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Isolated ventricular non-compaction is a rare cardiomyopathy associated with left heart failure, severe arrhythmias and thromboembolism. We report about our interdisciplinary strategy in a patient with severe isolated ventricular non-compaction cardiomyopathy scheduled for caesarean section in general anaesthesia. Monitoring included placement of an arterial line, a central venous catheter and a pulmonary artery catheter with pacing option. Small introducer gates were placed in the femoral artery and vein to facilitate quick percutaneous institution of extracorporeal life support via extracorporeal membrane oxygenation in case of acute cardiac failure refractory to medical treatment. Inotropic pharmacological therapy with 3 µg/kg/min dobutamine and 0.25 mg/kg/min milrinone was started before surgery. Induction of general anesthesia and rapid sequence intubation was performed with an analgesic dose of 0.5 mg/kg S ketamine, 0.25 mg/kg etomidate and 5 mg rocoronium followed by 1.5 mg/kg succinylcholine. This regimen provided completely stable hemodynamics in this critical period until delivery of the child and continuation of anaesthesia with continuous infusion of propofol and remifentanyl. The current strategies, particularly the preparation for femoro-femoral extracorporeal membrane oxygenation, may be considered in similar cases with a high risk of acute cardiac decompensation which may be refractory to medical treatment. Anaesthesiologist involved in performing caesarean section in women with complex cardiac disease, should encompass extracorporeal membrane oxygenation standby in management of the perioperative period.

Se estudian las contribuciones térmicas y termomecánicas a los parámetros temporales de aniquilación de positrones en muestras de la aleación superplástica Al-Ca-Zn. Los resultados obtenidos se correlacionan con observaciones microscópicas. Se encuentra que, en las etapas iniciales de deformación el comportamiento termomecánico no se diferencia apreciablemente del térmico, desde el punto de vista de la espectroscopía temporal positrónica; sin embargo, para mayores deformaciones, se observa una clara diferenciación entre los dos tratamientos Fil: Ayciriex, M. D.. Universidad Nacional del Centro de la Provincia de Buenos Aires. Instituto de Física de Materiales de Tandil (UNICEN-IFIMAT). Buenos Aires. Argentina Fil: Romero, R.. Universidad Nacional del Centro de la Provincia de Buenos Aires. Instituto de Física de Materiales de Tandil (UNICEN-IFIMAT). Buenos Aires. Argentina Fil: Somoza, A.. Universidad Nacional del Centro de la Provincia de Buenos Aires. Instituto de Física de Materiales de Tandil (UNICEN-IFIMAT). Buenos Aires. Argentina Fil: Silvetti, S. P.. Universidad Nacional de Córdoba. Facultad de Matemática, Astronomía y Física (UNC-FaMAF). Córdoba. Argentina Fil: Villagra, O.. Universidad Nacional de Córdoba. Facultad de Matemática, Astronomía y Física (UNC-FaMAF). Córdoba. Argentina

La aleación superplástica de Al (Al-Mg-Cu), conocida comercialmente como Neopral, fue deformada por tracción a 530°C y distintas velocidades de deformación, dentro de la región de comportamiento superplástico. Se presenta un análisis cuantitativo de la cavitación en función de la deformación y la velocidad de deformación y se analiza el efecto de la dirección de laminación sobre las propiedades mecánicas de la aleación, comparando los datos obtenidos cuando la dirección de laminación es perpendicular al eje tensil respecto de cuando es paralela al mismo Fil: Ayciriex, M. D.. Universidad Nacional del Centro de la Provincia de Buenos Aires. Instituto de Física de Materiales de Tandil (UNICEN-IFIMAT). Buenos Aires. Argentina Fil: Silvetti, S. P. . Universidad Nacional de Córdoba. Facultad de Matemática, Astronomía y Física (UNC-FaMAF). Córdoba. Argentina

Los materiales metálicos superplásticos se caracterizan por exhibir, en un cierto rango de temperaturas, un comportamiento plástico inusual con una muy alta ductibilidad y baja tensión de fluencia, que los convierte en materiales aptos para ser conformados, por ejemplo, con aire comprimido. Por otra parte, a temperatura ambiente, presentan un comportamiento similar al de una aleación metálica común. Uno de los principales inconvenientes encontrados en las aleaciones superplásticas durante la deformación es la formación de cavidades que pueden degradar las propiedades de una pieza fabricada por este método. Utilizando una técnica de medición fundada en la aniquilación de positrones, se ha estudiado el efecto de los tratamientos térmicos y termomecánicos sobre la aleación superplástica Al-5% wtCa-5%wtZn, en un intento de realizar un aporte para comprender el origen de la cavitación Fil: Romero, R.. Universidad Nacional del Centro de la Provincia de Buenos Aires. Instituto de Física de Materiales de Tandil (UNICEN-IFIMAT). Buenos Aires. Argentina Fil: Silvetti, S. P.. Universidad Nacional de Córdoba. Facultad de Matemática, Astronomía y Física (UNC-FaMAF). Córdoba. Argentina Fil: Somoza, A.. Universidad Nacional del Centro de la Provincia de Buenos Aires. Instituto de Física de Materiales de Tandil (UNICEN-IFIMAT). Buenos Aires. Argentina

Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on “standard” versus “non-standard” (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with “non-standard” strategy was higher than in patients with “standard” strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The “standard” antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.

We present MoonLight, a tool for monitoring temporal and spatio-temporal properties of mobile and spatially distributed cyber-physical systems (CPS). In the proposed framework, space is represented as a weighted graph, describing the topological configurations in which the single CPS entities (nodes of the graph) are arranged. Both nodes and edges have attributes modelling physical and logical quantities that can change in time. MoonLight is implemented in Java and supports the monitoring of Spatio-Temporal Reach and Escape Logic (STREL) introduced in [6]. MoonLight can be used as a standalone command line tool, as a Java API, or via Matlab ™interface. We provide here some examples using the Matlab ™interface and we evaluate the tool performance also by comparing with other tools specialized in monitoring only temporal properties.

Purpose Peripherally inserted central catheters (PICCs) are associated with some adverse events, the most frequent are thrombosis, tip catheter malposition and spontaneous late migration. However, the cause of spontaneous late migration in most cases remains unknown. We carried out this study to add data to the literature on PICCs late spontaneous migration. Methods We conducted a systematic review of all manuscripts describing PICC spontaneous late migration in adult populations and we also described two cases of late PICCs migration. Results We identified five studies for a total of 58 cases of PICC late migration. In our two cases, patients' activity is an important contributing factor for late spontaneous PICC migration. Conclusions To avoid late catheter misplacement, initial malposition should be immediately identified and promptly corrected and a detailed patients training should be carried out.

Objectives Democracy-based medicine is a combination of evidence-based medicine (systematic review), expert assessment, and worldwide voting by physicians to express their opinions and self-reported practice via the Internet. The authors applied democracy-based medicine to key trials in critical care medicine. Design and Setting A systematic review of literature followed by web-based voting on findings of a consensus conference. Participants A total of 555 clinicians from 61 countries. Interventions The authors performed a systematic literature review (via searching MEDLINE/PubMed, Scopus, and Embase) and selected all multicenter randomized clinical trials in critical care that reported a significant effect on survival and were endorsed by expert clinicians. Then they solicited voting and self-reported practice on such evidence via an interactive Internet questionnaire. Relationships among trial sample size, design, and respondents’ agreement were investigated. The gap between agreement and use/avoidance and the influence of country origin on physicians’ approach to interventions also were investigated. Measurements and Main Results According to 24 multicenter randomized controlled trials, 15 interventions affecting mortality were identified. Wide variabilities in both the level of agreement and reported practice among different interventions and countries were found. Moreover, agreement and reported practice often did not coincide. Finally, a positive correlation among agreement, trial sample size, and number of included centers was found. On the contrary, trial design did not influence clinicians’ agreement. Conclusions Physicians’ clinical practice and agreement with the literature vary among different interventions and countries. The role of these interventions in affecting survival should be further investigated to reduce both the gap between evidence and clinical practice and transnational differences.

OBJECTIVES: We aimed to identify all treatments that affect mortality in adult critically ill patients in multicenter randomized controlled trials. We also evaluated the methodological aspects of these studies, and we surveyed clinicians' opinion and usual practice for the selected interventions.DATA SOURCES: MEDLINE/PubMed, Scopus, and Embase were searched. Further articles were suggested for inclusion from experts and cross-check of references.STUDY SELECTION: We selected the articles that fulfilled the following criteria: publication in a peer-reviewed journal; multicenter randomized controlled trial design; dealing with nonsurgical interventions in adult critically ill patients; and statistically significant effect in unadjusted landmark mortality. A consensus conference assessed all interventions and excluded those with lack of reproducibility, lack of generalizability, high probability of type I error, major baseline imbalances between intervention and control groups, major design flaws, contradiction by subsequent larger higher quality trials, modified intention to treat analysis, effect found only after adjustments, and lack of biological plausibility.DATA EXTRACTION: For all selected studies, we recorded the intervention and its comparator, the setting, the sample size, whether enrollment was completed or interrupted, the presence of blinding, the effect size, and the duration of follow-up.DATA SYNTHESIS: We found 15 interventions that affected mortality in 24 multicenter randomized controlled trials. Median sample size was small (199 patients) as was median centers number (10). Blinded trials enrolled significantly more patients and involved more centers. Multicenter randomized controlled trials showing harm also involved significantly more centers and more patients (p = 0.016 and p = 0.04, respectively). Five hundred fifty-five clinicians from 61 countries showed variable agreement on perceived validity of such interventions.CONCLUSIONS: We identified 15 treatments that decreased/increased mortality in critically ill patients in 24 multicenter randomized controlled trials. However, design affected trial size and larger trials were more likely to show harm. Finally, clinicians view of such trials and their translation into practice varied.

Introduction: Activated protein C is associated with a risk of bleeding and its effects on survival in septic shock patients are questionable. Protein C zymogen has no risk of bleeding and improves the outcome of patients with septic shock. We hereby describe the largest published case series of adult patients receiving protein C zymogen. Design, setting and participants: A prospective study on 23 adult patients with severe sepsis or septic shock, two or more organ failures and at high risk for bleeding, treated with protein C zymogen (501U/kg bolus followed by continuous infusion of 31U/kg/h for 72 h). Results: The Z-test evidenced a significant reduction between the expected mortality (53%) and the observed mortality 30% (Z value =1.99, p=0.046) in our sample population. Protein C levels increased from 34 +/- 18% to 66 +/- 22% at 6 h after PC bolus (p

Standard inotropic treatment is often necessary in end-stage heart failure but may be harmful. We performed a meta-analysis of randomized controlled trials to investigate the effect of repeated administration of levosimendan on survival in patients with chronic heart failure. Four investigators independently searched in CENTRAL, Google Scholar MEDLINE/PubMed, Scopus and the Cochrane Central Register of clinical trials to identify any randomized study ever performed with intermittent levosimendan intravenous administration in adult patients with chronic heart failure with no restrictions on dose or time of administration. Data from a total of 326 patients from six randomized controlled studies using intermittent levosimendan in a cardiological setting were included in the analysis. Levosimendan was associated with a significant reduction in mortality at the longest follow-up available [32 of 168 (19 %) in the levosimendan group 46 of 133 (35 %) in the control arm, RR = 0.55 (95 % CI 0.37-0.84), p for effect = 0 0.005, p for heterogeneity = 0.3, I (2) = 23.4 %, NNT = 6 with 5 studies included]. Brain natriuretic peptide values, ejection fraction and number of patients with New York Heart Association a parts per thousand yenIII status were similar in survivors of both groups. A large randomized trial is necessary to confirm the promising beneficial effects of intermittent levosimendan administration on the mid-term survival of patients with chronic heart failure.

Objective To investigate the ability of early urinary neutrophil gelatinase-associated lipocalin to predict postoperative complications in adult patients with ventricular dysfunction undergoing cardiac surgery. Design Prospective observational study. Setting Single-center study, university hospital. Participants Fifty-six adult high-risk cardiac surgical patients with preoperative cardiac failure. Interventions None. Measurements and Main Results Demographic and clinical characteristics were obtained, and neutrophil gelatinase-associated lipocalin was measured at baseline and at several time points after surgery. Patient characteristics and neutrophil gelatinase-associated lipocalin levels were related to renal and patient outcome. On multivariate analyses, preoperative urinary neutrophil gelatinase-associated lipocalin was an independent predictor of length of intensive care stay (p = 0.004) and in-hospital stay (p = 0.04), but not of acute kidney injury or renal replacement therapy and was not associated with baseline renal function. Conclusions In a cohort of high-risk cardiac surgery patients, preoperative urinary neutrophil gelatinase-associated lipocalin value provided prognostic information that was independent of the onset of acute kidney injury or of preoperative renal function.

Objective The aim of this meta-analysis was to investigate the cardioprotective properties of isoflurane versus any comparator in terms of the rate of myocardial infarction and all-cause mortality. Design Pertinent studies were searched independently in Biomed, Central, PubMed, Embase, and the Cochrane Central Register of clinical trials. The primary endpoint was mortality at the longest follow-up available. Setting A hospital. Participants Randomized controlled trials. Intervention A meta-analysis of 37 trials. Measurements and Main Results The 37 included trials randomized 3,539 patients in cardiac (16 studies) and in noncardiac surgery (21 studies) with noninhalation comparators in 55% of trials. The overall analysis showed no difference in mortality between the isoflurane and control groups (16/1,602 [1.0%] v 23/1,937 [1.2%], odds ratios (OR) = 0.76 [0.39-1.47], p = 0.4 with 37 studies included) and no difference in the rate of myocardial infarction (3/1,312 [0.2%] v 1/1,532 [0.07%], OR = 2.03 [0.27-15.49], p = 0.5 with 30 studies included). Mortality was reduced in the isoflurane group when only studies with a low risk of bias were included in the analyses (0/540 [0%] v 5/703 [0.7%] in the control arm, OR = 0.13 [0.02-0.76], p = 0.02) with 4 cardiac and 6 noncardiac trials included and 5 noninhalation and 5 inhalation agents as the comparator. A trend was noted when a subanalysis was performed with propofol as a comparator (1/544 [0.2%] v 6/546 [1.1%], p = 0.05, with 16 studies included). Conclusions Isoflurane reduced mortality in high-quality studies and showed a trend toward a reduction in mortality when it was compared with propofol. No differences in the rates of overall mortality and myocardial infarction were noted.

Endogenous protein C levels are frequently decreased in septic patients, probably due to increased conversion to activated protein C. Protein C levels inversely correlate with morbidity and mortality of septic patients regardless of age, infecting microorganisms, presence of shock, disseminated intravascular coagulation, degree of hypercoagulation, or severity of illness. Taken together, these considerations suggest a strong correlation between protein C pathways and survival from severe sepsis/septic shock, and reinforce the rationale for the attempts to normalize plasma activity of protein C to improve survival, hamper coagulopathy, and modulate inflammation. We therefore conducted a systematic review of all manuscripts describing protein C concentrates administration in adult and pediatric populations. We identified 28 studies, for a total of 340 patients, 70 of whom died (20.6%). Septic patients were the most represented in this review of case reports and case series. In the majority of these patients sepsis was associated with meningitis, purpura fulminans or disseminated intravascular coagulation. No bleeding complications related to the study drug were reported and most studies underlined normalization of inflammatory markers and of coagulation abnormalities. We conclude that protein C concentrate is an attractive option in septic patients (especially those with meningitis, purpura fulminans, or disseminated intravascular coagulation) and that its cost-benefit ratio must be studied with a large multicenter randomized control trial, possibly including also high risk patients with septic shock and multiple organ failure.

Background Inotropes and vasopressors are frequently administered to critically ill patients in order to improve haemodynamic function and restore adequate organ perfusion. However, some studies have suggested a possible association between inotrope administration and increased mortality. We therefore performed a meta-analysis of randomized trials published in the last 20 yr to investigate the effect of these drugs on mortality. Methods BioMedCentral, PubMed, Embase and the Cochrane Central Register were searched (all updated April 8th, 2015). Inclusion criteria were: random allocation to treatment, at least one group receiving an inotropic or vasopressor drug compared with at least one group receiving a non-inotropic/vasopressor treatment, study published after 1st January 1994, and systemic drug administration. Exclusion criteria were overlapping populations, studies published as abstract only, crossover studies, paediatric studies and lack of data on mortality. Results A total of 28 280 patients from 177 trials were included. Overall, pooled estimates showed no difference in mortality between the group receiving inotropes/vasopressors and the control group [4255/14 036 (31.7%) vs 4277/14 244 (31.8%), risk ratio=0.98 (0.96–1.01), P for effect=0.23, P for heterogeneity=0.30, I2=6%]. A reduction in mortality was associated with inotrope/vasopressor therapy use in settings of vasoplegic syndromes, sepsis and cardiac surgery. Levosimendan was the only drug associated with improvement in survival. Subgroup analysis did not identify any groups with increased mortality associated with inotrope/vasopressor therapy. Conclusions Our systematic review found that inotrope/vasopressor therapy is not associated with differences in mortality in the overall population and in the majority of subsettings.

Objective: Good quality clinical research in anesthesiology is now performed all over the world. The aim of this article was to present and analyze the scientific contributions published in the Journal of Cardiothoracic and Vascular Anesthesia and to give a structured view focused on the countries where these studies were performed. Design: Bibliometric analysis. Setting: Teaching hospital. Participants: None. Interventions:The authors analyzed the geographic distribution of the authors publishing in cardiac anesthesia. Measurements and Main Results: Data were obtained from the Scopus database. All works belonging to document-type articles, reviews, letters, and editorials published over a 10-year period (2000-2009) in the Journal of Cardiothoracic and Vascular Anesthesia (JCVA) were tracked. For each article, the country of origin of the corresponding author was retrieved. JCVA published 1,816 articles from 45 different countries. The United States accounted for 43.8% of the total, followed by India (8.3%), Germany (5.5%), United Kingdom (4.7%), and Italy (4.4%). Conclusions: JCVA has a widespread influence and receives contributions from all over the world. More and more biomedical research is conducted outside North America and Europe, with India leading the group of "rest of the world" countries. The recent development of Asian countries clearly challenges North America and European countries that can no longer ignore the scientific contribution from these parts of the world. With this in mind, some journals such as JCVA are giving voice to these prolific countries, which represents a fundamental forum for these newcomers to the field of cardiac anesthesia. (C) 2010 Elsevier Inc. All rights reserved.

INTRODUCTION: Hypotensive state is frequently observed in several critical conditions. If an adequate mean arterial pressure is not promptly restored, insufficient tissue perfusion and organ dysfunction may develop. Fluids and catecholamines are the cornerstone of critical hypotensive states management. Catecholamines side effects such as increased myocardial oxygen consumption and development of arrhythmias are well known. Thus, in recent years, interest in catecholamine-sparing agents such as vasopressin, terlipressin and methylene blue has increased; however, few randomized trials, mostly with small sample sizes, have been performed. We therefore conducted a meta-analysis of randomized trials to investigate the effect of non-catecholaminergic vasopressors on mortality.METHODS: PubMed, BioMed Central and Embase were searched (update December 31st, 2014) by two independent investigators. Inclusion criteria were: random allocation to treatment, at least one group receiving a non-catecholaminergic vasopressor, patients with or at risk for vasodilatory shock. Exclusion criteria were: crossover studies, pediatric population, non-human studies, studies published as abstract only, lack of data on mortality. Studied drugs were vasopressin, terlipressin and methylene blue. Primary endpoint was mortality at the longest follow-up available.RESULTS: A total of 1,608 patients from 20 studies were included in our analysis. The studied settings were sepsis (10/20 studies [50%]), cardiac surgery (7/20 [35%]), vasodilatory shock due to any cause (2/20 [19%]), and acute traumatic injury (1/20 [5%]). Overall, pooled estimates showed that treatment with non-catecholaminergic agents improves survival (278/810 [34.3%] versus 309/798 [38.7%], risk ratio = 0.88, 95% confidence interval = 0.79 to 0.98, p = 0.02). None of the drugs was associated with significant reduction in mortality when analyzed independently. Results were not confirmed when analyzing studies with a low risk of bias.CONCLUSIONS: Catecholamine-sparing agents in patients with or at risk for vasodilatory shock may improve survival. Further researches on this topic are needed to confirm the finding.

"Neutrophil gelatinase-associated lipocalin (NGAL) is a protein of lipocalin family highly expressed in various pathologic states and is an early biomarker of acute kidney injury in cardiac surgery. We performed an observational study to evaluate the role of NGAL in predicting postoperative intensive care stay in high-risk patients undergoing cardiac surgery. We enrolled 27 consecutive patients who underwent high-risk cardiac surgery with cardiopulmonary bypass. Urinary NGAL (uNGAL) was measured before surgery, at intensive care unit (ICU) arrival and 24 h later. Univariate and multivariate predictors of ICU stay were performed. uNGAL was 18.0 (8.7-28.1) ng\/mL at baseline, 10.7 (4.35-36.0) ng\/mL at ICU arrival and 29.6 (9.65-29.5) 24 h later. The predictors of prolonged ICU stay at the multivariate analysis were body mass index (BMI), uNGAL 24 h after surgery, and aortic cross-clamp time. The predictors of high uNGAL levels 24 h after at a multivariate analysis were preoperative uNGAL and logistic European System for Cardiac Operative Risk Evaluation. At a multivariate analysis the only independent predictors of prolonged ICU stay were BMI, uNGAL 24 h after surgery and aortic cross-clamp time.. . "

Levosimendan is a calcium-sensitizing agent that improves cardiac function, hemodynamic performance, and survival in critically ill adult patient. Few data exist on its off-label use in paediatric patients. We therefore performed a systematic review updated in September 2013 of all the published articles describing the use of levosimendan in paediatric patients. We identified 24 studies published in the period 2004-2013 that included a total of 623 patients, the largest one being a case series of 293 patients. Most of the patients underwent cardiac surgery, other settings consisting of chronic heart failure, primary congenital heart diseases and sepsis and cancer-associated cardiac dysfunction. Most studies reported improvement in ventricular function, central venous oxygen saturation, serum lactate levels or cardiac index. The 5 randomized studies published so far have all been performed in cardiac surgery and suggest a beneficial effect on hemodynamic data with no effect on intensive care unit stay, hospital stay or survival. Side effects (e.g. hypotension) were reported. This inodilator merits to be investigated with further randomized trials focusing on clinically relevant outcomes.