare the differences in PDA treatment among these units. Methods: This was a cross-sectional study based on the CHNN VPI cohort, all of 22 525 VPI (gestational age<32 weeks) admitted to 79 tertiary NICU within 3 days of age from 2019 to 2021 were included. The overall PDA treatment rates were calculated, as well as the rates of infants with different gestational ages (≤26, 27-28, 29-31 weeks), and pharmacological and surgical treatments were described. PDA was defined as those diagnosed by echocardiography during hospitalization. The PDA treatment rate was defined as the number of VPI who had received medication treatment and (or) surgical ligation of PDA divided by the number of all VPI. Logistic regression was used to investigate the changes in PDA treatment rates over the 3 years and the differences between gestational age groups. A multivariate Logistic regression model was constructed to compute the standardized ratio (SR) of PDA treatment across different units, to compare the rates after adjusting for population characteristics. Results: A total of 22 525 VPI were included in the study, with a gestational age of 30.0 (28.6, 31.0) weeks and birth weight of 1 310 (1 100, 1 540) g; 56.0% (12 615) of them were male. PDA was diagnosed by echocardiography in 49.7% (11 186/22 525) of all VPI, and the overall PDA treatment rate was 16.8% (3 795/22 525). Of 3 762 VPI who received medication treatment, the main first-line medication used was ibuprofen (93.4% (3 515/3 762)) and the postnatal day of first medication treatment was 6 (4, 10) days of age; 59.3% (2 231/3 762) of the VPI had been weaned from invasive respiratory support during the first medication treatment, and 82.2% (3 092/3 762) of the infants received only one course of medication treatment. A total of 143 VPI underwent surgery, which was conducted on 32 (22, 46) days of age. Over the 3 years from 2019 to 2021, there was no significant change in the PDA treatment rate in these VPI (P=0.650). The PDA treatment rate decreased with increasing gestational age (P<0.001). The PDA treatment rates for VPI with gestational age ≤26, 27-28, and 29-31 weeks were 39.6% (688/1 737), 25.9% (1 319/5 098), and 11.4% (1 788/15 690), respectively. There were 61 units having a total number of VPI≥100 cases, and their rates of PDA treatment were 0 (0/116)-47.4% (376/793). After adjusting for population characteristics, the range of standardized ratios for PDA treatment in the 61 units was 0 (95%CI 0-0.3) to 3.4 (95%CI 3.1-3.8). Conclusions: From 2019 to 2021, compared to the peers in developed countries, VPI in CHNN NICU had a different PDA treatment rate; specifically, the VPI with small birth gestational age had a lower treatment rate, while the VPI with large birth gestational age had a higher rate. There are significant differences in PDA treatment rates among different units.
Infant ; Infant, Newborn ; Male ; Humans ; Female ; Ductus Arteriosus, Patent/drug therapy* ; Infant, Premature ; Cross-Sectional Studies ; Ibuprofen/therapeutic use* ; Infant, Very Low Birth Weight ; Persistent Fetal Circulation Syndrome ; Infant, Premature, Diseases/therapy*

Objective: To explore the related factors of the coronary microvascular disease (CMD) diagnosed with positron emission tomography(PET)/CT in patients with chest pain and without obstructive coronary artery disease (NOCA). Methods: This study was a single-center retrospective cross-sectional study. Consecutive patients with chest pain and NOCA on coronary angiography, who underwent PET/CT quantitative myocardial blood flow measurements at TEDA International Cardiovascular Hospital from August 2018 to January 2019, were enrolled for this study. The diagnostic criteria for NOCA was the absence of coronary artery diameter stenosis ≥50% on coronary angiography. Clinical data, global left ventricular myocardial blood flow on stress and rest, and the coronary flow reserve (CFR) were analyzed. Patients were divided into two groups according to CFR. Patients with CFR<2 were defined as CMD group, and the rest were classified as control group. Pearson correlation analysis and Logistics regression analysis were used for exploring the risk factors of the CMD. Results: A total of 66 patients, with an mean age of (56.7±9.6) years, were included in the study, including 41 females (62%). There were 20 patients with CMD (30%). Body mass index (BMI) was significantly higher in CND group than in control group ((28.1±3.6) kg/m² vs. (25.6±3.5) kg/m², P=0.01). Total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) were also significantly higher in CMD group than in control group ((4.89±1.03) mmol/L vs. (4.30±1.02) mmol/L and (3.23±0.81) mmol/L vs. (2.71±0.95) mmol/L respectively, P=0.038). Pearson correlation analysis showed that CFR was moderately correlated with BMI (r=-0.45, P<0.001), and was weakly correlated with TC and LDL-C (r=-0.271 and r=-0.280, respectively, P<0.05). Multivariate logistic regression analysis showed that BMI (the risk of CMD increased by 1.528 times for every 5 kg/m² increase in BMI, 95%CI 1.083-5.897, P<0.05) was an independent risk factor of CMD after adjusted by gender, hypertension, diabetic mellites and LDL-C. Conclusion: For patients with NOCA and chest pain, high BMI is independent risk factor of CMD diagnosed by PET/CT.
Aged ; Chest Pain/diagnostic imaging* ; Coronary Angiography ; Coronary Artery Disease/diagnostic imaging* ; Coronary Circulation ; Cross-Sectional Studies ; Female ; Humans ; Middle Aged ; Positron Emission Tomography Computed Tomography ; Retrospective Studies ; Risk Factors