Incidence of Acute Neurological Events in Neonates and Infants Undergoing Cardiac Surgery Using a High-Hematocrit/ High-Flow Bypass Strategy.

Background: The incidence of new acute neurological injury occurring in neonates and infants during cardiac surgery utilizing cardiopulmonary bypass is reportedly 3% to 5%. In 2013, we adopted a high flow rate, and high hematocrit bypass strategy, and sought to assess the incidence of early neurological injuries associated with this strategy. Methods: Neonates and infants undergoing cardiopulmonary bypass between January 2013 and December 2019 (n = 714) comprise the study. Adverse neurological events (ANEs) were defined as any abnormality of pupils, delayed awakening, seizures, focal neurological deficits, concerns prompting neurological consultation, or any abnormality on neurological imaging in the postoperative period. Our bypass strategy included a high flow rate (150-200 mL/kg/min), without reduction of flow rates during cooling and maintaining a target hematocrit on bypass > 32% with a terminal hematocrit of > 42%. Results: Median weight at the time of the procedure was 4.6 kg (IQR 3.6-6.1 kg) with the smallest patient weighing 1.36 kg. There were 46 premature patients (6.4%). There were 149 patients (20.9%) patients who underwent deep hypothermic circulatory arrest with a median time of 26 min (IQR 21-41 min). Hospital mortality was 3.5% (24/714, 95% CI: 2.28-5.13). The incidence of neurological events as defined above was 0.84% (6/714, 95% CI: 0.31-1.82). Neurological imaging identified ischemic injury in 4 patients and intraventricular hemorrhage in 2. Conclusions: High flow/high hematocrit bypass strategy was associated with a low incidence of ANE in this vulnerable population.

Preventing Cardiac Arrest in the Pediatric Cardiac Intensive Care Unit Through Multicenter Collaboration.

Importance: Preventing in-hospital cardiac arrest (IHCA) likely represents an effective strategy to improve outcomes for critically ill patients, but feasibility of IHCA prevention remains unclear. Objective: To determine whether a low-technology cardiac arrest prevention (CAP) practice bundle decreases IHCA rate. Design, Setting, and Participants: Pediatric cardiac intensive care unit (CICU) teams from the Pediatric Cardiac Critical Care Consortium (PC4) formed a collaborative learning network to implement the CAP bundle consistent with the Institute for Healthcare Improvement framework; 15 hospitals implemented the bundle voluntarily. Risk-adjusted IHCA incidence rates were analyzed across 2 time periods, 12 months (baseline) and 18 months after CAP implementation (intervention) using difference-in-differences (DID) regression to compare 15 CAP and 16 control PC4 hospitals that chose not to participate in CAP but had IHCA rates tracked in the PC4 registry. Patients deemed at high risk for IHCA, based on a priori evidence-based criteria and empirical hospital-specific criteria, were selected to receive the CAP bundle. Data were collected from July 2018 to December 2019, and data were analyzed from March to August 2020. Interventions: CAP bundle included 5 elements developed to promote increased situational awareness and communication among bedside clinicians to recognize and mitigate deterioration in high-risk patients. Main Outcomes and Measures: Risk-adjusted IHCA incidence rate across all CICU admissions (IHCA events divided by all admissions). Results: The bundle was activated in 2664 of 10 510 CAP hospital admissions (25.3%); admission characteristics were similar across study periods. There was a 30% relative reduction in risk-adjusted IHCA incidence rate at CAP hospitals (intervention period: 2.6%; 95% CI, 2.2-2.9; baseline: 3.7%; 95% CI, 3.1-4.0), but no change at control hospitals (intervention period: 2.7%; 95% CI, 2.3-2.9; baseline: 2.7%; 95% CI, 2.2-3.0). DID analysis confirmed significantly reduced odds of IHCA among all admissions at CAP hospitals compared with control hospitals during the intervention period vs baseline (odds ratio, 0.72; 95% CI, 0.56-0.91; P = .01). DID odds ratios were 0.72 (95% CI, 0.53-0.98) for the surgical subgroup, 0.74 (95% CI, 0.48-1.14) for the medical subgroup, and 0.72 (95% CI, 0.50-1.03) for the high-risk admission subgroup at CAP hospitals after intervention. All-cause risk-adjusted mortality rate did not change after intervention. Conclusions and Relevance: Implementation of this CAP bundle led to significant IHCA reduction across multiple pediatric CICUs. Future studies may determine if this bundle can be effective in other critically ill populations.

Pediatric Cardio-Oncology Medicine: A New Approach in Cardiovascular Care.

Survival for pediatric patients diagnosed with cancer has improved significantly. This achievement has been made possible due to new treatment modalities and the incorporation of a systematic multidisciplinary approach for supportive care. Understanding the distinctive cardiovascular characteristics of children undergoing cancer therapies has set the underpinnings to provide comprehensive care before, during, and after the management of cancer. Nonetheless, we acknowledge the challenge to understand the rapid expansion of oncology disciplines. The limited guidelines in pediatric cardio-oncology have motivated us to develop risk-stratification systems to institute surveillance and therapeutic support for this patient population. Here, we describe a collaborative approach to provide wide-ranging cardiovascular care to children and young adults with oncology diseases. Promoting collaboration in pediatric cardio-oncology medicine will ultimately provide excellent quality of care for future generations of patients.

Secure and Efficient High Throughput Medium Access Control for Vehicular Ad-Hoc Network.

The evolution of the internet has led to the growth of smart application requirements on the go in the vehicular ad hoc network (VANET). VANET enables vehicles to communicate smartly among themselves wirelessly. Increasing usage of wireless technology induces many security vulnerabilities. Therefore, effective security and authentication mechanism is needed to prevent an intruder. However, authentication may breach user privacy such as location or identity. Cryptography-based approach aids in preserving the privacy of the user. However, the existing security models incur communication and key management overhead since they are designed considering a third-party server. To overcome the research issue, this work presents an efficient security model namely secure performance enriched channel allocation (S-PECA) by using commutative RSA. This work further presents the commutative property of the proposed security scheme. Experiments conducted to evaluate the performance of the proposed S-PECA over state-of-the-art models show significant improvement. The outcome shows that S-PECA minimizes collision and maximizes system throughput considering different radio propagation environments.

Channel Allocation for Connected Vehicles in Internet of Things Services.

Based on the existing Internet of Vehicles communication protocol and multi-channel allocation strategy, this paper studies the key issues with vehicle communication. First, the traffic volume is relatively large which depends on the environment (city, highway, and rural). When many vehicles need to communicate, the communication is prone to collision. Secondly, because the traditional multi-channel allocation method divides the time into control time slots and transmission time slots when there are few vehicles, it will cause waste of channels, also when there are more vehicles, the channels will not be enough for more vehicles. However, to maximize the system throughput, the existing model Enhanced Non-Cooperative Cognitive division Multiple Access (ENCCMA) performs amazingly well by connected the Cognitive Radio with Frequency Division Multiple Access (FDMA) and Time Division Multiple Access (TDMA) for a multi-channel vehicular network.However, this model induces Medium Access Control (MAC) overhead and does not consider the performance evaluation in various environmental conditions.Therefore, this paper proposes a Distributed Medium Channel Allocation (DMCA) strategy, by dividing the control time slot into an appointmentand a safety period in the shared channel network. SIMITS simulator was used for experiment evaluation in terms of throughput, collision, and successful packet transmission. However, the outcome shows that our method significantly improved the channel utilizationand reduced the occurrence of communication overhead.

Association of persistent tachycardia with early myocardial dysfunction in children undergoing allogeneic hematopoietic cell transplantation.

Cancer survivors who have undergone hematopoietic cell transplantation (HCT) are at risk for myocardial dysfunction. Children who receive allogenic HCT encounter systemic inflammation resulting in tachycardia and hypertension. The effect of these abnormalities on myocardial function is not known. The aim of this study was to determine whether cardiac dysfunction early after HCT can be predicted by tachycardia or hypertension, within a retrospective single-center sample of pediatric HCT recipients. Early tachycardia or hypertension was defined as a majority of values taken from infusion date to 90 days post-infusion being abnormal. Ejection fraction <53% determined systolic dysfunction. A composite score of accepted pediatric diastolic abnormalities determined diastolic dysfunction. Among 80 subjects (median age 8 years), early tachycardia, systolic dysfunction, and diastolic dysfunction were present in 64%, 25%, and 48% of the sample, respectively. In multivariable models, early tachycardia was an independent predictor of early systolic dysfunction (OR = 12.6 [1.4-112.8], p = 0.024) and diastolic dysfunction (OR = 3.9 [1.3-11.5], p = 0.013). Tachycardia and cardiac dysfunction are common and associated with one another in the early period after pediatric HCT. Future studies may elucidate the role of tachycardia and myocardial dysfunction early after HCT as important predictors of future cardiovascular dysfunction.

Novel use of cangrelor in pediatrics: A pilot cohort study demonstrating use in ventricular assist devices.

Thromboembolic events and bleeding are major sources of morbidity among pediatric patients supported on a ventricular assist device (VAD). Pharmacokinetics and pharmacodynamics of enteral antiplatelet agents are affected and variable due to erratic enteral absorption in end-stage heart failure and VAD circulation. Additionally, 20%-40% of the population are poor metabolizers of clopidogrel, a prodrug, making cangrelor an alternative when antiplatelet therapy is crucial. Cangrelor has been used effectively and safely for short durations in adults during percutaneous coronary interventions, but the use of cangrelor is still under investigation in pediatrics. This case series utilized cangrelor, a novel short-acting, reversible, intravenous P2Y12 platelet inhibitor in managing pediatric patients supported with a VAD. We performed a retrospective, single-center review of patients admitted to a tertiary medical center with end-stage heart failure requiring mechanical circulatory support and concomitant cangrelor administration between January 2019 and March 2020. Platelet function testing, cangrelor dose, bleeding complications, thromboembolic events, and frequency of circuit interventions during the use of cangrelor were recorded. Optimal platelet reactivity, defined as P2Y12 < 180 platelet reaction units (PRU), was measured with serial point-of-care testing (VerifyNow). Seven patients, median age of 4.9 years, met the above criteria. Three patients had a diagnosis of complex congenital heart disease. Four patients had dilated or restrictive cardiomyopathy. All patients were on continuous flow VADs. The median VAD duration was 84.5 days (IQR 61.5-103). The median duration on cangrelor was 43 days (IQR 8-70). The median cangrelor dose to reach the therapeutic threshold was 0.75 µg/kg/min with the mean P2Y12 , while on cangrelor of 164.75 PRU. Bleeding complications included mild gastrointestinal bleeding and hematuria. There was one patient with pump thrombosis requiring intervention. There were no cerebrovascular events while on cangrelor. We report the first successful long-term use of cangrelor in pediatric patients. The reversibility and short half-life of cangrelor make it a feasible antiplatelet agent in selected patients. This data supports the use of cangrelor in children as a viable antiplatelet option; with minimal bleeding complications and no cerebrovascular events demonstrated in this cohort.

Indoor Large-Scale MIMO-Based RSSI Localization with Low-Complexity RFID Infrastructure.

Indoor localization based on unsynchronized, low-complexity, passive radio frequency identification (RFID) using the received signal strength indicator (RSSI) has a wide potential for a variety of internet of things (IoTs) applications due to their energy-harvesting capabilities and low complexity. However, conventional RSSI-based algorithms present inaccurate ranging, especially in indoor environments, mainly because of the multipath randomness effect. In this work, we propose RSSI-based localization with low-complexity, passive RFID infrastructure utilizing the potential benefits of large-scale MIMO technology operated in the millimeter-wave band, which offers channel hardening, in order to alleviate the effect of small-scale fading. Particularly, by investigating an indoor environment equipped with extremely simple dielectric resonator (DR) tags, we propose an efficient localization algorithm that enables a smart object equipped with large-scale MIMO exploiting the RSSI measurements obtained from the reference DR tags in order to improve the localization accuracy. In this context, we also derive Cramer-Rao lower bound of the proposed technique. Numerical results evidence the effectiveness of the proposed algorithms considering various arbitrary network topologies, and results are compared with an existing algorithm, where the proposed algorithms not only produce higher localization accuracy but also achieve a greater robustness against inaccuracies in channel modeling.

A Secure Enhanced Non-Cooperative Cognitive Division Multiple Access for Vehicle-to-Vehicle Communication.

The growth of the Internet has led to the increasing usage of smart infotainment applications on the vehicular ad-hoc network (VANET). Preserving privacy and security regarding the provision of smart infotainment applications while on the go is most desired. Thus, a secure authentication scheme is required. Many privacy-preserving security schemes have been developed in recent times using cryptography approaches. However, these incur key management and communication overhead. The usage of third-party servers incurs the overhead of key computation, storage and distribution. Post completion of the initialization phase, the message is secured using cryptography and is shared among vehicles. The design of the proposed secure enhanced non-cooperative cognitive division multiple access ( S - ENCCMA ) aims to eliminate the need for the local message available with the parties to be released for provisioning secure safety-related applications. To overcome the research challenges, this work presents a novel security scheme, namely secure non-cooperative cognitive medium access ( S - ENCCMA ). The experiment is conducted to evaluate the overhead incurred in provisioning security to ENCCMA . The outcome shows that the overhead incurred by S - ENCCMA over ENCCMA was negligible to provide the real-time security requirements of smart infotainment applications, which is experimentally shown in this paper in terms of throughput, collision and successful packet transmission considering varied environmental models such as cities, highways and rural areas.

Performance Enriching Channel Allocation Algorithm for Vehicle-to-Vehicle City, Highway and Rural Network.

Future safety applications require the timely delivery of messages between vehicles. The 802.11p has been standardized as the standard Medium Access Control (MAC) protocol for vehicular communication. The 802.11p uses Carrier Sense Multiple Access with Collision Avoidance (CSMA/CA) as MAC. CSMA/CA induces unbounded channel access delay. As a result, it induces high collision. To reduce collision, distributed MAC is required for channel allocation. Many existing approaches have adopted Time Division Multiple Access (TDMA) based MAC design for channel allocation. However, these models are not efficient at utilizing bandwidth. Cognitive radio technique is been adopted by various existing approach for channel allocation in shared channel network to maximize system throughput. However, it induces MAC overhead, and channel allocation on a shared channel network is considered to be an NP-hard problem. This work addresses the above issues. Here we present distributed MAC design PECA (Performance Enriching Channel Allocation) for channel allocation in a shared channel network. The PECA model maximizes the system throughput and reduces the collision, which is experimentally proven. Experiments are conducted to evaluate the performance in terms of throughput, collision and successful packet transmission considering a highly congested vehicular ad-hoc network. Experiments are carried out to show the adaptiveness of proposed MAC design considering different environments such City, Highway and Rural (CHR).

F-fluorodeoxyglucose-positive emission tomography/CT imaging for left ventricular assist device-associated infections in children.

Left ventricular assist device implantation is an important therapeutic option for children with end-stage heart failure. However, device-related complications such as infection may occur while the patient is supported. Device-associated infection can be life-threatening, and early detection is critical. F-fluorodeoxyglucose positron emission tomography and CT is a highly sensitive imaging modality for the detection of an inflammatory response and is useful to evaluate the response to antibiotic therapy. We present two case reports of a left ventricular assist device-associated infection detected by F-fluorodeoxyglucose positron emission tomography and CT in children.

The Use of Extracorporeal Membrane Oxygenation-Cardiopulmonary Resuscitation in Prolonged Cardiac Arrest in Pediatric Patients: Is it Time to Expand It?

Extracorporeal membrane oxygenation was instituted as an aid to in-hospital cardiopulmonary resuscitation (E-CPR) nearly 23 years ago, this led to remarkable improvement in survival considering the mortality rate associated with conventional cardiopulmonary resuscitation (CPR). Given this success, one begins to wonder whether the time has come for expanding the use of E-CPR to outside hospital cardiac arrests especially in the light of development of newer extracorporeal life support devices that are small, mobile, and easy to assemble. This editorial will review recent studies on this subject and address some key guidelines and limitations of this evolving and promising technology.

Noninvasive cardiac output monitoring in the pediatric cardiac Intensive Care Unit.

PURPOSE OF REVIEW: The present article explores some of the newer noninvasive techniques for monitoring cardiac output in the pediatric population. These new techniques can be utilized in both a wide variety of patient sizes and the unique pathology of congenital cardiopathy. These techniques may assist in optimizing therapy in the intensive care setting. RECENT FINDINGS: Recently, Hoffman et al. found that near-infrared spectroscopy positively correlates with SvO2. Esophageal Doppler is an accurate method only if used by experienced personnel. Both impedance cardiography and electrical cardiometry use thoracic electrical bioimpedance. However, the algorithm differs between the two methods. Cardiometry may be more accurate in patients with a low cardiac output state. Calamandrei et al. found that an analytical method using arterial pulse pressure recording (pressure recording analytical method) shows a high correlation with Doppler echocardiography. Finally, a method like partial CO2 rebreathing was studied by Levy et al., who suggested that this method may be used to trend cardiac output continuously, but not for providing absolute values. SUMMARY: Although promising, studies validating the use of these methods in a variety of real clinical situations are needed before they will be widely used in pediatric practice.The currently available data suggest that pressure recording analytical method and electrical cardiometry will prove to be useful in the pediatric cardiac ICU to monitor trends in cardiac output.