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Purpose: Rapid sequence intubation (RSI) in trauma patients is common; however, the induction agents used have been debated. We determined which induction medications were used most frequently for adult trauma RSIs and their associations with hemodynamics and outcomes. We hypothesized that etomidate is the most commonly used induction agent and has similar outcomes to other induction agents. Methods: This retrospective review at two U.S. level I trauma centers evaluated adult trauma patients undergoing RSI within 24 h of admission, between 01/01/2016 and 12/31/2017. We compared patient characteristics and outcomes by induction agent. Comparisons on the primary outcome of in-hospital mortality and secondary outcomes of peri-intubation hypotension, hospital and ICU length of stay (LOS), ventilator days, and complications used logistic regression or negative binomial regression. Regression models adjusted for hospital site, age, patient severity measures, and intubation location. Results: Among 1303 trauma patients undergoing RSI within 24 h of admission, 948 (73%) were intubated in the emergency department (ED) and 325 (25%) in the operating room (OR). The most common induction agents were etomidate (68%), propofol (17%), and ketamine (11%). In-hospital mortality was highest in the etomidate group (25.5%), followed by ketamine (17%), and propofol (1.8%). Conclusion: Etomidate was most commonly used in ED intubations; propofol was most used in the OR. Compared to propofol, patients induced with etomidate had higher mortality and complication rates. Findings should be interpreted with caution given limited generalizability and residual confounding by indication. [ABSTRACT FROM AUTHOR]

BACKGROUND: ARDS is a highly morbid condition characterized by diffuse pulmonary inflammation, which results in hypoxemic respiratory failure. Approximately 25% of patients with ARDS develop right ventricular dysfunction, with cor pulmonale being a common final pathway in a significant number of non-survivors. ARDS-related right ventricular dysfunction occurs due to acute elevation in ventricular afterload caused by mechanisms that are associated with increased pulmonary dead space fraction. Thus, we hypothesized that changes in pulmonary dead space fraction may reflect changes in pulmonary hemodynamics. METHODS: This was a prospective single-center study of 21 subjects with ARDS who underwent serial determination of pulmonary dead space fraction and pulmonary hemodynamics via transthoracic echocardiography. Linear mixed-effects modeling was performed to test for an association between a change in pulmonary dead space and a change in pulmonary hemodynamics. RESULTS: The tricuspid regurgitation velocity to right ventricular outflow track velocity time integral ratio, an echocardiographic surrogate for pulmonary vascular resistance, increased by 0.16 Wood units (Coefficient 0.16, 95% CI 0.09 - 0.23; P < .001), and the tricuspid regurgitation pressure gradient increased by 3.7 mm Hg (Coefficient 3.7, 95% CI 1.74 -5.63, P < .001) for every 10% increase in pulmonary dead space fraction. CONCLUSIONS: Increases in the pulmonary dead space fraction were associated with relative increases in both the tricuspid regurgitation velocity to right ventricular outflow track velocity time integral ratio and the tricuspid regurgitation pressure gradient, which likely contributed to the high incidence of ARDS-related right ventricular dysfunction encountered in clinical practice. Pulmonary dead space monitoring may serve as a clinical indicator to identify patients with ARDS at risk of developing right ventricular dysfunction and acute cor pulmonale. [ABSTRACT FROM AUTHOR]

Background Reduction in mitral regurgitation ( MR) after transcatheter aortic valve replacement ( TAVR) has previously been reported. However, the hemodynamic effects of TAVR in patients with MR have not been previously evaluated. Methods We analyzed 571 patients who underwent TAVR from December 2010 to December 2013. We studied 20 patients with moderate or severe preprocedural functional mitral regurgitation ( FMR) who also had a follow-up transthoracic echocardiography ( TTE) examination between 90 and 360 days (median 213 days) after TAVR (Significant FMR Group). We also studied age- and gender-matched 20 patients with mild or lesser MR (Nonsignificant MR Group). Left ventricular functional measurements were assessed using echocardiography before and after TAVR. Left ventricular outflow tract stroke volume measurements using pulsed-wave Doppler ( SVLVOT) were calculated as a representative of systolic forward flow, and stroke volume by the Simpson's method (SVSimpson) was calculated as a parameter of degree of LV contraction. Results MR grade improved in 22 of 40 patients after TAVR. In both groups, BNP level decreased, left ventricular ejection fraction increased, and SVLVOT increased after TAVR. SVSimpson increased in the Nonsignificant MR Group and remained unchanged in the Significant FMR Group. Vena contracta width of MR ( MRVC) decreased in the Significant FMR Group. Using multivariable analysis in the Significant FMR Group, the increase in SVLVOT significantly correlated with the decrease in MRVC (P < 0.05). Conclusions SVLVOT increased significantly after TAVR in patients with FMR. In these patients, increase in SVLVOT after TAVR was associated with decrease in severity of MR. [ABSTRACT FROM AUTHOR]

Objective This study aims to compare the effects of early and late (routine) initiation of caffeine in nonintubated preterm neonates. Study Design A total of 21 neonates < 29 weeks gestational age were randomized to receive intravenous caffeine citrate (20 mg/kg) or placebo either before 2 hours of age (early) or at 12 hours of age (routine). This was an observational trial to determine the power needed to reduce the need for endotracheal intubation by 12 hours of age. Other outcomes included comparisons of cerebral oxygenation, systemic and pulmonary blood flow, hemodynamics, hypotension treatment, oxygen requirement, and head ultrasound findings. Results There was no difference in the need for intubation (p = 0.08), or vasopressors (p = 0.21) by 12 hours of age. Early caffeine was associated with improved blood pressure (p = 0.03) and systemic blood flow (superior vena cava flow, p = 0.04 and right ventricular output, p = 0.03). Heart rate, left ventricular output, and stroke volume were not significantly affected. Cerebral oxygenation transiently decreased 1 hour after caffeine administration. There were no differences in other outcomes. Conclusion This pilot study demonstrated the feasibility of conducting such a trial in extremely preterm neonates. We found that early caffeine administration was associated with improved hemodynamics. Larger studies are needed to determine whether early caffeine reduces intubation, intraventricular hemorrhage, and related long-term outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVE: Delayed cord clamping (DCC) is recommended for premature infants to improve blood volume. Most preterm infants are born by cesarean delivery (CD), and placental transfusion may be less effective than in vaginal delivery (VD). We sought to determine whether infants <32 weeks born by CD who undergo umbilical cord milking (UCM] have higher measures of systemic blood flow than infants who undergo DCC. METHODS: This was a 2-center trial. Infants delivered by CD were randomly assigned to undergo UCM or DCC. Infants delivered by VD were also randomly assigned separately. UCM (4 stoppings) or DCC (45-60 seconds) were performed. Continuous hemodynamic measurements and echocardiography were done at site 1. RESULTS: A total of 197 infants were enrolled (mean gestational age 28 ± 2 weeks). Of the 154 infants delivered by CD, 75 were assigned to UCM and 79 to DCC. Of the infants delivered by CD, neonates randomly assigned to UCM had higher superior vena cava flow and right ventricular output in the first 12 hours of life. Neonates undergoing UCM also had higher hemoglobin, delivery room temperature, blood pressure over the first 15 hours, and urine output in the first 24 hours of life. There were no differences for the 43 infants delivered by VD. CONCLUSIONS: This is the first randomized controlled trial demonstrating higher systemic blood flow with UCM in preterm neonates compared with DCC. UCM may be a more efficient technique to improve blood volume in premature infants delivered by CD. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study was to evaluate pain and hyperalgesia in response to different depths of intradermal ( ID) capsaicin injections in healthy volunteers. Design Double-blind, cross-over study. Setting Clinical Research Laboratory. Subjects Fifteen healthy male subjects received ID capsaicin injections into the volar aspect of each forearm at depths of 1 mm, 3 mm, 5 mm, and 7 mm. After injection, spontaneous pain, elicited pain, flare response, heat thresholds, and area of hyperalgesia were measured at various time points. Outcomes Measure Spontaneous pain, elicited pain (pinprick, stroking, and hot pain), hyperalgesia area, and allodynia area. Results No significant difference was found between any depths in spontaneous pain, elicited pain (pinprick, stroking, hot pain), hyperalgesia area, or allodynia area. A significant difference was found in the change in heat threshold between 5 mm and 1 mm, 7 mm and 1 mm, 5 mm and 3 mm, 7 mm and 3 mm depths. A significant difference was found in flare area between 5 mm and 3 mm depths. A significant difference was found in systolic blood pressure area under the curve ( AUC) between 7 mm and 1 mm depths, and for both systolic and diastolic pressures for 5 mm and 1 mm depths, and 5 mm and 3 mm depths. A significant difference was found in pulse AUC between 5 mm and 1 mm depths and 5 mm and 3 mm depths. Conclusions Injection of capsaicin at different depths in the skin had different effects on heart rate and blood pressure but no effect on pain. These results may have implications on the pharmacology and analgesic predictive value of the model of ID capsaicin. [ABSTRACT FROM AUTHOR]

Background: Significant alterations in autonomic nervous system (ANS) function, vasomotor reactivity, and cerebral blood flow may develop from damage to brain ANS regulatory areas in heart failure (HF). This preferentially right-sided injury occurs largely in autonomic structures perfused by the middle cerebral artery. Indications of altered, asymmetrical perfusion raise the potential for further neural damage. Objective: To determine whether the extent of middle cerebral artery blood flow velocity and vasomotor reactivity is altered on one side of the brain over the other in HF versus control subjects, three ANS challenges were administered-each challenge recruited ANS regulatory areas potentially injured in HF. Methods: Transcranial Doppler ultrasonography was used to measure cerebral blood flow velocity and vasomotor reactivity in 40 HF (mean age = 52.7 years, SD = 7.5; 27 men; left ventricular ejection fraction = 26.8, SD = 8.3) and 42 control subjects (mean age = 48.3 years, SD = 6.0; 22 men) during 5% CO2 and hyperventilation, Valsalva, and orthostatic (upper body tilt) challenges. Results: Lower cerebral blood flow velocity and abnormal vasomotor reactivity (p < .01) were noted in HF middle cerebral arteries during all challenges. More right-sided flow velocity reductions appeared in HF, with laterality differences noted during CO2 and orthostatic (p < .05), but not Valsalva challenges. Discussion: Diminished cerebral blood flow velocity and altered vasomotor reactivity were associated with HF, changes being preferentially on the right side; the asymmetry was more pronounced during CO2 and orthostatic challenges. The impaired blood flow regulation may contribute to the lateralized brain pathology in ANS areas, undermining autonomic control in HF. [ABSTRACT FROM AUTHOR]

Objective:To evaluate the hemodynamic changes occurring after rescue surfactant dosing in relation to the clinical respiratory response in preterm infants with respiratory distress syndrome.Study Design:We studied 20 infants who received surfactant (poractant alfa) after failing continuous positive airway pressure (CPAP) beyond 2 h of life. Consecutive echocardiograms were performed before the surfactant dose, 10 min after and 1 h after the surfactant dose. Superior vena cava flow, right ventricular output, atrial and patent ductus arteriosus diameter and direction of shunting were measured. A surfactant responder (SR) was defined as an infant whose inspired fraction of oxygen was reduced to air (0.21) by 3 h after surfactant administration. A surfactant non-responder (SNR) was defined as an infant who remained on more than 0.21 at 3 h postsurfactant administration. Concurrent physiological parameters (heart rate, transcutaneous CO2, mean arterial blood pressure, mean airway pressure) were also recorded. Subject characteristics were compared relative to noted hemodynamic effects.Results:Of the 20 infants enrolled in the study, 12 were SR. These infants received surfactant earlier and had increased measures of systemic blood flow after receipt of surfactant compared with baseline. SNR did not have changes in systemic blood flow from baseline after surfactant dosing. There was no change in ductal shunting or atrial shunting between the two groups.Conclusions:A good clinical response to rescue surfactant is seen in infants who received surfactant earlier and is associated with increase in systemic blood flow. Timing of rescue surfactant administration needs to be further evaluated in larger prospective studies. [ABSTRACT FROM AUTHOR]

ACADEMIC EMERGENCY MEDICINE 2010; 17:926–931 © 2010 by the Society for Academic Emergency Medicine Background: The goal of out-of-hospital endotracheal intubation (ETI) is to reduce mortality and morbidity for patients with airway and ventilatory compromise. Yet several studies, mostly involving trauma patients, have demonstrated similar or worse neurologic outcomes and survival-to-hospital discharge rates after out-of-hospital ETI. To date, there is no study comparing out-of-hospital ETI to bag-valve-mask (BVM) ventilation for the outcome of survival to hospital discharge among nontraumatic adult out-of-hospital cardiac arrest (OOHCA) patients. Objectives: The objective was to compare survival to hospital discharge among adult OOHCA patients receiving ETI to those managed with BVM. Methods: In this retrospective cohort study, the records of all OOHCA patients presenting to a municipal teaching hospital from November 1, 1994, through June 30, 2008, were reviewed. The type of field airway provided, age, sex, race, rhythm on paramedic arrival, presence of bystander cardiopulmonary resuscitation (CPR), whether the arrest was witnessed, site of arrest, return of spontaneous circulation (ROSC), survival to hospital admission, comorbid illnesses, and survival to hospital discharge were noted. A univariate odds ratio (OR) was first computed to describe the association between the type of airway and survival to hospital discharge. A multivariable logistic regression analysis was performed, adjusting for rhythm, bystander CPR, and whether the arrest was witnessed. Results: A cohort of 1,294 arrests was evaluated. A total of 1,027 (79.4%) received ETI, while 131 (10.1%) had BVM, 131 (10.1%) had either a Combitube or an esophageal obturator airway, and five (0.4%) had incomplete prehospital records. Fifty-five of 1,294 (4.3%) survived to hospital discharge; there were no survivors in the Combitube/esophageal obturator airway cohort. Even after multivariable adjustment for age, sex, site of arrest, bystander CPR, witnessed arrest, and rhythm on paramedic arrival, the OR for survival to hospital discharge for BVM versus ETI was 4.5 (95% confidence interval [CI] = 2.3–8.9; p<0.0001). Conclusions: In this cohort, when compared to BVM ventilation, advanced airway methods were associated with decreased survival to hospital discharge among adult nontraumatic OOHCA patients. [ABSTRACT FROM AUTHOR]

Background: Frontotemporal Lobar Degeneration (FTLD) is a heterogeneous disorder characterized by impairment in executive functions, behavioural disturbance and language deficit. Reliable scales of global impairment are under evaluation. A consortium of Mayo Clinic and University of California FTLD Centers has recently developed the FTLD-modified Clinical Dementia Rating (CDR) scale to assess FTLD severity. Objective: To evaluate whether FTLD-modified CDR scores correlate with the pattern and degree of brain SPECT hypoperfusion in patients with FTLD. Methods: Ninety-nine patients with FTLD entered the study. Patients underwent a clinical evaluation and a wide standardized neuropsychological assessment, including mini-mental state examination (MMSE) and FTLD-modified CDR. A brain SPECT perfusion imaging study was carried out in each patient. A linear correlation analysis between frontotemporal dementia-modified CDR or neuropsychological tests scores and perfusion data was performed. Results: There was a significant relationship between higher FTLD-modified CDR score and lower global regional cerebral blood flow in the frontal and temporal lobes, bilaterally. No significant correlation between MMSE and brain frontotemporal hypoperfusion was found. The correlation between brain hypoperfusion pattern and neuropsychological test scores tapping different cognitive domains fitted with previously published data. Conclusions: The recently introduced FTLD-modified CDR scale correlates with the degree of frontotemporal hypoperfusion in patients with FTLD. This study confirms and further supports the usefulness of FTLD-modified CDR in future clinical trials to monitor disease progression. [ABSTRACT FROM AUTHOR]

This article discusses findings of a study which investigated the role of fish oil supplementation in the endothelial function of healthy volunteers. An investigation of endothelial function in peripheral conduit vessels has been conducted using high-resolution ultrasound on flow-mediated vasodilation in the brachial artery. The study focused on 27 non-smoking, asymptomatic men and women with no significant medical problems who were recruited from a pool of medical residents at the Olive View Medical Center of the University of California in Los Angeles.

Presents abstracts of studies on peripheral circulation, presented at the Experimental Biology/International Union of Physiological Sciences 2005 congress held in San Diego, California. "Time Course and Variability of the Venoarteriolar Reflex," by Angel Dimitrov Kurtev and Milcho Emilov Georgiev; "Mechanisms of Acetylcholine-Mediated Cutaneous Vasolidation," by Lacy A. Holowatz, Christopher T. Minson et al.; "Effects of Sublingual Nitroglycerin on Venous Hemodynamic Function in Young Adults," by Colin Neal Young, Michael E. Stillabower et al.

Presents abstracts of studies on regulation of blood flow and vascular function, presented at the Experimental Biology/International Union of Physiological Sciences 2005 congress held in San Diego, California. "A Computational Model of Coronary Autoregulation," by Jack Chul Joo Lee and Nicolas P. Smith; "The Effect of Chronic Stress on the Hemodynamics of the Small Intestine: Role of Endothelin Receptor Antagonists," by Salah Gandur, Sule Cetinel and Hizir Kurtel; "High Blood Flow Increases Levels of Tetrahydrobiopterin in Rat Aorta," by Chen Fuh Lam, Darcy M. Anderson et al.

Presents abstracts of studies on renal hemodynamics, presented at the Experimental Biology/International Union of Physiological Sciences 2005 congress held in San Diego, California. "Regulation of Macula Densa Nitric Oxide Synthase," by Peter Komlosi, Yi Xie et al.; "Direct Effect of Furosemide on Renin Secretion of Juxtaglomerular Cells," by Pernille B. Hansen, Ulla G. Friis et al.; "Contractility of Glomerular Arterioles in SM-B Myosin Deficient Mice," by Andreas Reinhold Patzak, Daria Petzhold et al.

Presents abstracts of studies on microvascular mechanics and hemodynamics presented at the Experimental Biology/International Union of Physiological Sciences 2005 congress in San Diego, California. "Effect of Red Blood Cells on the Shear-Induced Aggregation of Human Neutrophils," by Harry Goldsmith, Fiona McIntosh, et al; "Correlation Between Whole Blood Viscosity (WBV) and Microvascular Abnormalities in Type-2 Diabetes Mellitus (T2DM) Patients," Anthony Cheung, Sahana Ramanujam, et al; "Correlation of Sickle Cell Disease Whole Blood Interaction With Extracellular Matrix Under a Defined Shear Condition With Conjunctival Blood Flow (red-cell velocity)," by Anthony Cheung, Patricia Duong, et al.

Presents abstracts of several studies concerning heart blood and circulation, presented at the Experimental Biology/International Union of Physiological Sciences 2005 Congress held in San Diego, California. "The Effects of Stretch on Auxotonic Force and Intracellular Calcium Transients in Single Cardiac Ventricular Myocytes From Rainbow Trout (Oncorhynchus mykiss)," by Holly Shiels and Ed White; "Is There a Role for Natriuretic Peptide Receptor, Subtype C (NPR-C), in the Hemodynamic Actions of Atrial or B-type Natriuretic Peptides (ANP or BNP)?," by Robyn Woods, Clive May and Colleen Thomas; "Effects of Changes in Extracellular Solution on Intrinsic Heart Rate of Spontaneously Contracting Right Atria From Normoxic- and Anoxic-acclimated Turtles," by Jonathan Anthony William Stecyk and Anthony Farrell.

Examines alterations in lower extremity venous hemodynamics associated with normal pregnancy in women in California. Difference in venous filling index between left and right extremities; Evaluation of lower extremity venous physiology using air plethysmography; Relevance of residual volume fraction to venous dilation.

Objective: Investigation of asymptomatic carotid stenosis treatment is hindered by the lack of a contemporary population-based disease cohort. We describe the use of natural language processing (NLP) to identify stenosis in patients undergoing carotid imaging., Methods: Adult patients with carotid imaging between 2008 and 2012 in a large integrated health care system were identified and followed through 2017. An NLP process was developed to characterize carotid stenosis according to the Society of Radiologists in Ultrasound (for ultrasounds) and North American Symptomatic Carotid Endarterectomy Trial (NASCET) (for axial imaging) guidelines. The resulting algorithm assessed text descriptors to categorize normal/non-hemodynamically significant stenosis, moderate or severe stenosis as well as occlusion in both carotid ultrasound (US) and axial imaging (computed tomography and magnetic resonance angiography [CTA/MRA]). For US reports, internal carotid artery systolic and diastolic velocities and velocity ratios were assessed and matched for laterality to supplement accuracy. To validate the NLP algorithm, positive predictive value (PPV or precision) and sensitivity (recall) were calculated from simple random samples from the population of all imaging studies. Lastly, all non-normal studies were manually reviewed for confirmation for prevalence estimates and disease cohort assembly., Results: A total of 95,896 qualifying index studies (76,276 US and 19,620 CTA/MRA) were identified among 94,822 patients including 1059 patients who underwent multiple studies on the same day. For studies of normal/non-hemodynamically significant stenosis arteries, the NLP algorithm showed excellent performance with a PPV of 99% for US and 96.5% for CTA/MRA. PPV/sensitivity to identify a non-normal artery with correct laterality in the CTA/MRA and US samples were 76.9% (95% confidence interval [CI], 74.1%-79.5%)/93.1% (95% CI, 91.1%-94.8%) and 74.7% (95% CI, 69.3%-79.5%)/94% (95% CI, 90.2%-96.7%), respectively. Regarding cohort assembly, 15,522 patients were identified with diseased carotid artery, including 2674 exhibiting equal bilateral disease. This resulted in a laterality-specific cohort with 12,828 moderate, 5283 severe, and 1895 occluded arteries and 326 diseased arteries with unknown stenosis. During follow-up, 30.1% of these patients underwent 61,107 additional studies., Conclusions: Use of NLP to detect carotid stenosis or occlusion can result in accurate exclusion of normal/non-hemodynamically significant stenosis disease states with more moderate precision with lesion identification, which can substantially reduce the need for manual review. The resulting cohort allows for efficient research and holds promise for similar reporting in other vascular diseases., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

An abstract of the article "Aortic coarctation augments changes in thoracic aortic hemodynamics in pediatric and young adult patients with bicuspid aortic valve," by Bradley D. Allen, Alex J. Barker, Maya Gabbour, Michael Markl, Cynthia Rigsby, and Joshua D. Robinson is presented.

An abstract of the article "Quantification of left atrial flow velocity distribution in atrial fibrillation using 4D flow MRI," by Jacob U. Fluckiger, Jeffrey J. Goldberger, Daniel C. Lee, Jason Ng, Richard Lee, Andrew B. Olsen, James Carr, and Michael Markl is presented.

An abstract of the article "4D flow MRI of the aorta becomes practical: performance and observer variability for a new semi-automated workflow for 3D visualization and quantification of aortic hemodynamics," by Susanne Schnell and colleagues is presented.

Presents abstracts of studies on spinal cord injury and long-term plasticity, presented at the Experimental Biology/International Union of Physiological Sciences 2005 congress held in San Diego, California. "Mechanisms of Hemodynamics and Somatosensory Streams in the Restoration of Functions of the Damaged Spinal Cord," by Sergey Lytaev, Galina Andreeva et al.; "Neurotrophic Factors Promote Locomotor Recovery and Changes in Muscle Electromyography in Chronically Spinalized Animals," by Michel A. Lemay, Vanessa S. Boyce et al.; "Use of Intraspinal Electrical Stimulation for Inducing Locomotion in Spinal Cats," by Dorothy Barthélemy, Hugues Leblond et al.

Presents abstracts of studies on pulmonary vascular pharmacology, presented at the Experimental Biology/International Union of Physiological Sciences 2005 congress held in San Diego, California. "Therapeutic Effect of San-Huang-Xie-Xin-Tang and Baicalin on Lipopolysaccharide Induced Lung Injury in Rats," by Yi-Ching Lo; "Platelet Activating Factor (PAF) and Ovine Fetal Pulmonary Vascular Smooth Muscle Cell Proliferation," by Basil O. Ibe, Ada Mae D. Portugal and J. Usha Raj; "Pulsatile Hemodynamic Analysis of B-Type Natriuretic Peptide (BNP) in the Newborn Pulmonary Arterial Circulation," by Robert Stewart, Steve Schomisch et al.

Presents abstracts of studies on vasculogenesis and angiogenesis, presented at the 2005 Experimental Biology/International Union of Physiological Sciences Congress in San Diego, California. "VLA4 Promotes Bone Marrow Derived Progenitor Cell Recruitment to the Neovasculature," by Judith A. Varner, et. al.; "Endothelial Barrier Disruption by VEGF-Mediated Src Activity Potentiates Tumor Cell Extravasation and Metastasis," by David A. Cheresh, et. al.; "Hemodynamics Control Embryonic Arterial Venous Branching Morphogenesis," by F. A. Le Noble, et. al.

Purpose Substantial differences between sexes exist with respect to cardiovascular diseases, including congenital heart disease. Nevertheless, clinical decisions in the long-term follow-up of patients with repaired tetralogy of Fallot (rTOF) are currently based on unisex thresholds for cardiac magnetic resonance (CMR) measurements. This study aimed to assess whether sex differences exist in cardiac adaptation to hemodynamic loading conditions in patients with rTOF. Methods and Results This cross-sectional, two-center, combined pediatric and adult cohort included 320 rTOF patients (163 males, 51%) who underwent routine CMR. Despite similar age (median and interquartile range [m + IQR] 23.4 [15.2-34.4] years), surgical history, and hemodynamic loading, males with rTOF demonstrated higher biventricular CMR-derived volumes and masses, indexed for body surface area, compared to females (e.g. m + IQR right ventricular (RV) end-diastolic volume: males 123 [100-151] mL/m 2 , females 114 [94-131] mL/m 2 , P = 0.007). Sex-specific Z-scores of biventricular volumes and masses were similar for males and females. RV volumes and masses correlated with hemodynamic loading, but these relations did not differ between sexes. Biventricular ejection fraction (EF) appeared to be lower in male patients, compared to female patients (e.g. m + IQR RVEF: males 48 [43-54]%, females 52 [46-57]%, P < 0.001). Conclusion Indexed ventricular volumes and masses are higher in males with rTOF, compared to females, similar to the healthy population. RV hypertrophy and dilatation correlated to loading conditions similarly for both sexes. However, under comparable loading conditions, males demonstrated more severe functional impairment. These results indicate that sex-differences should no longer be ignored in treatment strategies, including timing of pulmonary valve replacement.

Introduction: Intra-Aortic Balloon Pumps (IABPs) can be utilized to provide hemodynamic support in high risk patients awaiting coronary artery bypass grafting (CABG). There are many indications for IABP and institutional practice patterns regarding the placement of IABPs is variable. As a result, the preoperative placement of an IABP in a patient awaiting CABG is not standardized and may vary according to non-clinical factors. We hypothesize that the rate of IABP placement varies by day of the week., Methods: A retrospective cohort analysis of the Office of Statewide Health Planning and Development database from 2006 to 2010 was performed. All patients admitted for CABG were included. Patients who died within 24 h of admission and those who had absolute contraindications to IABP placement were excluded. The primary outcome was preoperative IABP placement versus non-placement. A multivariable logistic regression analysis to identify predictors of IABP placement was performed, adjusting for patient demographics, clinical factors, and system variables., Results: A total of 46,347 patients underwent CABG, of which 7695 (16.60%) had an IABP placed preoperatively. On unadjusted analysis, IABP rates were significantly higher on weekends versus weekdays (20.83% vs. 15.70%, p < 0.001). On adjusted analysis, patients awaiting CABG were 1.30 times more likely to have an IABP placed on weekends than on weekdays (OR: 1.30, 95% CI 1.20-1.40, p < 0.001)., Conclusion: The odds of preoperative IABP placement prior to CABG is significantly increased on weekends compared to weekdays, even when controlling for clinical factors. Further exploration of this phenomenon and its associations are warranted.

Introduction: About 42 million surgeries are performed annually in the USA. While the postoperative mortality is less than 2%, 12% of all patients in the high-risk surgery group account for 80% of postoperative deaths. New onset of haemodynamic instability is common in surgical patients and its delayed treatment leads to increased morbidity and mortality. The goal of this proposal is to develop, validate and test real-time intraoperative risk prediction tools based on clinical data and high-fidelity physiological waveforms to predict haemodynamic instability during surgery., Methods and Analysis: We will initiate our work using an existing annotated intraoperative database from the University of California Irvine, including clinical and high-fidelity waveform data. These data will be used for the training and development of the machine learning model (Carnegie Mellon University) that will then be tested on prospectively collected database (University of California Los Angeles). Simultaneously, we will use existing knowledge of haemodynamic instability patterns derived from our intensive care unit cohorts, medical information mart for intensive care II data, University of California Irvine data and animal studies to create smart alarms and graphical user interface for a clinical decision support. Using machine learning, we will extract a core dataset, which characterises the signatures of normal intraoperative variability, various haemodynamic instability aetiologies and variable responses to resuscitation. We will then employ clinician-driven iterative design to create a clinical decision support user interface, and evaluate its effect in simulated high-risk surgeries., Ethics and Dissemination: We will publish the results in a peer-reviewed publication and will present this work at professional conferences for the anaesthesiology and computer science communities. Patient-level data will be made available within 6 months after publication of the primary manuscript. The study has been approved by University of California, Los Angeles Institutional review board. (IRB #19-0 00 354)., Competing Interests: Competing interests: MC is a consultant for Edwards Lifesciences and Masimo, and has funded research from Edwards Lifesciences and Masimo. He is also the founder of Sironis owns patents and receive royalties for closed loop haemodynamic management that have been licensed to Edwards Lifesciences. MC department receives funding from the NIH (R01GM117622; R01 NR013012; U54HL119893; 1R01HL144692). JR is the founder of Sironis owns patents and receive royalties for closed loop haemodynamic management that have been licensed to Edwards Lifesciences. CL is an engineer at Edwards Lifesciences., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)