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The objective of this research was to predict the death of a newborn based on particular features. We propose a method called RIGOR to identify 68 deaths of children who did not complete a year of life. We conclude that the Brazilian government can prevent child deaths by emphasizing the need to monitor fetal weight.

Anxiety disorders are highly prevalent and disabling but seem particularly tractable to investigation with translational neuroscience methodologies. Neuroimaging has informed our understanding of the neurobiology of anxiety disorders, but research has been limited by small sample sizes and low statistical power, as well as heterogenous imaging methodology. The ENIGMA‐Anxiety Working Group has brought together researchers from around the world, in a harmonized and coordinated effort to address these challenges and generate more robust and reproducible findings. This paper elaborates on the concepts and methods informing the work of the working group to date, and describes the initial approach of the four subgroups studying generalized anxiety disorder, panic disorder, social anxiety disorder, and specific phobia. At present, the ENIGMA‐Anxiety database contains information about more than 100 unique samples, from 16 countries and 59 institutes. Future directions include examining additional imaging modalities, integrating imaging and genetic data, and collaborating with other ENIGMA working groups. The ENIGMA consortium creates synergy at the intersection of global mental health and clinical neuroscience, and the ENIGMA‐Anxiety Working Group extends the promise of this approach to neuroimaging research on anxiety disorders., Anxiety disorders are highly prevalent and disabling but seem particularly tractable to investigation with translational neuroscience methodologies. Neuroimaging has informed our understanding of the neurobiology of anxiety disorders, but research has been limited by small sample sizes and low statistical power, as well as heterogenous imaging methodology. The ENIGMA‐Anxiety Working Group has brought together researchers from around the world, in a harmonized and coordinated effort to address these challenges and generate more robust and reproducible findings. The ENIGMA consortium creates synergy at the intersection of global mental health and clinical neuroscience, and the ENIGMA‐Anxiety Working Group extends the promise of this approach to neuroimaging research on anxiety disorders.

Contains fulltext : 202693.pdf (Publisher’s version ) (Open Access) Schizophrenia is a severe mental disorder characterized by numerous subtle changes in brain structure and function. Machine learning allows exploring the utility of combining structural and functional brain magnetic resonance imaging (MRI) measures for diagnostic application, but this approach has been hampered by sample size limitations and lack of differential diagnostic data. Here, we performed a multi-site machine learning analysis to explore brain structural patterns of T1 MRI data in 2668 individuals with schizophrenia, bipolar disorder or attention-deficit/ hyperactivity disorder, and healthy controls. We found reproducible changes of structural parameters in schizophrenia that yielded a classification accuracy of up to 76% and provided discrimination from ADHD, through it lacked specificity against bipolar disorder. The observed changes largely indexed distributed grey matter alterations that could be represented through a combination of several global brain-structural parameters. This multi-site machine learning study identified a brain-structural signature that could reproducibly differentiate schizophrenia patients from controls, but lacked specificity against bipolar disorder. While this currently limits the clinical utility of the identified signature, the present study highlights that the underlying alterations index substantial global grey matter changes in psychotic disorders, reflecting the biological similarity of these conditions, and provide a roadmap for future exploration of brain structural alterations in psychiatric patients.

The goal of this study was to compare brain structure between individuals with generalized anxiety disorder (GAD) and healthy controls. Previous studies have generated inconsistent findings, possibly due to small sample sizes, or clinical/analytic heterogeneity. To address these concerns, we combined data from 28 research sites worldwide through the ENIGMA-Anxiety Working Group, using a single, pre-registered mega-analysis. Structural magnetic resonance imaging data from children and adults (5–90 years) were processed using FreeSurfer. The main analysis included the regional and vertex-wise cortical thickness, cortical surface area, and subcortical volume as dependent variables, and GAD, age, age-squared, sex, and their interactions as independent variables. Nuisance variables included IQ, years of education, medication use, comorbidities, and global brain measures. The main analysis (1020 individuals with GAD and 2999 healthy controls) included random slopes per site and random intercepts per scanner. A secondary analysis (1112 individuals with GAD and 3282 healthy controls) included fixed slopes and random intercepts per scanner with the same variables. The main analysis showed no effect of GAD on brain structure, nor interactions involving GAD, age, or sex. The secondary analysis showed increased volume in the right ventral diencephalon in male individuals with GAD compared to male healthy controls, whereas female individuals with GAD did not differ from female healthy controls. This mega-analysis combining worldwide data showed that differences in brain structure related to GAD are small, possibly reflecting heterogeneity or those structural alterations are not a major component of its pathophysiology.

Background Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by deficits in self-controlling attention, behavior, and emotions. In recent years, noninvasive optical techniques, such as near infrared spectroscopy (NIRS), have been used to measure the neural correlates of pharmacological-therapy outcomes in children and adolescents with ADHD. Methods We reviewed a short series of articles that investigated the results of functional NIRS (fNIRS) on developmental-age ADHD. The review was limited to fNIRS studies that investigated the cortical responses that occurred during neuropsychological tasks in ADHD patients who received methylphenidate or atomoxetine. Results The majority of the reviewed studies revealed the presence of increased oxygenated hemoglobin concentrations in the prefrontal cortex following pharmacotherapy in ADHD samples. A higher frequency of right-lateralized results was found. Limitations The considered studies are characterized by substantial methodological heterogeneity in terms of the patients’ medication status and washout period, explored cerebral regions, and neuropsychological tasks. Conclusions fNIRS seems to be a promising tool for the detection of pharmacological-treatment biomarkers in samples of children and adolescents with ADHD.

ENPACT group., Sex-related differences are tied into neurodevelopmental and lifespan processes, beginning early in the perinatal and developmental phases and continue into adulthood. The present study was designed to investigate sexual dimorphism of changes in gray matter (GM) volume in post-adolescence, with a focus on early and middle-adulthood using a structural magnetic resonance imaging (MRI) dataset of healthy controls from the European Network on Psychosis, Affective disorders and Cognitive Trajectory (ENPACT). Three hundred and seventy three subjects underwent a 3.0 T MRI session across four European Centers. Age by sex effects on GM volumes were investigated using voxel-based morphometry (VBM) and the Automated Anatomical Labeling atlas regions (ROI). Females and males showed overlapping and non-overlapping patterns of GM volume changes during aging. Overlapping age-related changes emerged in bilateral frontal and temporal cortices, insula and thalamus. Both VBM and ROI analyses revealed non-overlapping changes in multiple regions, including cerebellum and vermis, bilateral mid frontal, mid occipital cortices, left inferior temporal and precentral gyri. These findings highlight the importance of accounting for sex differences in cross-sectional analyses, not only in the study of normative changes, but particularly in the context of psychiatric and neurologic disorders, wherein sex effects may be confounded with disease-related changes., This study was partly supported by grants from the Italian Ministry of Health (GR-2018-12367789 to EM, RF-2016-02364582 to PB).

Background: Extracorporeal cardiopulmonary resuscitation is increasingly recognised as a rescue therapy for refractory cardiac arrest, nevertheless data are scanty about its effects on neurologic and cardiac outcome. The aim of this study is to compare clinical outcome in patients with cardiac arrest of ischaemic origin (i.e. critical coronary plaque during angiography) and return of spontaneous circulation during conventional cardiopulmonary resuscitation vs refractory cardiac arrest patients needing extracorporeal cardiopulmonary resuscitation. Moreover, we tried to identify predictors of survival after successful cardiopulmonary resuscitation. Methods: We enrolled 148 patients with ischaemic cardiac arrest admitted to our hospital from 2011–2015. We compared clinical characteristics, cardiac arrest features, neurological and echocardiographic data obtained after return of spontaneous circulation (within 24 h, 15 days and six months). Results: Patients in the extracorporeal cardiopulmonary resuscitation group ( n=63, 43%) were younger (59±9 vs 63±8 year-old, p=0.02) with lower incidence of atherosclerosis risk factors than those with conventional cardiopulmonary resuscitation. In the extracorporeal cardiopulmonary resuscitation group, left ventricular ejection fraction was lower than conventional cardiopulmonary resuscitation at early echocardiography (19±16% vs 37±11 pConclusions: Extracorporeal cardiopulmonary resuscitation patients are younger and have less comorbidities than conventional cardiopulmonary resuscitation, but they have worse survival and lower early left ventricular ejection fraction. Survivors after extracorporeal cardiopulmonary resuscitation have a neurological outcome and recovery of heart function comparable to subjects with return of spontaneous circulation. Total cardiac arrest time is the only predictor of survival after cardiopulmonary resuscitation in both groups.

Purpose: To evaluate the feasibility and efficacy of an apnea test (AT) technique that combines the application of positive end expiratory pressure (PEEP) with subsequent pulmonary recruitment in a large cohort of brain-dead patients. Methods: This study was a retrospective analysis of prospectively collected data on brain-dead patients admitted to our institution (Hospital San Gerardo, Monza, Italy) between January 2010 and December 2014. The rate of aborted apnea tests (ATs), occurrence of complications (i.e., pneumothorax, cardiac arrhythmias, cardiac arrest, and severe hypoxia, defined as PaO2 < 40 mmHg), ventilator settings, hemodynamics, and blood gas analyses were evaluated. Subgroup analysis was performed, with patients classified into veno-arterial extracorporeal membrane oxygenation (ECMO) or non-ECMO groups, and into hypoxic (i.e., baseline PaO2/FiO2 < 200 mmHg) and non-hypoxic (i.e., baseline PaO2/FiO2 > 200 mmHg) groups. Results: In total, 169 consecutive patients including 25 on ECMO were included in the study. No AT abortion nor severe complications were detected. The AT was completed in all patients. Fluid boluses and increases or initiation of vasoactive drugs were required in less than 10 and 3 % of the AT procedures, respectively. No clinically meaningful alteration in hemodynamics was recorded. Severe hypoxia occurred during 7 (2.4 %) and 4 (8 %) of the ATs performed in non-ECMO and ECMO patients, respectively (p = 0.063), and it occurred more frequently in hypoxic patients than in non-hypoxic patients (11.1 vs. 4.8 %, respectively; p = 0.002). Conclusions: In a large cohort of consecutive patients, including the largest patient population on ECMO reported to date, our AT technique that combines the application of PEEP with subsequent pulmonary recruitment proved to be feasible and safe.

Objective Weaning from veno-arterial extracorporeal life support is challenging. The objective of this trial was to investigate the endothelial and hemodynamic effects of levosimendan in cardiogenic shock patients supported with veno-arterial extracorporeal life support. Design This was a prospective observational trial. Setting Cardiovascular intensive care unit of a large tertiary care university hospital in Monza, Italy. Participants and Interventions Flow-mediated dilatation of the brachial artery and hemodynamic parameters were assessed in 10 cardiogenic shock patients supported with veno-arterial extracorporeal life support, before and after the infusion of levosimendan. Measurements and Results Flow-mediated dilatation increased both as absolute value and as a percentage after levosimendan, from 0.10±0.12 to 0.61±0.21 mm (p

Objective: Extracorporeal membrane oxygenation (ECMO) support has been suggested to improve the survival rate in patients with refractory in- and out-of-hospital cardiac arrest (IHCA and OHCA). The aim of our study is to report our experience with ECMO in these patients. Design: Retrospective, single-centre, observational study. Patients: From January 2006 to February 2011 we studied 42 patients (31 males) with refractory cardiac arrest. Measurement and main results: ECMO implantation was successful in 38 (90%) of the 42 patients. ECMO support was positioned: three times (8%) in the operating room, six (16%) in the cardiac surgery intensive care unit, 21 (55%) in the emergency room, five (13%) in the catheterisation laboratory and three (8%) in the general ward. A total of 14 IHCA (58%) and three OHCA (16%) patients were weaned from ECMO (. p

Extracorporeal membrane oxygenation (ECMO) is often applied for acute cardiorespiratory failure. Left ventricular distension can compromise recovery of the failing heart. To overcome this complication, we describe a new technique to decompress the left heart through the insertion of a venting cannula in the pulmonary artery. A 43-year-old woman was connected to ECMO for refractory cardiogenic shock after left pneumonia and severe sepsis. Transesophageal echocardiography (TEE) revealed a large intraventricular clot. A 15F venous cannula was placed percutaneously in the pulmonary artery and connected to the venous limb of the ECMO circuit to decompress the left heart, and to prevent left ventricular ejection and potential embolization. After myocardial recovery, when the thrombus was judged as stable, the patient was weaned, and ECMO was removed on day 16. The patient was discharged from the cardiac surgery intensive care unit on day 30 and subsequently had an uneventful recovery. This new percutaneous approach represent a feasible and effective method to vent the left heart during ECMO, when it becomes necessary to reduce wall tension or to prevent ejection.

OBJECTIVE It is commonly assumed that lung volume at zero end-expiratory pressure (functional residual capacity) is not affected by positive end-expiratory pressure (PEEP) even in presence of alveolar recruitment, and it is often ignored when measuring lung recruitment by pressure-volume curves. Aim of the study was to investigate the effect of PEEP on functional residual capacity, and quantify the error of considering equal functional residual capacity in measuring alveolar recruitment. DESIGN Interventional human study. SETTING A 10-bed general intensive care unit in a university hospital. PATIENTS Ten sedated, curarized, mechanically ventilated acute respiratory distress syndrome patients. INTERVENTIONS Three levels of PEEP (5, 10, and 15 cm H2O), were randomly applied, for 1 hr each. MEASUREMENTS AND MAIN RESULTS At each PEEP we obtained a pressure-volume curve, the volume expired from PEEP to zero pressure (PEEP related lung volume) and functional residual capacity by helium dilution method. Functional residual capacity increased at increasing PEEP levels. Functional residual capacity was 507 +/- 292, 607 +/- 311, and 681 +/- 312 ml (p < .05), respectively, at PEEP 5, 10, and 15 cm H2O. Pressure-volume curves were aligned starting from PEEP related lung volume (relative volume method) or from end-expiratory lung volume at PEEP (absolute volume method). Recruitment was measured as vertical distance of pressure-volume curves at 20 cm H2O airway pressure. The relative volume method led to underestimation of recruitment (43 +/- 28% and 35 +/- 18 %, respectively, at PEEP 10 and 15). CONCLUSIONS Functional residual capacity is affected by PEEP. Ignoring this effect leads to relevant underestimation of alveolar recruitment as measure by pressure-volume curve displacement.

Adult patients supported on extracorporeal membrane oxygenation (ECMO) are very sick and many complications are often present in each single patient; therefore, it is not always easy to find some risk factors that can predict the early outcome. This retrospective study reports our experience in ECMO support treatment in adult cardiac patients suffering from cardiac failure (CF) in which one or more predictive factors of 30-day mortality were analyzed. Between January 2002 and August 2009, 42 consecutive adult cardiac patients with cardiogenic shock (mean age 64.3+/-11.3 years) were supported on ECMO for >2 days. They were divided into patients who had a survival 30 days (n=22). Twenty-nine patients (69%) survived on ECMO. Sixteen patients were discharged with a survival rate of 38.1%. The overall mean ECMO duration was 7.9+/-5.3 days. The following variables were significantly different between the two groups: number of platelets and packed red blood cells (PRBCs) transfused per day during ECMO (P=0.002 and P=0.003), blood lactate levels 48 h and 72 h after the initiation of ECMO (P=0.01 and P=0.04), indexed blood flow after 48 h and 72 h (P=0.01 and P3 mmol/l after 48 h. The blood lactate level at 48 h and PRBCs transfused per day can be considered as important parameters to predict the mortality in adult cardiac patients supported by ECMO for CF. Keywords: Extracorporeal membrane oxygenation; Heart failure; Postinfarction cardiac complication.

Although microporous polypropylene hollow fiber oxygenators are standard devices used for extracorporeal membrane oxygenation (ECMO), they have limitations such as development of plasma leakage. Poly-methylpentene (PMP) is a new material used for the last generation of oxygenators. We reviewed our experience with a new PMP oxygenator (Quadrox D) and a centrifugal pump (RotaFlow) used to support adult patients with refractory cardiogenic shock. Between January 2000 and April 2007, 25 patients required ECMO for primary or postcardiotomy cardiogenic shock. Eighteen patients were analyzed [mean age 60.2 years; 11 (61%) men; 7 (39%) women]. Nine patients (50%) suffered primary cardiogenic shock. Cardiopulmonary resuscitation was applied in 11 patients (61%) with a mean duration time of 31.5 minutes. Mean ECMO duration time was 7.1 +/- 6.3 days (range, 1-27 days). Intra-aortic balloon pump was used in 13 patients (72.2%) with a mean duration time of 7.7 +/- 5 (range, 2-17 days). Twelve patients (66.7%) survived on ECMO and five patients (27.8%) were discharged. Our results indicate the PMP oxygenator and the centrifugal pump provided acceptable results in terms of surviving on ECMO and discharge. Patients with an initial catastrophic hemodynamic status could benefit by means of a rapid institution of ECMO with PMP oxygenators.

OBJECTIVE: We describe a simplified helium dilution technique to measure end-expiratory lung volume (EELV) in mechanically ventilated patients. We assessed both its accuracy in comparison with quantitative computerized tomography (CT) and its precision. DESIGN AND SETTING: Prospective human study. PATIENTS: Twenty-one mechanically ventilated ALI/ARDS patients. INTERVENTIONS: All patients underwent a spiral CT scan of the thorax during an end-expiratory occlusion. From the CT scan we computed the gas volume of the lungs (EELVCT).Within a few minutes, a rebreathing bag, containing a known amount of helium, was connected to the endotracheal tube, and the gas mixture diluted in the patient's lungs by delivering at least ten large tidal volumes. From the final helium concentration, EELV could be calculated by a standard formula (EELVHe). MEASUREMENT AND RESULTS: The results obtained by the two techniques showed a good correlation (EELVHe=208+0.858xEELV(CT), r=0.941; P

Background: The aim of our study was to assess the effect of periodic hyperinflations (sighs) during pressure support ventilation (PSV) on lung volume, gas exchange, and respiratory pattern in patients with early acute respiratory distress syndrome (ARDS). Methods: Thirteen patients undergoing PSV were enrolled. The study comprised 3 steps: baseline 1, sigh, and baseline 2, of 1 h each. During baseline 1 and baseline 2, patients underwent PSV. Sighs were administered once per minute by adding to baseline PSV a 3- to 5-s continuous positive airway pressure (CPAP) period, set at a level 20% higher than the peak airway pressure of the PSV breaths or at least 35 cm H2O. Mean airway pressure was kept constant by reducing the positive end-expiratory pressure (PEEP) during the sigh period as required. At the end of each study period, arterial blood gas tensions, air flow and pressures traces, end-expiratory lung volume (EELV), compliance of respiratory system (Crs), and ventilatory parameters were recorded. Results: PaO2 improved (P < 0.001) from baseline 1 (91.4 27.4 mmHg) to sigh (133 42.5 mmHg), without changes of PaCO2. EELV increased (P < 0.01) from baseline 1 (1,242 507 ml) to sigh (1,377 484 ml). Crs improved (P < 0.01) from baseline 1 (40.2 12.5 ml/cm H2O) to sigh (45.1 15.3 ml/cm H2O). Tidal volume of pressure-supported breaths and the airway occlusion pressure (P0.1) decreased (P < 0.01) during the sigh period. There were no significant differences between baselines 1 and 2 for all parameters. Conclusions: The addition of 1 sigh per minute during PSV in patients with early ARDS improved gas exchange and lung volume and decreased the respiratory drive. CURRENT ventilatory approaches to the acute respiratory distress syndrome (ARDS) suggest the use of low tidal volumes (V T ) 1 to limit alveolar distending pressure 2,3 and relatively high positive end-expiratory pressure (PEEP) 4 to prevent alveolar collapse and cyclical opening and closing. 5 In a recent large multicenter trial, ventilation with VT as low as 6 ml/kg of predicted body weight reduced mortality compared with traditional ventilation with larger V T . 1 Although it is effective in limiting injury associated with alveolar stretching, 2,3 ventilation with low VT may lead to progressive atelectasis and consequent hypoxia. 6 Although the use of high PEEP levels may partially counteract this tendency and stabilize alveoli, minimize cyclical inspiratory opening, and prevent further lung collapse, 7,8 atelectatic lung regions may persist. Lung recruitment maneuvers (RMs) such as sighs have been successfully used in patients during general anesthesia to restore the decreased respiratory system compliance (Crs) and arterial oxygenation commonly associated with use of low V T . 9 This result has led investigators to test the use of RMs in patients with ARDS during ventilation with low VT and high PEEP, improving lung function 10 and outcome. 4 Cyclically delivered RMs have been effective in ARDS patients managed with continuous positive pressure ventilation (CPPV), to induce alveolar recruitment 11 and allow the use of lower PEEP and mean airway pressure (Pawm), while preserving gas exchange and lung volumes. 12 Recently, many clinicians and investigators underscored the potential role and benefits of maintaining spontaneous breathing by using modes of partial ventilatory support such as pressure support ventilation (PSV).