Rheumatic Heart Disease

本病例由苏州⼤学附属第二医院雷锋锐教授提供，该患者为截趾后创面迁延不愈的糖足患者，经过血运重建、清创术和香雷糖足膏的治疗后，创口实现愈合。 病例分享专家 雷锋锐 苏州大学附属第二医院 苏大附二院血管外科副主任医师 国际血管联盟（IUA）中国分部转化医学专家委员会委员 中国医疗保健国际交流促进会外周血管医学分会委员 江苏省医学会血管外科分会下肢动脉学组委员 苏州市介入医学学会外周血管学组委员会委员 苏州市医学会心血管外科学分会委员 专注血管外科临床疾病十五年余，擅长血管外科常见静脉及动脉疾病的介入治疗 目前主攻方向：下肢动脉硬化闭塞症介入治疗；糖尿病足下肢动脉介入及综合治疗，糖尿病足创面修复；下肢深静脉血栓介入治疗；Stanford B型主动脉夹层及腹主动脉瘤介入治疗 十余年来发表核心期刊及SCI文章十余篇，参加临床药物及器械临床试验研究四项，发明国家专利两项，参与国家级及省部级课题六项。 01 基本信息 患者：王**，性别：女性，年龄：77岁 主诉 左足第一趾局部切除术后不愈合两月 现病史 两月前出现左足第一趾局部感染、逐渐发黑，后因感染性休克入住ICU，经历感染性休克、酮症酸中毒、心衰、房颤、稳定后手足外科行“(左足拇趾)截断残端的修复术+(任意皮瓣修复术)滑动皮瓣移植术+开放性创面负压吸引术(VAC)+肌肉清创术”，术后患者一般情况良好，但切口一直不愈合。现为求进⼀步治疗，⻔诊以“左足2型糖尿病足”收住⼊院。 既往史 2型糖尿病二十年；主动脉瓣狭窄伴有关闭不全、风湿性心脏病。 体格检查 左足背动脉搏动未触及，胫后动脉搏动未触及，左足第一趾趾端创面及部分足背创面少量渗液，内有空腔。 辅助检查 图片可能引起不适  请谨慎“点击”查看 点击查看｜两月前术前照片 图片可能引起不适 请谨慎“点击”查看 点击查看｜两月前术后照片 图片可能引起不适  请谨慎“点击”查看 点击查看｜两月前术后照片 入院诊断 1、2型糖尿病足； 2、糖尿病性周围血管病变 3、糖尿病末梢神经病变 4、风湿性心脏病 5、主动脉瓣狭窄伴重度关闭不全 治疗经过 ⼊院后完善⾎常规、生化电解质、凝血等常规检查，完善CT血管成像（CTA）检查示：左侧腘动脉多发粥样硬化性斑块，局部管腔约重度狭窄，左侧胫后动脉断续显影；右侧腘动脉多发粥样硬化性斑块，管腔约轻度-中度狭窄，右侧胫后动脉近段钙化斑块，相应管腔约轻度狭窄。 图片可能引起不适  请谨慎“点击”查看 点击查看｜入院时照片 CTA影像 结合患者症状体征，手术指征明确，对患者行血运重建（胫后动脉球囊血管成形术+胫前动脉球囊扩张成形术），术后予抗凝、创面换药等对症处理。患者左足血运较前明显改善。 为进一步促进创⾯愈合，一周后于神经阻滞麻醉下⾏清创术（皮肤和皮下坏死组织切除清创术+开放性创面负压吸引术）。术后创面持续负压吸引。五天后拆除负压装置见创面对合良好，皮缘无发黑坏死。 术中影像 术后患者⼀般情况良好，残留左足背创面，予以出院后门诊换药。 术后一周创口面积为2.0cm*1.5cm，开始使用香雷糖足膏，使用后约三周，面积缩小为面积为0.6cm*1cm，33天后创面愈合。 左右滑动查看｜治疗后照片 02 专家分析1 糖尿病足溃疡（DFU）是糖尿病患者的一种严重并发症，主要表现为足部组织的感染、破溃、变性坏死，以及下肢血管和神经病变等临床特征。糖尿病患者中，DFU发病率高达19%~34%，而其中 20%的足部溃疡因发生感染等原因导致不同节段的截肢，是下肢非外伤性截肢的主要原因1。 该患者为77岁老年女性，且合并风湿性心脏病、主动脉瓣狭窄伴重度关闭不全等疾病，查体时见左足血运欠佳，左足第一趾截趾残端创面不愈合，足背创面不愈合。CTA示左侧腘动脉局部管腔约重度狭窄，左侧胫后动脉断续显影； 考虑患者足部面积缺损较大，有多种合并症，给予血运重建和清创术，术后仍有2.0cm*1.5cm的创口面积，再外用香雷糖足膏治疗，约一月后创面愈合。 香雷糖足膏是中国第1个天然药物1.1类新药，临床研究证实，其治疗DFU完全愈合率>60%，明显高于亲水性纤维敷料对照组，且能更快促进创面愈合，也具有良好的临床安全性。该例患者使用香雷糖足膏1月，术后2.0cm*1.5cm的创口面积实现愈合，这也充分证实了其促进DFU创面愈合的作用。 03 专家分析2 DFU是糖尿病最严重的慢性并发症之一，其难治愈，高致残、高致死及复发率严重危害患者的健康和生命。 该例患者为老年女性，2月前因DFU达Wagner 4级行手术治疗，左足残端创面迁延不愈，患者入院时DFU达Wagner3级，且患者合并多种疾病，结合患者症状、体征和辅助检查，手术指征明确，行血运重建和清创术，术后仍有面积为2.0cm*1.5cm的创口，使用香雷糖足膏约3周后创面明显减小，约33天后创面愈合。 糖尿病患者伤口免疫微环境紊乱，免疫表型失调，相关免疫细胞数量和功能发生改变，M1巨噬细胞增多，并且M1向M2的转化严重受损，导致炎症状态的持续；糖尿病微环境加剧了M1巨噬细胞产生和慢性炎症的恶性循环，引起炎症期停滞，过量炎性因子产生导致了伤口愈合延迟3。而香雷糖足膏可以抑制促炎M1，刺激前脂肪细胞分泌粒细胞集落刺激因子（G-CSF）及CXC 趋化因子配体 3 (CXCL3) 细胞因子，增加修复型M2a／M2c巨噬细胞4。该例患者年龄大，有合并症，创面有迁延不愈，有一定的治疗难度，而在血运重建和清创术后，加用香雷糖足膏，1月后患者创面即痊愈，得到较好的结果。可见香雷糖足膏的风险较小，而且方便实用，能明显加快创面愈合。 04 专家简介 第一位点评专家 陆宏虹 苏州市立医院 苏州市立医院北区内分泌科主任医师 苏州医学会内分泌分会副主任委员 苏州市中西医结合学会内分泌分会副主任委员 苏州市医师协会理事 苏州市医疗卫生监督技术组专家 苏州市卫计委健康管理专家 江苏省中西医糖尿病一体化诊疗委员会委员 江苏省医学会糖尿病分会委员 中国中西医结合微循环学会委员 第二位点评专家 戎建杰 苏州市中医医院 苏州市中医医院血管外科主任 医学博士，主任医师，硕士研究生导师 美国斯坦福大学血管外科访问学者 姑苏卫生青年拔尖人才 江苏省中西医结合学会周围血管病专业委员会副主任委员 江苏省中西医结合学会理事会理事 苏州市中西医结合学会周围血管病专业委员会主任委员 苏州市中西医结合学会介入治疗专业委员会副主任委员 《中华血管外科杂志》第三届编辑委员会青年编委 参考文献 1.中国老年医学学会烧创伤分会，中华医学会烧伤外科学分会，中国医师协会创面修复专业委员会. 糖尿病足溃疡合并下肢血管病变的外科诊疗全国专家共识（2024版）. 中华烧伤与创面修复杂志，2024，40(03):206-220. DOI:10.3760/cma.j.cn501225-20231122-00202 2.Huang YY, et al. Effect of a Novel Macrophage-Regulating Drug on Wound Healing in Patients With Diabetic Foot Ulcers: A Randomized Clinical Trial. JAMA Netw Open. 2021 Sep 1;4(9):e2122607. 3.Zhu Y, et al. Mapping intellectual structure and research hotspots in the field of fibroblast-associated DFUs: a bibliometric analysis. Front Endocrinol (Lausanne). 2023;14:1109456. 4.Lin CW, et al. Restoring Prohealing/Remodeling-Associated M2a/c Macrophages Using ON101 Accelerates Diabetic Wound Healing. JID Innov. 2022;2(5):100138. 免责声明：本文仅作最新前沿信息交流之目的，文中所有观点不代表梅斯医学立场，亦不代表梅斯医学支持或反对文中观点。如需获得治疗方案指导，请前往正规医院就诊！

ACOG supports cfDNA testing as a reasonable alternative for fetal RBC testing among alloimmunized patients MENLO PARK, Calif., July 26, 2024 /PRNewswire/ -- BillionToOne, a molecular diagnostics company with a mission to create powerful and accurate tests that are accessible to all, is thrilled to announce a new publication that shows cfDNA analysis is highly sensitive and specific for determining fetal antigen genotype as early as 10 weeks gestation. The new study published online in Obstetrics and Gynecology, the official journal of the American College of Obstetricians and Gynecologists (ACOG), also known as "The Green Journal," supports the implementation of cfDNA testing to manage alloimmunized pregnancies in the United States. This study follows the recent ACOG clinical practice update that supports cfDNA testing as a reasonable alternative to amniocentesis for fetal RBC testing among alloimmunized patients. Hemolytic disease of the fetus or newborn (HDFN) is a potentially life-threatening form of anemia caused by alloimmunization. ACOG recommends testing the reproductive partner's antigen status when alloimmunization is diagnosed in pregnancy. However, rates of reproductive partner screening uptake are low, and results can be misleading in the setting of nonpaternity. In September 2022, BillionToOne's UNITY Fetal Antigen NIPT became the first commercially available cfDNA test in the US, providing highly accurate assessments of the fetal status for RhD, c, C, E, K and Fya antigens. It is the only clinically available NIPT in the US that includes antigens beyond RhD and is offered as an add on to UNITY Complete, the first and only test that uses cell-free DNA to provide precise fetal insights for both recessive and chromosomal conditions. The Green Journal study demonstrates the accuracy of an NGS-based cfDNA analysis assay using BillionToOne's proprietary Quantitative Counting Templates™ (QCT™) for the detection of fetal red blood cell antigen status in a large, diverse U.S.-based cohort. With 100% accuracy and no need for paternal testing or invasive procedures, the study finds that this assay will result in more alloimmunized individuals receiving informative results about fetal risk when compared to the traditional approach. "We commend ACOG for acknowledging the role of NIPT for fetal red blood cell antigen genotyping and are thrilled that this new study highlights the UNITY Fetal Antigen NIPT screen's accuracy across all gestational ages and ethnicities, including complex maternal and fetal genotypes," said Jennifer Hoskovec, Certified Genetic Counselor and Vice President of Medical Affairs at BillionToOne. "The implications of this ACOG update are significant for patients and providers alike, reducing the need for resource intensive pregnancy surveillance for fetal anemia for many patients." ACOG also recently announced that the use of RhD NIPT to conserve supply of Rh immunoglobulin (RhIg), also known as RhoGAM, is a reasonable consideration in the practice setting that is experiencing RhIg shortages. Since becoming available in 2020, BillionToOne's Fetal RhD NIPT has served over 100,000 patients. The test offers a reliable and convenient alternative to traditional methods of determining fetal RhD status via cell-free DNA from maternal blood only as early as 9 weeks gestation. About BillionToOne Headquartered in Menlo Park, California, BillionToOne is a precision diagnostics company on a mission to make molecular diagnostics more accurate, efficient, and accessible for all. The company's patented Quantitative Counting Templates™ (QCT™) molecular counting platform is the only multiplex technology that can accurately count DNA molecules at the single-molecule level. For more information, please visit . Media Contact: [email protected] SOURCE BillionToOne

FRIDAY, June 7, 2024 -- Mortality related to rheumatic heart disease (RHD) is high and is correlated with the severity of valve disease, according to a study published online June 5 in the Journal of the American Medical Association. Ganesan Karthikeyan, D.M., from the All India Institute of Medical Sciences in New Delhi, and colleagues assessed the risk and predictors of major patient-important clinical outcomes in patients with clinical RHD. Analysis included 13,696 patients in 24 low- and middle-income countries. The researchers found that over a median duration of 3.2 years, 15 percent of patients died overall (4.7 percent per patient-year). Vascular causes accounted for most deaths (67.5 percent), mainly heart failure or sudden cardiac death. Both stroke (0.6 percent per year) and recurrent rheumatic fever was rare. Higher mortality was seen with markers of severe valve disease, including congestive heart failure (hazard ratio [HR], 1.58), pulmonary hypertension (HR, 1.52), and atrial fibrillation (HR, 1.30). Lower mortality was seen with surgical treatment (HR, 0.23) or valvuloplasty (HR, 0.24). Lower mortality was also seen with higher country income level, when adjusting for patient-level factors. "Study findings suggest a greater need to improve access to surgical and interventional care, in addition to the current approaches focused on antibiotic prophylaxis and anticoagulation," the authors write. Several authors disclosed ties to pharmaceutical companies, including Bayer, which funded the study.