Text mining and word embedding for classification of decision making variables in breast cancer surgery.

INTRODUCTION: Decision making in surgical oncology of the breast has increased its complexity over the last twenty years. This Delphi survey investigates the opinion of an expert panel about the decision making process in surgical procedures on the breast for oncological purposes. METHODS: Twenty-seven experts were invited to partake into a Delphi Survey. At the first round they have been asked to provide a list of features involved in the decision making process (patient's characteristics; disease characteristics; surgical techniques, outcomes) and comment on it. Using text-mining techniques we extracted a list of mono-bi-trigrams potentially representative of decision drivers. A technique of "natural language processing" called Word2vec was used to validate changes to texts using synonyms and plesionyms. Word2Vec was also used to test the semantic relevance of n-grams within a corpus of knowledge made up of books edited by panel members. The final list of variables extracted was submitted to the judgement of the panel for final validation at the second round of the Delphi using closed ended questions. RESULTS: 52 features out of 59 have been approved by the panel. The overall consensus was 87.1% CONCLUSIONS: Text mining and natural language processing allowed the extraction of a number of decision drivers and outcomes as part of the decision making process in surgical oncology on the breast. This result was obtained transforming narrative texts into structured data. The high level of consensus among experts provided validation to this process.

ECPella: Concept, Physiology and Clinical Applications.

Addition of Impella on top of venoarterial extracorporeal membrane oxygenation (VA-ECMO) has gained wide interest as it might portend improved outcomes in patients with cardiogenic shock. This has been consistently reported in retrospective propensity-matched studies, case series, and meta-analyses. The pathophysiologic background is based on the mitigation of ECMO-related side effects and the additive benefit of myocardial unloading. In this perspective, thorough knowledge of these mechanisms is required to optimize the management of mechanical circulatory support with this approach and introduce best practices, as the interplay between the two devices and the implantation-explantation strategies are key for success.

Management strategies in venovenous extracorporeal membrane oxygenation: a retrospective comparison from five European centres.

OBJECTIVE: To investigate contemporary clinical practice in the management of venovenous (VV) extracorporeal membrane oxygenation (ECMO) in critically ill patients with bacterial pneumonia. METHODS: In this multicentre retrospective study, 48 patients with severe respiratory failure due to bacterial pneumonia receiving VV ECMO therapy in five experienced European ECMO centres were included. Ventilator and ECMO settings were analysed. RESULTS: Ventilator settings showed great variability between participating centres, particularly relating to positive end-expiratory pressure, peak inspiratory pressure and driving pressure. Different strategies in cannulation, ECMO setting and weaning procedures were also observed. CONCLUSION: There is great diversity in management modalities for ventilator and ECMO settings for patients with bacterial pneumonia. Our study emphasises the lack of clinical consensus in VV ECMO management.

The high incidence of anti-Ro/SSA and anti-p200 antibodies in female patients with connective tissue diseases confirms the importance of screening for congenital heart block-associated autoantibodies during pregnancy.

It is known that anti-Ro/SSA positivity leads to higher risk of miscarriage and fetal cardiac malformations. Particularly, anti-p200 antibodies against a finer specificity of the Ro/SSA antigen, have been associated with congenital heart block. The aim of the study was to assess the frequency of anti-p200 among female patients with different connective tissue diseases and, among these, the relevance of anti-p200 values in patients with cutaneous diseases compared to systemic diseases. Anti-p200 were investigated in 110 anti-Ro/SSA positive female sera, sent to our laboratory between 2008 and 2014 with suspect of connective disease, by using ELISA testing. Positivity was found in 40.9 % samples, 34 of them showed a strong positivity (values ≥ 1.0, cut off = 0.7). Patients with systemic diseases were anti-p200 positive in the 45.9 % of cases while patients with cutaneous diseases were positive in the 24.0 % of cases. Positivity for anti-p200 antibodies was revealed in 24.0 % of patients with discoid lupus erythematosus; 100 % of patients with dermatomyositis; 40.0 % of patients with mixed connective tissue disease; 25.0 % of patients with rheumatoid arthritis; 100 % of patients with Sjögren's syndrome; 33.3 % of patients with subacute cutaneous lupus erythematosus; 42.9 % of patients with systemic lupus erythematosus; 80.0 % of patients with systemic sclerosis. No significant difference in anti-p200 prevalence was found between systemic and cutaneous involvement, nevertheless, considering only positive sera, the antibody titer was higher in systemic diseases rather than in cutaneous diseases (2.6 ± 1.7 and 1.7 ± 1.9; p = 0.041). The authors think screenings for anti-Ro/SSA and anti-p200 antibodies should be included in the laboratory checklist for pregnancy.

Protein C zymogen in adults with severe sepsis or septic shock.

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 (50IU/kg bolus followed by continuous infusion of 3IU/kg/h for 72h). 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 6h after PC bolus (p<0.001), and kept on increasing during 72h of administration (p<0.001 to baseline). Sequential Organ Failure Assessment (SOFA), score of organ dysfunction, decreased from baseline to 7 days after administration of protein C from 14±2 to 7±4 (p<0.001). No adverse event drug related was noted. CONCLUSION: Protein C zymogen administration is safe and its use in septic patients should be investigated through a randomized controlled trial.

Cesarean section in a patient with non-compaction cardiomyopathy managed with ECMO.

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.

The pivotal role of echocardiography in the assessment of multivalvular heart disease.

Multivalvular heart disease (MHD) accounts for approximately 15% of the patients undergoing valve surgery in the EuroHeart Survey and for 8.6% of all valvular surgical interventions. Most clinical studies on valvular heart disease are focused on single-valve disease and very few data stress the difficulties encountered in the diagnostic assessment and clinical decision making of multiple defects, also concerning the reciprocal hemodynamic influence or the overlap of surgical indications. Many fields related to multiple valve disease are not encountered in the European Guidelines on Valvular Heart Disease (ESC) or the American College of Cardiology/American Heart Association (ACC/AHA). Increasing age and new trends of mixed population have newly aroused interest in multivalvular heart disease in the developed countries, still in need of new clinical insights. According to the high comorbidities of candidates, the appropriate diagnostic framework necessary for the correct diagnosis and best clinical outcome may still be challenging. The paper reviews multivalvular heart disease (except congenital heart disease) from aetiology and background definition to surgical outcome, with special emphasis on echocardiographic assessment and clinical interpretation.

Infections occurring in adult patients receiving mechanical circulatory support: the two-year experience of an Italian National Referral Tertiary Care Center.

OBJECTIVE: Infection during mechanical circulatory support is a frequent adverse complication. We analyzed infections occurring in this population in a national tertiary care center, and assessed the differences existing between the setting of extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs). DESIGN, SETTING, AND PARTICIPANTS: An observational study was made of patients treated with ECMO or VAD in the San Raffaele Scientific Institute (Italy) between 2009 and 2011. INTERVENTIONS: None. RESULTS: Thirty-nine percent of the 46 patients with ECMO and 69% of the 15 patients with VAD developed infection. We observed a mortality rate of 36.1% during mechanical circulatory support and of 55.7% during the global hospitalization period. Although Gram-negative infections were predominant overall, patients with ECMO were more prone to develop Candida infection (29%), and patients with VAD tended to suffer Staphylococcus infection (18%). Patients with infection had longer ECMO support (p=0.03), VAD support (p=0.01), stay in the intensive care unit (p=0.002), and hospital admission (p=0.03) than patients without infection. Infection (regression coefficient=3.99, 95% CI 0.93-7.05, p=0.02), body mass index (regression coefficient=0.46, 95% CI 0.09-0.83, p=0.02), fungal infection (regression coefficient=4.96, 95% CI 1.42-8.44, p=0.009) and obesity (regression coefficient=10.47, 95% CI 1.77-19.17, p=0.02) were predictors of the duration of ECMO support. Stepwise logistic regression analysis showed the SOFA score at the time of implant (OR=12.33, 95% CI 1.15-132.36, p=0.04) and VAD (OR=1.27, 95% CI 1.04-1.56, p=0.02) to be associated with infection. CONCLUSIONS: Infection is a major challenge during ECMO and VAD support. Each mechanical circulatory support configuration is associated with specific pathogens; fungal infections play a major role.

A new phosphorylcholine-coated polymethylpentene oxygenator for extracorporeal membrane oxygenation: a preliminary experience.

Phosphorylcholine coating has a major role in the improvement of biocompatibility, durability and antihrombogenicity of the circuit for extracorporeal membrane oxygenation (ECMO). Moreover, if heparin-induced thrombocytopenia ensues, removal of all the sources of heparin is challenging if the circuit is coated with heparin. We report our preliminary experience with the new EUROSETS A.L.ONE ECMO oxygenator (Eurosets, Medolla, MO, Italy), which is aimed at providing better biocompatibility thanks to its full coating with phosphorylcholine. We retrospectively collected data on the 16 patients supported with ECMO and with the EUROSETS A.L.ONE ECMO oxygenator at San Raffaele Hospital. Mean ECMO duration was 6 ± 4 days, and 37.5% of the patients died on ECMO. Four episodes of major bleeding and three episodes of minor bleeding were recorded. The oxygenator had an excellent performance in gas exchange and the median pressure drop was 57 (26-85) mmHg at full blood flow (2.5 L/m2/min). The EUROSETS A.L.ONE ECMO oxygenator was an excellent device in our preliminary experience. Further evaluation on a larger sample is encouraged.

Argatroban anticoagulation for heparin induced thrombocytopenia in patients with ventricular assist devices.

BACKGROUND: Patients receiving implantation of ventricular assist devices (VAD) suffer a high incidence of heparin induced thrombocytopenia (HIT); the occurrence of this condition is associated with increased complications and worse outcomes. We report our experience in the management of patients who were diagnosed with HIT either before (HITpre) or after (HITpost) implantation of VAD with argatroban, a direct thrombin inhibitor. METHODS: This retrospective analysis assessed data of VAD patients diagnosed with HIT at Deutsches Herzzentrum Berlin between November 2005 and April 2009. Argatroban dose requirements, anticoagulation efficacy and adverse events (death, thromboembolism, bleeding) were recorded. Procedural success (discharge from the hospital, heart transplantation, or recovery of the failing heart) was also assessed. RESULTS: Twenty-seven patients were identified (11 HITpre, 16 HITpost). Argatroban was effective in obtaining adequate anticoagulation with a reduced dose regimen (0.02-0.42 mcg/Kg/min starting dose; 0.02-1.5 mcg/Kg/min maintenance dose). We noted 5 thromboembolic complications (18%), 6 cases of major bleeding (22%) and 5 deaths (18%), all cause composite adverse end point occurring in 40% of patients. Procedural success was obtained in 81% of patients (92% HITpre, 69% HITpost). As compared to historical controls of patients treated with lepirudin in the period 2000-2005, results were significantly improved. CONCLUSION: Argatroban anticoagulation is feasible in patients with HIT after VAD implantation, without increasing bleeding risk. Its impact in terms of survival should be reviewed also in the light of the technological improvements of assist devices.

An unusual cause of cardiogenic shock: tricuspid regurgitation and right ventricular perforation due to vena cava filter migration.

Dislocation and migration of the inferior vena cava filter to the right heart is an uncommon but serious complication, requiring prompt diagnosis and appropriate therapy. We report the case of a seventy-year old man, who had previously undergone vena cava filter implantation and who was admitted to the Intensive Care Unit due to acute respiratory distress with the suspect of pneumonia-related sepsis. Due to the worsening of hemodynamics and the development of cardiogenic shock, the patient underwent bedside echocardiography, which on the contrary revealed dislocation of the filter and the entrapment of the device within the tricuspid valve and chordae tendineae. This evidence was confirmed also by the chest-abdominal X-ray. The patient underwent tricuspid valve surgical replacement and successfully recovered. The transthoracic and transesophageal echocardiographies performed in the intensive care unit were able to first orient the diagnostic efforts toward the correct cause.

Perioperative evaluation of primary hemostasis in patients undergoing mitral valve repair.

INTRODUCTION: No data exist on the prevalence of primary hemostatic defects and acquired von Willebrand disease in mitral valve prolapse with severe regurgitation. METHODS: Primary hemostasis was evaluated by PFA-100, von Willebrand Factor Antigen (vWF:Ag) and Ristocetin cofactor (vWF:RiCof) assays in a prospective observational trial. Sixty-five consecutive patients with mitral regurgitation (study group) or aortic stenosis (control group) who were operated for mitral valve repair or aortic valve replacement were enrolled in the study. RESULTS: There were no differences in Closure Time in the two groups at all time points. The concentration of plasma vWF: Ag was within normal limits in all patients preoperatively; after surgery, a significant increase was observed in both groups from baseline (199 +/- 144 mcg/dL vs. 295 +/-141 mcg/dL in the study group, p=0.002; 243 +/- 141 mcg/dLl vs 338 +/- 154 mcg/dL in the control group, p=0.009). The ratio of vWF:RiCof to vWF:Ag was slightly decreased preoperatively in both groups (ratio= 0.91) and showed a marked increase in the postoperative period (ratio=0.22) as, probably, new hemostatically effective large multimeric forms of vWF were released. CONCLUSIONS: Patients who present for surgery with a valvular pathology with high shear stress have some degree of primary hemostasis defect; nevertheless, the potent stimulus of surgery and the correction of the underlying disease allow quick restoration of vWF activity and normalization of PFA-100.

Bioline heparin-coated ECMO with bivalirudin anticoagulation in a patient with acute heparin-induced thrombocytopenia: the immune reaction appeared to continue unabated.

Heparin-induced thrombocytopenia (HIT) is a serious, antibody-mediated complication of heparin which significantly confers risks of thrombosis and devastating outcomes. Once diagnosed, it requires immediate cessation of heparin and therapy with an alternative anticoagulant. No data are available in the literature on the pathophysiology and clinical implications of performing prolonged extracorporeal membrane oxygenation with a heparin-coated system in a patient with acute HIT treated with bivalirudin.

Cardiac protection by volatile anesthetics in non-cardiac surgery? A meta-analysis of randomized controlled studies on clinically relevant endpoints.

INTRODUCTION: Volatile anesthetics improve post-ischemic recovery. A meta-analysis suggested that the cardioprotective properties of desflurane and sevoflurane could reduce mortality and cardiac morbidity in cardiac surgery. Recent American College of Cardiology / American Heart Association Guidelines recommended volatile anesthetic agents during non-cardiac surgery for the maintenance of general anesthesia in patients at risk for myocardial infarction but whether these cardioprotective properties exist in non-cardiac surgery settings is controversial. We therefore performed a meta-analysis of randomized studies to investigate this issue. METHODS: Two investigators independently searched PubMed. Inclusion criteria were random allocation to treatment, comparison of a total intravenous anesthesia regimen vs an anesthesia plan including desflurane or sevoflurane, performed on adult patients undergoing non-cardiac surgery. The primary endpoints were the incidence of perioperative myocardial infarction and death. RESULTS: A total of 6219 patients from 79 randomized trials were identified. No myocardial infarctions or deaths were reported in any of the studies we examined. CONCLUSIONS: This meta-analysis highlights a weakness in the literature and the results can be used to design future studies: the cardioprotective properties of desflurane and sevoflurane have never been studied in noncardiac surgery. No randomized study, among those which compared desflurane or sevoflurane to intravenous anesthetics, has addressed major outcomes such as myocardial infarction or mortality. Large, multicentre, randomized clinical trials including patients undergoing high-risk non-cardiac surgery and reporting clinically relevant outcomes such as myocardial infarction and mortality are needed.

Tricks and pitfalls regarding the hemodynamics of patients undergoing non-transplantation surgery for heart failure.

This paper aims to address the mechanisms responsible for poor perioperative cardiac performance, analyzing the pathophysiology of heart failure and the main hemodynamic parameters (contractility, preload, afterload, systemic vascular resistance, and pulmonary artery pressure) used in diagnosing patients and assessing their response to therapy. It will also discuss potential therapeutic approaches to cardiac surgery patients. With advances in monitoring and life support, our critically ill patients often become trapped in a sheer, impenetrable net of wires and tubes. Unfortunately, technology can seriously compromise patient safety if the data obtained is misinterpreted. While advanced technology has become a part of daily life in the Intensive Care Unit (ICU), there remains a crucial step that cannot be performed by computers: the link from sensors to patient status. We should always remember to look past the cables and monitors and to look at the patient. This would not only reduce the number of ever-present wires, but would also help improve patient outcome. The field of non-transplant cardiac surgery for heart failure is extremely challenging for the cardiac anesthesiologist. The high incidence of postoperative low cardiac output syndrome should mandate aggressive monitoring and therapy. Nevertheless, a comprehensive understanding of the pathophysiology of heart failure and the hemodynamic implications of surgical therapies is mandatory for optimal patient management. In particular, the presence of systolic dysfunction should not automatically rule out other potential causes of poor global cardiac performance.