Objective:To summarize the efficacy of artificial blood vessel bypass grafting in patients with acute type A aortic dissection (ATAAD) complicated with lower extremity malperfusion.Methods:From January 2004 to January 2021, a total of 896 patients with ATAAD underwent surgical operations in Nanjing First Hospital, Among which 75 patients with lower extremity malperfusion was retrospectively analyzed.Results:There were 61 males and 14 females with mean age (50.9±11.3) years old. The cardiopulmonary bypass time (CPB) was (181.9±27.0) min, the cross-clamp time was (125.7±25.0)min, and the lower body circulatory arrest time was (20.4±3.1) min. Fifty-five patients had total aortic arch replacement and 20 cases had hemi-arch replacement surgery. Lower extremity arterial perfusion was restored in 48 patients after dissection surgery. Twenty-six patients underwent dissection surgery concurrently with extra-anatomic bypass grafting. The main postoperative complications were: acute kidney injury in 9 cases, delayed extubation (≥72 h) in 10, pulmonary infection in 13, tracheotomy in 6, paralysis in 1, stroke in 2 and lower limb amputation in 3. ICU stay time was (5.8±4.5) days, in-hospital time was (21.4±13.8) days. Nine patients (12%) died in the whole group: pulmonary infection, respiratory failure in 2 cases, multiple organ failure in 3 cases, iliac artery rupture in 1 case, intestinal necrosis in 1 case, severe cerebral infarction in 1 case, and giving-up in 1 case. A total of 66 patients (88%) were successfully discharged. The follow-up time was (55.8±33.4) months. The results of survival analysis showed that the 5-year survival rate was (96.7±4.2)%, and the 10-year survival rate was (56.4±16.3)%.Conclusion:Extra-anatomic bypass grafting is a feasible method to solve ATAAD complicated with lower extremity malperfusion. It is simple and easy to operate, and the long-term effect is satisfactory.

Cryptococcus gattii is a kind of Cryptococcus that infects the lungs and central nervous system through the inhalation of infectious particles such as spores or Cryptococcus yeast cells. The development of clinical disease of Cryptococcus gattii may be determined by the sex, immunity and genetics of the host factors, in which immune system factors play an important role in host injury. Their defects will have serious clinical consequences. Cryptococcus gattii mainly infects the population with normal immune, and the infection of immunosuppressed population is rare. The infection mechanism, molecular types, clinical characteristics, treatment and prognosis of Cryptococcus gattii meningitis were different between the two populations. This article reviews the main differences in different immune status with Cryptococcus gattii meningitis.

Objective:To summarize treatment strategies and outcomes of patient suffer from acute Stanford type A aortic dissection(ATAAD) with mesenteric malperfusion.Methods:We collected 13 patients with mesenteric malperfusion among 321 ATAAD patients underwent surgery at Nanjing First Hospital during January 2019 to September 2022. Characteristics of these patients were recorded. We analyzed their early and late clinical outcomes.Results:Two patients underwent revascularization-first strategy in hybrid operation room had no in-hospital mortality or complication related to mesenteric ischemia. There were 11 patients with central repair-first strategy. Eight patients appeared mesenteric complications and 2 of them needed extra gastrointestinal surgery. Six in-hospital mortality were recorded in central repair-first patients.Conclusion:We recommended revascularization-first strategy with followed central repair in hybrid operation room for patients suffered from ATAAD with mesenteric malperfusion. Those who underwent central repair-first strategy because of coronary artery or cerebral malperfusion and unstable hemodynamic needed percutaneous angiography of mesenteric artery.

Cryptococcal meningitis is a common fungal meningitis that may present with an abnormal immune response during effective antifungal therapy and is called immune reconstitution inflammatory syndrome in human immunodeficiency virus (HIV)-infected patients. Similar phenomenon can also be seen in non-HIV patients with normal immune function in the past. Paradoxical clinical and/or imaging deterioration occurs due to strong immune response during treatment, which is called post-infectious inflammatory response syndrome. At present, it has not attracted attention. This complication is an important cause of poor prognosis in non-HIV patients. Early identification and treatment of post-infectious inflammatory response syndrome is of great significance. This article will review its possible pathogenesis, clinical manifestations, imaging characteristics, risk prediction, diagnosis, treatment and prognosis.

Objective:To explore the optimal monochromatic level for the observation of coronary in-stent lumen by dual-layer spectral CT (DLCT).Methods:Forty-nine patients with 74 stents after percutaneous coronary intervention (PCI) who underwent coronary CTA (CCTA) examinations by a DLCT between January 2016 and September 2017 were retrospectively enrolled. A total of 12 groups of images including 60-120 keV (kilo electron voltage) images with 10 keV interval, 140-200 keV images with 20 keV interval and conventional images. In-stent lumen diameter of proximal, mid and distal portion was measured. Difference of CT values between in-stent lumen and ascending aorta was used to describe as blooming artifact, and noise of in-stent lumen as image noise. Then Likert 5-point scale was performed to evaluate images noise, enhancement of in-stent lumen, blooming artifact and diagnostic confidence. Differences of objective and subjective parameters among conventional and various monochromatic images were compared by Friedman test.Results:In the diameter measurement of the proximal, middle and distal segments of the stent, the difference between the images of each group was statistically significant (χ 2 = 427.270, 426.375, 400.981, P< 0.001). The diameter of the lumen measured by 120-200 keV single-level image was larger than that measured by 60-100 keV single-level image, and the difference was statistically significant ( P< 0.05). In the comparison of CT difference between the stent lumen and ascending aorta, the difference between the images of each group was statistically significant (χ 2 = 242.193, P< 0.001), and 100-200 keV single-level images were lower than the conventional images, the difference was statistically significant ( P< 0.05). In the comparison of noise values, the difference between the images of each group was statistically significant (χ 2 = 420.161, P< 0.001), and the difference was statistically significant ( P< 0.05). In the subjective scores of noise, enhancement, halo artifact and diagnostic confidence, there were statistically significant differences among the groups (χ2= 333.827, 455.989, 276.824, 399.497, P< 0.001). The noise score of 100-200 keV single-level image was higher than that of conventional image, the difference was statistically significant ( P< 0.05). The enhancement score of 60 keV was significantly higher than that of other images ( P< 0.05). The halo artifact score of 100-200 keV single level image was higher than that of 60-90 keV image, the difference was statistically significant ( P<0.05). The scores of 90-120 keV single-level images were higher than those of other single-level images, and the difference was statistically significant ( P< 0.05). Conclusions:CCTA examinations can be effectively performed by DLCT in patients after PCI in clinical settings, and 120 keV is recommended as the optimal monochromatic image for the observation of in-stent lumen.

Objective:To summarize the surgical treatment and it’s results of patients with acute type A aortic dissection with cerebral malperfusion.Methods:We collected and analyzed the clinical date of 16 patients, who were hospitalized and underwent operation Between January 2010 to June 2019, presented cerebral malperfusion due to acute type A aortic dissection. All of them showed preoperative newly developed neurologic deficits, left hemiplegia in 8 cases, left paraparesis in 5 cases and right paraparesis in 3 cases.Results:Aortic valve was involved in 5 patients, 2 of whom underwent AVR surgery, 2 cases of CABG and 2 cases of artificial graft bypass were performed at the same time, 1 case underwent left leg amputation postoperatively. Seven patients died after surgery.Conclusion:The results of surgical management of acute type A aortic dissection with cerebral malperfusion demonstrated high hospital mortality, which needs us to restore the cerebral perfusion as soon as possible. The specific method should be decided according to the patients' condition.

Objective To compare early outcomes of the minimally invasive aortic valve surgery (MIAVS) through right parasternal mini-thoracotomy with conventional mitral valve surgery (AVS),and evaluate feasibility and safety of MIAVS.Methods From January 2017 to December 2017,60 patients undergoing elective AVS in Nanjing First Hospital were prospectively enrolled in this study.There were 32 male and 28 female patients with their age of 28-72 (46.5 ± 10.2)years.Using a random number table,all the patients were randomly divided into a port-access MIAVS group (MIAVS group,n =20) and a conventional AVS group (conventional group,n =60).MIAVS group patients received port-access cardiopulmonary bypass (CPB) establishment via femoral artery,femoral vein and right internal jugular vein cannulation through right the 3rd in tercostal space with 5-6 cm right parasternal incision in length.Special MIAVS operative instruments were used for mitral valve repair or replacement.Conventional group patients received mitral valve repair or replacement under conventional CPB through median sternotomy.Perioperative clinical data,morbidity and mortality were compared between the 2 groups.Results There was no death in-hospital or shortly after discharge in this study.CPB time [(106.0 ± 21.0) minutes vs (73.0 ± 15.0) minutes] and aortic cross-clamping time [(78.0 ± 10.0) minutes vs (47.0 ± 7.0) minutes] of MIAVS group were significantly longer than those of conventional group (P ≤ 0.05).Postoperative mechanical ventilation time [(7.0 ±4.2) hours vs (10.2 ±5.3)hours],length of intensive care unit (ICU) stay [(19.0 ± 4.0) hours vs (27.5 ± 8.0) hours] and postoperative hospital stay [(8.5 ± 2.5) days vs (13.0 ± 3.0) days] of MIAVS group were significantly shorter than those of conventional group (P ≤ 0.05).Chest drainage volume within postoperative 12 hours [(100.0 ±40.0)ml vs (410.0 ±80.0)ml] and the percentage of patients receiving blood transfusion (15.0％ vs 55.0％) of MIAVS group were significantly lower than those of conventional group (P ≤0.05).Patients were followed up for 1-12 months,and the follow-up rate was 96.7％.There was no statistical difference in postoperative morbidity or mortality between the 2 groups (P ＞ 0.05).Conclusions Minimally invasive aortic valve surgery through right right parasternal mini-thoracotomy is a safe and feasible procedure for surgical treatment of mitral valve diseases.MIAVS can achieve similar clinical outcomes as conventional AVS,with more quickly recovery and less blood transfusion,and is a good alternative to conventional AVS.

OBJECTIVE:To prepare Diacerein (DCR)-loaded (poly lactic-co-glycolic acid) PLGA microspheres for intra-articular injection and investigate its related properties. METHODS:PLGA was used as microspheres material,and the microsphere was prepared by emulsification solvent evaporation method. The contents of DCR-PLGA microspheres were determined by HPLC,and drug-loading amount and entrapment efficiency were also calculated. Using entrapment efficiency as evaluation index,the preparation technology was optimized by orthogonal test. The morphology and particle size of microspheres were observed by optical microscope and SEM. Accumulative release rate was investigated by using in vitro release test. RESULTS:The linear range of DCR was 2.1-105.0 μg/mL(r＝0.999 9). RSDs of precision,stability,reproducibility and recovery tests were all lower than 2.0%. The optimal technology was PLGA concentration of 200 mg/mL,volume ratio of oil-water 1∶50,polyvinyl alcohol concentration of 1%. The prepared DCR-PLGA microspheres were spherical,average particle size was(11.2±4.7)μm, drug-loading amount was(4.25 ± 0.26)% and encapsulation rate was(92.30 ± 1.93)%,respectively. The drug release rate of DCR-PLGA microspheres within 360 h was about(73.08 ± 5.33)%. CONCLUSIONS:DCR-PLGA microspheres are prepared successfully with good morphology,suitable particle size and obvious sustained release effect,which are suitable for intra-articular injection.

Objective To determine the solubility of rhein in different vehicles and its partition coefficients in the n-octanol-water system for designing new formulations. Methods High performance liquid chromatography(HPLC) method was established to determine the concentration of rhein in water,different pH solutions and different solvents;the partition coefficients for the n-octanol- buffer solution systems were determined by shaking flask method. Results The equilibrium solubility of Rhein was 3.89 μg·mL-1and the lgP was 2.79 in water at 37 ℃.The solubility of rhein was increased with the raise of pH, which could reach 362.20 and 431.65 μg·mL-1in phosphate buffer solution at pH 6.8 and 7.4,respectively.Solubility of rhein in the semi polar solvent was relatively good,which can up to 2 971.74 μg·mL-1in PEG400.The oil-water partition coefficients of rhein were decreased with the increase of pH,and were 0.83 and 0.54 in phosphate buffer solution at pH 6.8 and 7.4,respectively. Conclusion Rhein is almost not soluble in water.With the raise of pH,the solubility is increased but the oil-water partition coefficient is decreased.

Objective    To analyze the clinical effect of partial aortic root remodeling for root reconstruction on Stanford type A aortic dissection. Methods    From January 2010 to December 2015, 30 patients (25 males, 5 females) underwent partial aortic root remodeling for root reconstruction on Stanford type A aortic dissection with involvement of aortic root. The range of age was from 27 to 72 years, and the mean age was 51.2±8.0 years. The proximal aortic dissection received partial aortic root remodeling, and the operation procedures included partial aortic root remodeling+ascending aortic replacement in 9 patients, partial aortic root remodeling+ascending aortic replacement+hemi-arch replacement in 6 patients, partial aortic root remodeling+ascending aortic replacement+Sun's procedure in 15 patients. The patients were followed up for 10 to 60 months with a mean of 37.9±3.2 months. Preoperative and postoperative degrees of aortic regurgitation were compared. Results    All patients survived from the operation, and one patient died from severe pulmonary infection 15 days after operation. The overall survival rate was 96.7% (29/30). One patient died during the follow-up. Two patients underwent aortic valve replacement in the 12th and 15th postoperative month respectively because of severe aortic regurgitation (AI). Up to the last follow-up, trivial or no aortic regurgitation was demonstrated in 24 patients, but mild aortic regurgitation occurred in 2 patients. Conclusion    The surgical treatment for aortic root pathology due to Stanford type A aortic dissection is challenging, and partial aortic root remodeling operations could restore valve durability and function, and obtains the early- and mid-term results.