From seed to bread: variation in quality in a set of old durum wheat cultivars.

BACKGROUND: Old durum wheat varieties are being appreciated again because of their interesting genetic diversity and low fertilizer needs. RESULTS: The agronomic and bread-making performances of 14 old Italian durum wheat varieties grown under two low nitrogen (N) inputs (46 and 86 kg ha-1 ) were determined and the relationships among grain, semolina, dough and bread quality parameters were established. The old varieties yielded similarly to the check modern variety Svevo under both N levels. Increasing N fertilization from 46 to 86 kg ha-1 did not increase grain yield or the mg of N in the grain, although grain protein percentage increased as a result of a decrease in grain weight and an increase in gliadin content. Despite the resulting decrease in the gluten index, dough and bread quality improved at the higher N rate, highlighting the influential role of protein percentage and gliadin in bread quality. The genotypic variation in grain protein percentage among old varieties was more strongly associated with glutenin than with gliadin content. Variation in the gluten index was high (4-54); indeed, it was the most variable semolina parameter, and proved to contribute the most to variation in bread quality. This variation was independent of the glutenin alleles (HMW 20, 20*, 7, 13+16, 6+8) and was linked to the quality of the grain in terms of grain weight and the associated mg of N per grain. Remarkably, two old varieties, namely Calabria and Cappelli, were able to produce both a good yield and high-quality bread. CONCLUSION: Old Italian durum wheats continue to boast significant biodiversity and are worth exploring in low-input production systems. © 2019 Society of Chemical Industry.

Climate change impact and adaptation for wheat protein.

Wheat grain protein concentration is an important determinant of wheat quality for human nutrition that is often overlooked in efforts to improve crop production. We tested and applied a 32-multi-model ensemble to simulate global wheat yield and quality in a changing climate. Potential benefits of elevated atmospheric CO2 concentration by 2050 on global wheat grain and protein yield are likely to be negated by impacts from rising temperature and changes in rainfall, but with considerable disparities between regions. Grain and protein yields are expected to be lower and more variable in most low-rainfall regions, with nitrogen availability limiting growth stimulus from elevated CO2 . Introducing genotypes adapted to warmer temperatures (and also considering changes in CO2 and rainfall) could boost global wheat yield by 7% and protein yield by 2%, but grain protein concentration would be reduced by -1.1 percentage points, representing a relative change of -8.6%. Climate change adaptations that benefit grain yield are not always positive for grain quality, putting additional pressure on global wheat production.

From ancient to old and modern durum wheat varieties: interaction among cultivar traits, management, and technological quality.

Following the boom in durum wheat breeding, ancient wheat disappeared from the human diet and old durum wheat varieties were replaced by what is believed to be their better versions: higher yielding modern varieties grown in high-input systems. Breeders have worked intensely ever since to improve the quality of durum wheat traits - mainly gluten subunit alleles - to obtain superior technological quality in the main durum wheat end products (first pasta and then bread) but conflicts about predicting their quality still exist. This is because quality is neither governed by one trait alone nor conditioned by a single controllable factor. This review discusses the evolution of wheat varieties from ancient to old, and then modern durum wheat in terms of agronomy, genetics, technological, and end-product qualities. Environmental effects will not be discussed. Moving from ancient to modern durum wheat varieties, grain yield increased, grain protein concentration decreased, and gluten strength and dough toughness improved, ameliorating the quality of pasta but decreasing the durum wheat versatility. © 2018 Society of Chemical Industry.

Clinical Performance and Safety of Closed-Loop Systems: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Automated systems can improve the stability of controlled variables and reduce the workload in clinical practice without increasing the risks to patients. We conducted this review and meta-analysis to assess the clinical performance of closed-loop systems compared with manual control. Our primary outcome was the accuracy of closed-loop systems in comparison with manual control to maintain a given variable in a desired target range. The occurrence of overshoot and undershoot episodes was the secondary outcome. We retrieved randomized controlled trials on accuracy and safety of closed-loop systems versus manual control. Our primary outcome was the percentage of time during which the system was able to maintain a given variable (eg, bispectral index or oxygen saturation) in a desired range or the proportion of the target measurements that was within the required range. Our secondary outcome was the percentage of time or the number of episodes that the controlled variable was above or below the target range. The standardized mean difference and 95% confidence interval (CI) were calculated for continuous outcomes, whereas the odds ratio and 95% CI were estimated for dichotomous outcomes. Thirty-six trials were included. Compared with manual control, automated systems allowed better maintenance of the controlled variable in the anesthesia drug delivery setting (95% CI, 11.7%-23.1%; percentage of time, P < 0.0001, number of studies: n = 15), in patients with diabetes mellitus (95% CI, 11.5%-30.9%; percentage of time, P = 0.001, n = 8), and in patients mechanically ventilated (95% CI, 1.5%-23.1%; percentage of time, P = 0.03, n = 8). Heterogeneity among the studies was high (>75%). We observed a significant reduction of episodes of overshooting and undershooting when closed-loop systems were used. The use of automated systems can result in better control of a given target within a selected range. There was a decrease of overshooting or undershooting of a given target with closed-loop systems.

Lung Ultrasound Pattern Is Normal during the Last Gestational Weeks: An Observational Pilot Study.

BACKGROUND/AIMS: The normal lung ultrasound (US) pattern during a regular pregnancy has not been evaluated extensively in the current literature. Pregnancy-related changes in the respiratory tract affect maternal predisposition to several respiratory complications; consequently, it is important to differentiate between a physiologic pattern during pregnancy and a pathologic lung pattern, due to respiratory failure. The goal of our study was to assess the normal US lung pattern in women without known comorbidities in the last weeks of pregnancy. METHODS: We conducted a prospective cross-sectional observational pilot study. Chest wall was examined in 8 areas, 1 scan for each area with women in supine position. RESULTS: One hundred fifty parturients were enrolled during the 36th-38th gestational weeks. None of the participants showed pleural effusion, pneumothorax or lung consolidation. None presented an interstitial syndrome US pattern. One hundred thirteen participants out of 150 (75%) showed A-lines in all the regions. The remaining 25% showed 1 or 2 B-lines in at least 3 regions. Only 2 participants showed 2 positive regions also. CONCLUSIONS: We found that, in the majority of the women examined, the lung US pattern matches the physiological pattern in non-pregnant patients. Lung US assessment is a feasible and a helpful diagnostic tool during pregnancy.

A novel system for automated propofol sedation: hybrid sedation system (HSS).

Closed-loop systems for propofol have been demonstrated to be safe and reliable for general anesthesia. However, no study has been conducted using a closed-loop system specifically designed for sedation in patients under spinal anesthesia. We developed an automatic anesthesia sedation system that allows for closed-loop delivery of propofol for sedation integrating a decision support system, called the hybrid sedation system (HSS). The objective of this study is to compare this system with standard practice. One hundred fifty patients were enrolled and randomly assigned to two groups: HSS-Group (N = 75), in which propofol was administered using a closed-loop system; Control Group (N = 75), in which propofol was delivered manually. The clinical performance of the propofol sedation control is defined as efficacy to maintain bispectral index (BIS) near 65. The clinical control was called 'Excellent', 'Good', 'Poor' and 'Inadequate' with BIS values within 10 %, from 11 to 20 %, 21 to 30 %, or greater than 30 % of the BIS target of 65, respectively. The controller performance was evaluated using Varvel's parameters. Data are presented as mean ± standard deviation, groups were compared using t test or Chi square test, P < 0.05. Clinical performance of sedation showed 'Excellent' control in the HSS-group for a significantly longer period of time (49 vs. 26 % in the control group, P < 0.0001). 'Poor' and 'Inadequate' sedation was significantly shorter in the HSS Group compared to the Control Group (11 and 10 % vs. 20 and 18 %, respectively, P < 0.0001). The novel, closed-loop system for propofol sedation showed better maintenance of the target BIS value compared to manual administration.

Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials.

PURPOSE: The transversus abdominal plane (TAP) block has been described as an effective pain control technique after abdominal surgery. We performed a systematic review and meta-analysis of randomized-controlled trials (RCTs) to account for the increasing number of TAP block studies appearing in the literature. The primary outcome we examined was the effect of TAP block on the postoperative pain score at six, 12, and 24 hr. The secondary outcome was 24-hr morphine consumption. SOURCE: We searched the United States National Library of Medicine database, the Excerpta Medica database, and the Cochrane Central Register of Controlled Clinical Studies and identified RCTs focusing on the analgesic efficacy of TAP block compared with a control group [i.e., placebo, epidural analgesia, intrathecal morphine (ITM), and ilioinguinal nerve block after abdominal surgery]. Meta-analyses were performed on postoperative pain scores at rest at six, 12, and 24 hr (visual analogue scale, 0-10) and on 24-hr opioid consumption. PRINCIPAL FINDINGS: In the 51 trials identified, compared with placebo, TAP block reduced the VAS for pain at six hours by 1.4 (95% confidence interval [CI], -1.9 to -0.8; P < 0.001), at 12 hr by 2.0 (95% CI, -2.7 to -1.4; P < 0.001), and at 24 hr by 1.2 (95% CI, -1.6 to -0.8; P < 0.001). Similarly, compared with placebo, TAP block reduced morphine consumption at 24 hr after surgery (mean difference, -14.7 mg; 95% CI, -18.4 to -11.0; P < 0.001). We observed this reduction in pain scores and morphine consumption in the TAP block group after gynecological surgery, appendectomy, inguinal surgery, bariatric surgery, and urological surgery. Nevertheless, separate analysis of the studies comparing ITM with TAP block revealed that ITM seemed to have a greater analgesic efficacy. CONCLUSIONS: The TAP block can play an important role in the management of pain after abdominal surgery by reducing both pain scores and 24-hr morphine consumption. It may have particular utility when neuraxial techniques or opioids are contraindicated.

RéSUMé: OBJECTIF: Le bloc dans le plan du muscle transverse de l'abdomen (ou TAP bloc) a été décrit comme une technique efficace de contrôle de la douleur après une chirurgie abdominale. Nous avons réalisé une revue systématique et une méta-analyse des études randomisées contrôlées (ERC) pour faire un état des lieux du nombre croissant d'études sur le TAP bloc qui s'ajoutent à la littérature. Le critère d'évaluation principal était l'effet d'un TAP bloc sur les scores de douleur postopératoire à six, 12 et 24 h. Le critère d'évaluation secondaire était la consommation de morphine à 24 h. SOURCE: Nous avons effectué des recherches dans la base de données de la Bibliothèque nationale américaine de médecine (United States National Library of Medicine) ainsi que dans le Registre central Cochrane des études cliniques contrôlées (Cochrane Central Register of Controlled Clinical Studies). Nous avons ensuite identifié les ERC se concentrant sur l'efficacité analgésique des TAP blocs par rapport à un groupe témoin [c.-à-d. placebo, analgésie péridurale, morphine intrathécale (MIT) et bloc nerveux ilio-inguinal] après une chirurgie abdominale. Des méta-analyses ont été réalisées en examinant les scores de douleur postopératoire au repos à six, 12 et 24 h (échelle visuelle analogique [EVA], 0-10) et la consommation d'opioïdes sur une période de 24 h. CONSTATATIONS PRINCIPALES: Parmi les 51 études identifiées, par rapport à un placebo, le TAP bloc a réduit le score de douleur de 1,4 sur l'EVA après six heures (intervalle de confiance [IC] 95 %, −1,9 à −0,8; P < 0,001), de 2,0 après 12 h (IC 95 %, −2,7 à −1,4; P < 0,001) et de 1,2 après 24 h (IC 95 %, −1,6 à −0,8; P < 0,001). De la même façon, par rapport au placebo, le TAP bloc a réduit la consommation de morphine à 24 h après la chirurgie (différence moyenne, −14,7 mg; IC 95 %, −18,4 à −11,0; P < 0,001). Nous avons observé cette réduction en matière de scores de douleur et de consommation de morphine dans le groupe TAP bloc après des chirurgies gynécologiques, des appendicectomies, des chirurgies inguinales, des chirurgies bariatriques et des chirurgies urologiques. Toutefois, une analyse séparée des études comparant la MIT au TAP bloc a révélé que la MIT semblait avoir une efficacité analgésique plus prononcée. CONCLUSION: Le TAP bloc peut jouer un rôle important dans la prise en charge de la douleur après une chirurgie abdominale en réduisant les scores de douleur et la consommation de morphine à 24 h. Il pourrait être particulièrement utile lorsque l'utilisation de techniques neuraxiales ou les opioïdes sont contre-indiqués.

Genetic variation for the duration of pre-anthesis development in durum wheat and its interaction with vernalization treatment and photoperiod.

A recombinant inbred durum wheat population was grown under three contrasting regimes: long days following vernalization (LDV), long days without vernalization (LD), and short days following vernalization (SDV). The length of several pre-anthesis stages and the number of leaves and the phyllochron were measured. Different groups of genes were involved in determining the phenology in the three treatments, as demonstrated by a quantitative trait locus (QTL) analysis. The length of the period required to reach the terminal spikelet stage was correlated with the time to anthesis only in the case of LDV- and LD-grown plants where the timing of anthesis depended on the final leaf number. However, for SDV-grown plants, anthesis date was more dependent on the length of the period between the terminal spikelet stage and anthesis and was independent of leaf number. The involvement of the phyllochron in determining the duration of pre-anthesis development was also treatment-dependent. QTL mapping of the various flowering time associated traits uncovered some novel loci (such as those associated with the phyllochron), in addition to confirming the presence of several well-established loci.

Global needs for nitrogen fertilizer to improve wheat yield under climate change.

Increasing global food demand will require more food production1 without further exceeding the planetary boundaries2 while simultaneously adapting to climate change3. We used an ensemble of wheat simulation models with improved sink and source traits from the highest-yielding wheat genotypes4 to quantify potential yield gains and associated nitrogen requirements. This was explored for current and climate change scenarios across representative sites of major world wheat producing regions. The improved sink and source traits increased yield by 16% with current nitrogen fertilizer applications under both current climate and mid-century climate change scenarios. To achieve the full yield potential-a 52% increase in global average yield under a mid-century high warming climate scenario (RCP8.5), fertilizer use would need to increase fourfold over current use, which would unavoidably lead to higher environmental impacts from wheat production. Our results show the need to improve soil nitrogen availability and nitrogen use efficiency, along with yield potential.

Clipping Effect on the Grain Nitrogen and Protein Fractions of Ancient and Old Wheats Grown in a Mediterranean Environment.

This study is the first to assess the effects of clipping, cultivar, season, and their interactions on the protein composition of six old and ancient wheat cultivars (n = 6). For this, nitrogen content, the proportion of wheat protein fractions, and the molecular weight distribution of the extractable and unextractable glutenin polymers were investigated as a function of cultivar and clipping in two consecutive seasons. The relationships between genotypic variation in grain nitrogen and protein fraction content under clipping and non-clipping conditions were also assessed. Clipping delayed and shortened the grain filling period of all of the cultivars. The protein composition of some cultivars behaved differently to clipping due to differences in the environmental conditions of S1 (exceptional dry season) and S2 (rainy season). In S1, clipping decreased the ratio of gliadins over glutenins (GLI/GLU) (<1) of Cappelli and Giovanni Paolo, while in S2, clipping improved the GLI/GLU of Giovanni Paolo, Monlis, and Norberto. The unextractable polymeric proteins were not affected by clipping. Khorasan was shown to be indifferent to clipping in S1 and S2. These results suggest that it is possible to have ancient/old wheats suitable for a dual-purpose system, in different climatic conditions, while maintaining good grain quality traits. The increased market demand for ancient and old wheats presents an economic opportunity for farmers who adopt the dual-purpose technique to cultivate these resilient crops again and increase their profit margins and revenues.

[Lung ultrasound imaging of H1N1 influenza]. / Imaging polmonare dell'influenza H1N1.

We describe the case of a 8 year-old child with acute respiratory distress syndrome (ARDS) during H1N1 swine flu. Lung ultrasound performed at the time of admission showed a typical ARDS ultrasound pattern, with multiple sonographic signs of interstitial oedema (also known as B-lines or ultrasound lung comets), and diffuse bilateral sub-pleural lung consolidations. After five days of anti-viral therapy, lung ultrasound showed a reduction of the dimension of consolidations, not clearly visible at chest X-ray, helping in the management of the patient.

Antioxidant and neuroprotective properties of blueberry polyphenols: a critical review.

OBJECTIVE: The aim of this work was to highlight the effects and the possible mechanisms of the action of blueberry polyphenols on the central nervous system (CNS). METHODS: An analysis was carried out, in a temporal order, of the most important literature about this topic and the results have been correlated with the beneficial and protective effects, mainly concerning the CNS. DISCUSSION: Over the last 10 years an increasing scientific interest has developed about polyphenols, which are very abundant in blueberries, as they have been seen to produce favourable effects related to neuroprotection and linked to a possible decrease of age-related cognitive and motor decline, as shown by the improvement of such functions in animal models with a supplemented diet. Such effects could not only be explained through a purely antioxidant action but also through more complex mechanisms related to inflammation, genic expression, and regulation of cell survival. CONCLUSIONS: Despite the wealth of data from animal studies, there is a relative lack of data concerning human beings, even if some positive results are beginning to emerge. Therefore, blueberry polyphenols could become useful pharmacological agents for various conditions including neurological diseases, but further studies are still necessary to attain this objective.

RIFLE-based data collection/management system applied to a prospective cohort multicenter Italian study on the epidemiology of acute kidney injury in the intensive care unit.

The epidemiology of acute kidney injury (AKI) has been difficult to explore in the past, due to different definitions across various studies. Nevertheless, this is a very important topic today in light of the high morbidity and mortality of critically ill patients presenting renal dysfunction during their stay in the intensive care unit (ICU). The case mix has changed over the years, and AKI is a common problem in critically ill patients often requiring renal replacement therapy (RRT). The RIFLE and AKIN initiatives have provided a unifying definition for AKI, making possible large retrospective studies in different countries. The present study aims at validating a unified web-based data collection and data management tool based on the most recent AKI definition/classification system. The interactive database is designed to elucidate the epidemiology of AKI in a critically ill population. As a test, we performed a prospective observational multicenter study designed to prospectively evaluate all incident admissions in ten ICUs in Italy and the relevant epidemiology of AKI. Thus, a simple user-friendly web-based data collection tool was created with the scope to serve for this study and to facilitate future multicenter collaborative efforts. We enrolled 601 consecutive incident patients into the study; 25 patients with end-stage renal disease were excluded, leaving 576 patients for analysis. The median age was 66 (IQR 53-76) years, 59.4% were male, while median Simplified Acute Physiology Score II and Acute Physiology and Chronic Health Evaluation II scores were 43 (IQR 35-54) and 18 (IQR 13-24), respectively. The most common diagnostic categories for ICU admission were: respiratory (27.4%), followed by neurologic (17%), trauma (14.4%), and cardiovascular (12.1%). Crude ICU and hospital mortality were 21.7% and median ICU length of stay was 5 (IQR 3-14) days. Of 576 patients, 246 patients (42.7%) had AKI within 24 h of ICU admission, while 133 developed new AKI later during their ICU stay. RIFLE-initial class was Risk in 205 patients (54.1%), Injury in 99 (26.1%) and Failure in 75 (19.8%). Progression of AKI to a worse RIFLE class was seen in 114 patients (30.8% of AKI patients). AKI patients were older, with higher frequency of common risk factors. 116 AKI patients (30.6%) fulfilled criteria for sepsis during their ICU stay, compared to 33 (16.7%) of non-AKI patients (p < 0.001). 48 patients (8.3%) were treated with RRT in the ICU. Patients were started on RRT a median of 2 (IQR 0-6) days after ICU admission. AKI patients were started on RRT a median of 1 (IQR 0-4) day after fulfilling criteria for AKI. Median duration of RRT was 5 (IQR 2-10) days. AKI patients had a higher crude ICU mortality (28.8 vs. 8.1%, non-AKI; p < 0.001) and longer ICU length of stay (median 7 vs. 3 days, non-AKI; p < 0.001). Crude ICU mortality and ICU length of stay increased with greater severity of AKI. 225 (59.4% of AKI patients) had complete recovery of renal function, with a serum creatinine at time of ICU discharge which was ≤120% of baseline; an additional 51 AKI patients (13.5%) had partial renal recovery, while 103 (27.2%) had not recovered renal function at the time of death or ICU discharge. The study supports the use of RIFLE as an optimal classification system to stage AKI severity. AKI is indeed a deadly complication for ICU patients, where the level of severity is correlated with mortality and length of stay. The tool developed for data collection was user-friendly and easy to implement. Some of its features, including a RIFLE class alert system, may help the treating physician to systematically collect AKI data in the ICU and possibly may guide specific decisions on the institution of RRT.

Environmental conditions affect semolina quality in durum wheat (Triticum turgidum ssp. durum L.) cultivars with different gluten strength and gluten protein composition.

BACKGROUND: Sowing time may impact semolina and pasta cooking quality by changing the environmental conditions during grain filling. The effect of an optimum and a delayed sowing time on semolina quality was studied by comparing six cultivars under irrigation, in order to isolate temperature from drought effects. RESULTS: Protein content was higher in the old cultivars and in the late sowings, according to the number of days with temperature between 30 and 40 °C during ripening. Gluten index increased as temperature rose to a threshold of about 30 °C, then decreased under higher temperatures. Mixograph parameters were less sensitive to high temperatures. Gliadin:glutenin correlated with gluten strength. Spaghetti firmness and protein content were positively correlated independently of sowing date. Cultivars Trinakria and Cappelli had the highest spaghetti firmness (900 and 828 g). CONCLUSIONS: Late sowings may represent a way of increasing pasta cooking quality whenever they place grain filling under thermal conditions able to increase protein percentage, although the accompanying decrease in yield may represent a drawback in environments prone to drought stress during ripening. The lower protein percentages of modern durum wheat cultivars under conventional sowing times results in a lower pasta cooking quality despite higher gluten strength.

Is the Technological Quality of Old Durum Wheat Cultivars Superior to That of Modern Ones When Exposed to Moderately High Temperatures during Grain Filling?

The growing interest in old durum wheat cultivars, due to enhanced consumer attention on healthy, traditional products and low-input agricultural systems, partly relies on their different quality characteristics compared to modern cultivars. Nine Italian durum wheat cultivars from different breeding periods were compared in two late-sown (January) field trials in order to subject their grain filling period to high temperatures similar to those expected in the future. Late sowing moved anthesis forward by about 10 days and increased the mean temperature during grain filling by 1.3 °C compared to that obtained when using the common sowing period of November-December. In these conditions, old cultivars were on average less productive than modern ones (2.36 vs. 3.54 tons ha-1, respectively), had a higher protein percentage (13.8% vs. 11.1%), a lower gluten index (24.3% vs. 56.3%), and a lower alveographic W (baking strength) (64 vs. 100 J 10-4). The differences were partly associated to variations in the gliadins:glutenins ratio. It depended on the genotype whether the grain and semolina protein percentage and gluten strength compensated one another in terms of alveographic indices to give the dough a strength similar to that of the modern cultivars in the range of moderately high temperatures, which resulted from delayed sowing. Further studies aimed at exploring the genetic variability of quality traits in the large genetic pool represented by the several Italian old and intermediate durum wheat cultivars still available are therefore advisable.

N Partitioning between Gluten Fractions in a Set of Italian Durum Wheat Cultivars: Role of the Grain N Content.

Grain protein content constitutes a key quality trait for durum wheat end-products and may also impact grain protein composition. A total of sixteen durum wheat cultivars were analyzed in a field trial during two seasons at two nitrogen (N) levels to evaluate whether and to what extent the variation in total grain N was associated with variation in the quantity of the various protein fractions and grain quality parameters. Genotypic variation in grain N content correlated with the variation in the content of all three protein fractions, although the strength of the correlation with gliadin and albumin-globulin was higher than that with glutenins. Genotypic variation in gliadin and glutenin content was more tightly correlated with the variation in the sulfur (S)-rich protein groups than with the S-poor protein groups and subunits. The variation in the percentage of unextractable polymeric proteins (UPP%) among genotypes was independent of their glutenin allelic composition. The significant genotypic differences in UPP% and in the ratios between protein groups and subunits were not influenced by the corresponding variation in grain N content. The final grain N content can only account for part of the variation in quality parameters and in the partitioning of total grain N between protein fractions since genotypic differences other than grain N content also contribute to these variations.

Volatile anesthetics reduce mortality in cardiac surgery.

OBJECTIVES: A recent meta-analysis suggested that volatile anesthetics reduce postoperative mortality after cardiac surgery. Nonetheless, whether volatile anesthetics improve the outcome of cardiac surgical patients is still a matter of debate. The authors investigated whether the use of volatile anesthetics reduces mortality in cardiac surgery. DESIGN, SETTING, AND INTERVENTIONS: A longitudinal study of 34,310 coronary artery bypass graft interventions performed in Italy estimated the risk-adjusted mortality ratio for each center. A survey was conducted among these centers to investigate whether the use of volatile anesthetics showed a correlation with mortality. MEASUREMENTS AND MAIN RESULTS: All 64 eligible centers provided the required data. The median unadjusted 30-day mortality among participating centers was 2.2% (0.3-8.8), whereas the median risk-adjusted 30-day mortality was 1.8% (0.1-7.2). Risk-adjusted analysis showed that the use of volatile anesthetics was associated with a significantly lower rate of risk-adjusted 30-day mortality (beta = -1.172 [-2.259, -0.085], R(2) = 0.070, p = 0.035). Dichotomization into centers using volatile anesthetics in at least 25% of their cases or in less than 25% yielded even more statistically significant results (p = 0.003). Furthermore, a longer use of volatile anesthetics was associated with a significantly lower death rate (p = 0.022); and exploring the impact of the specific volatile anesthetic agent, the use of isoflurane was associated with significant reductions in risk-adjusted mortality rates (p = 0.039). CONCLUSIONS: This survey among 64 Italian centers shows that risk-adjusted mortality may be reduced by the use of volatile agents in patients undergoing coronary artery bypass graft surgery.

Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial.

CONTEXT: Polymyxin B fiber column is a medical device designed to reduce blood endotoxin levels in sepsis. Gram-negative-induced abdominal sepsis is likely associated with high circulating endotoxin. Reducing circulating endotoxin levels with polymyxin B hemoperfusion could potentially improve patient clinical outcomes. OBJECTIVE: To determine whether polymyxin B hemoperfusion added to conventional medical therapy improves clinical outcomes (mean arterial pressure [MAP], vasopressor requirement, oxygenation, organ dysfunction) and mortality compared with conventional therapy alone. DESIGN, SETTING, AND PATIENTS: A prospective, multicenter, randomized controlled trial (Early Use of Polymyxin B Hemoperfusion in Abdominal Sepsis [EUPHAS]) conducted at 10 Italian tertiary care intensive care units between December 2004 and December 2007. Sixty-four patients were enrolled with severe sepsis or septic shock who underwent emergency surgery for intra-abdominal infection. INTERVENTION: Patients were randomized to either conventional therapy (n=30) or conventional therapy plus 2 sessions of polymyxin B hemoperfusion (n=34). MAIN OUTCOME MEASURES: Primary outcome was change in MAP and vasopressor requirement, and secondary outcomes were PaO(2)/FIO(2) (fraction of inspired oxygen) ratio, change in organ dysfunction measured using Sequential Organ Failure Assessment (SOFA) scores, and 28-day mortality. RESULTS: MAP increased (76 to 84 mm Hg; P = .001) and vasopressor requirement decreased (inotropic score, 29.9 to 6.8; P < .001) at 72 hours in the polymyxin B group but not in the conventional therapy group (MAP, 74 to 77 mm Hg; P = .37; inotropic score, 28.6 to 22.4; P = .14). The PaO(2)/FIO(2) ratio increased slightly (235 to 264; P = .049) in the polymyxin B group but not in the conventional therapy group (217 to 228; P = .79). SOFA scores improved in the polymyxin B group but not in the conventional therapy group (change in SOFA, -3.4 vs -0.1; P < .001), and 28-day mortality was 32% (11/34 patients) in the polymyxin B group and 53% (16/30 patients) in the conventional therapy group (unadjusted hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.20-0.94; adjusted HR, 0.36; 95% CI, 0.16-0.80). CONCLUSION: In this preliminary study, polymyxin B hemoperfusion added to conventional therapy significantly improved hemodynamics and organ dysfunction and reduced 28-day mortality in a targeted population with severe sepsis and/or septic shock from intra-abdominal gram-negative infections. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00629382.

Continuous hemodynamic monitoring during laparoscopic gastric bypass in superobese patients by pressure recording analytical method.

BACKGROUND: Morbid obesity, compromising cardiovascular and respiratory function, may increase the risk of anesthesia and was initially considered a contraindication to laparoscopy. The aim of this study was to investigate hemodynamic effects induced by pneumoperitoneum in superobese patients, assessed by arterial pulse contour method. METHODS: We prospectively studied 10 obese patients (BMI 53 +/- 9 kg/m(2)), scheduled for laparoscopic gastric bypass. After anesthesia induction, patients were intubated and mechanically ventilated. A radial artery was cannulated to obtain hemodynamic data implemented by means of a new pulse contour analysis method-the pressure recording analytical method (PRAM). Data were recorded after anesthesia induction (Tbas), at peritoneal insufflation (T0), at 1, 3, 5, 10, 30, and 60 min after pneumoperitoneum induction (T1, T3, T5, T10, T15, T30, T60), at abdominal desufflation (Tdef) and 5 min after desufflation (T5def). RESULTS: MAP increased after pneumoperitoneum, returning to its baseline after deflation (79 +/- 7 Tbas, 81 +/- 6 mmHg T5def). HR remained unchanged. Systemic vascular resistance index (SVRI) increased after pneumoperitoneum induction and progressively returned to baseline (3,903 +/- 330 Tbas, 4,596 +/- 148 T1, and 3,786 +/- 202 dyn s m(2) cm(-5) T5def). Stroke volume index (SVI) and cardiac index (CI) increased after pneumoperitoneum and remained elevated. Stroke volume variation (SVV) decreased after insufflation remaining lower than the basal value (28 +/- 4% Tbas, 15 +/- 5% T5des). Cardiac Cycle Efficiency (CCE) transient decreased after insufflation and subsequently increased (0.029 +/- 0.146 Tbas, 0.008 +/- 0.178 T5def). Aortic dP/dt max increased after insufflation, returning to baseline only after desufflation (0.68 +/- 0.07 Tbas, 0.94 +/- 0.08 T30 and 0.86 +/- 0.06 mmHg s(-1) T5def). CONCLUSION: As assessed by PRAM, this study showed no deterioration in hemodynamic indices or ventricular performance during laparoscopic gastric bypass.

Xenon induces transcription of ADNP in neonatal rat brain.

Xenon and other inhalational agents induce cell and organ protection through different and only partially elucidated molecular mechanisms. Anesthesia induced or pharmacologic preconditioning is a recognized mechanism of cell protection. In this study we explored the gene transcription of activity-dependent neuroprotective protein (ADNP) in neonatal rat brain as consequence to xenon exposure, comparing the noble gas to nitrogen. Seven-day-old Sprague Dawley rats were exposed for 120 min to 75% xenon and 25% oxygen or control condition consisting of 75% nitrogen and 25% oxygen (Air). ADNP was found to be differentially expressed by SSH, validated by Relative Real-Time PCR (RT-PCR) and confirmed by western blot and immunohistochemistry. The differential expression of ADNP in the rat neonatal brain may account for the preconditioning and neuroprotective effects exerted by gas xenon.