Quantum state features of the FEL radiation from the occupation number statistics.

The coherence of free-electron laser (FEL) radiation has so far been accessed mainly through first and second order correlation functions. Instead, we propose to reconstruct the energy state occupation number distribution of FEL radiation, avoiding the photo-counting drawbacks with high intensities, by means of maximum likelihood techniques based on the statistics of no-click events. Though the ultimate goal regards the FEL radiation statistical features, the interest of the proposal also resides in its applicability to any process of harmonic generation from a coherent light pulse, ushering in the study of the preservation of quantum features in general non-linear optical processes.

Mortality Predictors After Liver Transplant in the Intensive Care Unit.

BACKGROUND: The goal of this study was to evaluate the predictive factors of mortality in patients after liver transplantation in an intensive care unit from the University Hospital. METHODS: This observational study was conducted by using a database analysis of University Hospital. The sample consisted of patients after liver transplantation registered in the database. The study variables of Sequential Organ Failure Assessment score, Acute Physiology and Chronic Health Disease Classification II (APACHE II), Model for End-Stage Liver Disease, and Child-Pugh scores, and the days of hospitalization in intensive care unit, mechanical ventilation time, and reintubation rate, were correlated. Statistical analysis was performed by using the χ2 test or Fisher exact test, the Mann-Whitney test, and logistic regression analysis. RESULTS: Fifty-eight individuals were analyzed. In the death group, the days of hospitalization in the intensive care unit were within 12 ± 14 days, the time of mechanical ventilation was 180 ± 148 hours, the APACHE II value was 17.6 ± 7.3, the Sequential Organ Failure Assessment score was 8.2 ± 2.7, and reintubation was 40%. In the multivariate regression, the predictive indexes of mortality were the mortality given by APACHE II (odds ratio, 1.1; CI, 1.03-1.17; P = .004), mechanical ventilation time (odds ratio, 1.02; CI, 1.01-1.04; P = .001), and reintubation (odds ratio, 9.06; CI, 1.83-44.9; P = .007). An increase of 1 unit in APACHE II mortality increases the risk of death by 10.2%, and each hour of mechanical ventilation increases the risk of death by 2.6%. CONCLUSIONS: The time of mechanical ventilation, orotracheal reintubation, and the mortality given by APACHE II were the variables that best predicted death in this study.

Model for End-Stage Liver Disease Score Before Hepatic Transplantation and Root Mean Square of the Diaphragmatic Domes Affect Postoperative Extubation Time.

INTRODUCTION: The liver transplantation procedure, in addition to its prolonged surgical time, also predisposes to complications such as changes in respiratory mechanics, lung volumes, and gas exchange. OBJECTIVE: This study aims to verify if clinical factors related to the recipient, namely immediate pretransplant Model for End-Stage Liver Disease (MELD) score, surgical time, and root square metric (RMS) of the diaphragmatic domes, affect the extubation time after liver transplantation. METHOD: A prospective study, with a sample collected for convenience, gathered age (years), sex (male or female), MELD score immediately prior to transplantation (without the addition of special situation scores), and surgical time and time for extubation (in minutes). The latter were obtained from the physiotherapy team records, and surface electromyography was performed within 30 minutes after elective extubation, by a single researcher, with supplemental oxygen support, maintaining SpO2 ≥ 95% and following protocol of positioning and acquisition of electromyographic signals based on the study of Oliveira et al (2012). RESULTS: For the 21 patients studied, the RMS of the left dome showed a moderate-intensity correlation (-0.56) with the time of extubation, and linear multiple regression model the left dome (P = .013) and preoperative MELD score (P = .048) showed significant correlation with extubation time. CONCLUSION: The preoperative MELD score and the RMS values of the left dome significantly correlate with the time for patient extubation after liver transplantation, showing the effect of previously acquired muscle weakness and preoperative MELD score on postoperative outcome.

Diaphragm Muscle Surface Electromyography in Patients Submitted to Liver Transplant and Eligible for Extubation.

INTRODUCTION: Liver disease induces many organic and metabolic changes, leading to malnutrition and weight and muscular function loss. Surface electromyography is an easily applicable, noninvasive study, through which the magnitudes of the peaks on the charts depict voluntary muscle activity. AIM: To evaluate the diaphragmatic surface electromyography of postoperative liver transplantation subjects. METHODS: Subjects were patients who underwent liver transplantation and extubation in the Clinical Hospital of State University of Campinas. Electromyography data were collected with support pressure of ≤10 cm H2O, Glasgow Coma Scale = 11, and minimum dosages of vasoactive drugs, and data were collected again 30 minutes after extubation. Signal collection was performed with sEMG System Brazil SAS1000V3 electromyograph and electrode stickers. Statistical analysis was performed using R software. RESULTS: The average time of surgery was 345.36 ± 125.62 minutes. Time from spontaneous mode until extubation was 417.14 ± 362.97 minutes. The RMS (root mean square) values of the right and left domes in spontaneous mode with minimal ventilation parameters were 26.68 ± 10.92 and 26.55 ± 10.53, respectively, and the RMS values after extubation were 31.93 ± 18.69 to 34.62 ± 13.55, for right and left domes. The last calculated pretransplant Model for End-stage Liver Disease score averaged 19.64 ± 8.41. CONCLUSION: There were significant differences between the RMS of the diaphragm domes under mechanical ventilation and after extubation, showing lower effectiveness of the diaphragm muscle against resistance, without the aid of positive pressure and the existing overload of the left dome.

Percutaneous closure after inadvertent carotid artery cannulation. Puncture repair with angio-seal deployment. A case report.

Inadvertent placement of an introducer sheath in an artery during central venous cannulation is rare and can result in devastating complications. Although traditional closure devices have been employed as prompt and adequate treatment, more innovative devices such as collagen plugs are being studied for their efficacy. We report a case of inadvertent insertion of an 8 French sheath into the right carotid artery which occurred in the electrophysiological laboratory during scheduled transjugular measurement of portal pressure gradient. The consultant neuroradiologist successfully removed the arterial sheath and the puncture site was sealed with a collagen-based vascular closure device (Angio-Seal STS Plus). Accidental insertion of an arterial sheath is an uncommon but potentially serious complication of jugular venous catheterization. When the carotid artery is inadvertently cannulated, sheath removal can be complicated by significant hemorrhage and acute dyspnea due to location of the vessel near the upper airways. Although traditional manual compression and closure devices have been effective at restoring hemostasis, collagen seals or plugs may be more viable to treat this precarious situation. This averted an otherwise emergent open surgical procedure to remove the sheath and repair the carotid artery in a high-risk patient.

Cardiovascular abnormalities in special conditions of advanced cirrhosis. The circulatory adaptative changes to specific therapeutic procedures for the management of refractory ascites.

Advanced liver disease is characterized by decreased arterial blood pressure and peripheral vascular resistances, increased cardiac output and heart rate in the setting of a hyperdynamic circulatory pattern favoured by total blood volume expansion, circulatory overload and overactivity of the endogenous vasoactive systems. Reduced heart responses to stressful conditions such as changes in loading conditions of the heart in presence of further deterioration of liver function such as refractory ascites, hepatorenal syndrome, spontaneous bacterial peritonitis and bleeding esophageal varices have been recently identified and the knowledge of the cirrhotic cardiomyopathy syndrome has gained the dignity of a new clinical entity. Facing the availability of therapeutic interventions (paracentesis, transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, orthotopic liver transplantation) currently employed to manage the life-threatening complications of the most advanced phases of cirrhotic disease, the knowledge of their impact on cardiovascular function is of paramount relevance.

The pulmonary involvement in portal hypertension: portopulmonary hypertension and hepatopulmonary syndrome.

Pulmonary abnormalities are common in patients with advanced chronic liver disease. Two distinct syndromes strictly related to the presence of portal hypertension, but clearly different from a pathophysiologic point of view, have been identified. Portopulmonary hypertension, characterized by an increased pulmonary arterial pressure, is due to a progressive arteriolar vasoconstriction induced by excess local production of vasoconstrictor substances. Hepatopulmonary syndrome results from intrapulmonary microvascular dilation caused by an inadequate synthesis or metabolism of putative pulmonary vasoactive substances leading to a functional vasodilation of the pulmonary vasculature, ultimately leading to hypoxemia. Controversies on pathogenesis imply different tentative therapeutic approaches for the medical management of these conditions. The development of portopulmonary hypertension or the hepatopulmonary syndrome has important clinical and prognostic implications facing the impact of new therapeutic strategies for the management of the main complications of advanced liver diseases on cardiopulmonary function.

[Diastolic dysfunction in liver cirrhosis]. / Disfunción diastólica en la cirrosis hepática.

The presence of a hyperdynamic circulation in cirrhotic liver is currently a well established concept. The first studies of cardiac function in patients with cirrhosis suggested the existence of an alcoholic cardiomyopathy. More recently, altered left ventricular response to physiological and/or pharmacological stimuli in patients with post-viral liver cirrhosis has been established, and clinically insignificant diastolic cardiac function has also been observed. Neurohumoral hyperactivity and hyperdynamic circulation, which are associated with chronic exposure to the cardiodepressant substances present in advanced liver disease, play a decisive role in the genesis of this process. The lack of relaxation of the left ventricle and alteration in the pattern of transmitral flow, both of which are characteristics of this clinical entity, are easily detected by echocardiography. The growing evidence of diastolic dysfunction in liver cirrhosis, particularly in decompensated cirrhosis, suggests the clinical importance of the problem, thus introducing the concept of "cirrhotic cardiomyopathy". Greater insight into this phenomenon could help to decrease cardiovascular risk, especially during maneuvers commonly used in the treatment of the complications of liver cirrhosis, such as paracentesis, transjugular intrahepatic portosystemic shunt stent implantation, and liver transplantation.

Pathophysiology of portal hypertension in HCV-related cirrhosis. Putative role of assessment of portal pressure gradient in Peginterferon-treated patients.

Chronic HCV infection is the leading aetiologic factor for cirrhosis, end-stage liver disease, hepatocellular carcinoma and liver transplantation worldwide. Pegylation of alfa interferons has improved the management of this disease. Interferon treatment has antifibrotic and immunomodulatory activities. Recent evidence supports the contention that Hepatitis C virus-related cirrhosis of the liver should no more be considered an irreversible disease; fibrosis is a potentially reversible process. Fibrosis and even cirrhosis reversal have been previously demonstrated either in experimental or clinical studies of other liver diseases. Development of portal hypertension is the main drive to the complications of advanced liver diseases: prognosis worsens significantly when portal hypertension becomes clinically significant. It is thus conceivable that within therapeutic trials involving patients with advanced fibrosis of the liver, measurement of the hepatic venous pressure gradient, the gold standard in the clinical assessment of portal hypertension and its management, could provide information on the portal pressure-lowering effects of interferon treatment affecting the fibrosis score. This can be accomplished by either sustained virological response either by fibrosis reduction achieved by chronic low-dose Peginterferon administration. If the introduction of drug therapy with non-selective beta blockers in the treatment of portal hypertension represents a milestone in the treatment of patients with cirrhosis and high-degree portal hypertension, the next step must then be prophylactic reversal of initial portal hypertension prompted by either HCV eradication and pharmacological inhibition of fibrosis progression by long-term Peginterferon before higher degrees of portal hypertension ensue.

Time-course of diastolic dysfunction in different stages of chronic HCV related liver diseases.

AIM: A hyperdynamic circulatory pattern in advanced liver disease is known since a long time. The first studies evaluating cardiac function in cirrhosis were performed in patients with alcoholic liver disease and thus this condition was attributed to the toxic effects of ethanol. A reduced performance of the left ventricle after physical and pharmacological strains along with an altered diastolic function has been demonstrated also in postviral cirrhosis. Many factors are involved in advanced cirrhosis whereas little is known in the earlier stages of disease. METHODS: To this aim we have investigated patients with different stages of hepatitis C virus (HCV)-related liver disease to detect the time-course of diastolic dysfunction. An impaired relaxation and increased thickness of left ventricular walls along with an altered pattern of transmitral flow can be easily detected by means of echocardiography. RESULTS: In chronic hepatitis diastolic function is preserved but increased thickness of left ventricle parietal walls can be detected in patients with fibrosis on liver biopsy. The typical pattern of diastolic dysfunction is observed in Child A cirrhotic patients and in Child C ascitic patients but thickness of parietal walls is more relevant in the former group. Chronic aldosterone blockade could exert favourable effects in heart remodeling suggesting a potential role of these drugs in cirrhotic cardiomyopathy. CONCLUSIONS: The presence of increased thickness of left ventricle parietal walls in chronic hepatitis C in the precirrhotic stage point to a putative role of HCV in this heart structural abnormality that can become a co-factor in the more advanced stages of cirrhosis when portal hypertension and its deleterious effects on systemic hemodynamics, cardiac function and structure become manifest.

Patterns of regional sympathetic nerve traffic in preascitic and ascitic cirrhosis.

Overactivity of the sympathetic nervous system and portal hypertension are key factors in the development of ascites in cirrhosis. The sympathoexcitation that characterizes the more advanced stages of liver diseases is less clearly defined in preascitic cirrhosis. We measured sympathetic nerve traffic to skeletal muscle (peroneal nerve) and to skin districts by microneurography in (1) 12 Child class A cirrhotic patients with clinically significant portal hypertension (portal pressure gradient > 10 mm Hg, 14.8 +/- 1.2 mm Hg, mean +/- SEM) but without actual or previous ascites, (2) 16 Child class C cirrhotic patients with tense ascites, and (3) 10 patients with mild congestive heart failure, a condition paradigmatic of a marked sympathetic activation. Muscle sympathetic nerve traffic was markedly increased in Child class C subjects as compared with controls (23.9 +/- 1.6 bursts/min, P <.01) and superimposable to that recorded in heart failure patients (52.9 +/- 4.7 vs. 60.3 +/- 2 bursts/min, P = not significant). Muscle sympathetic nerve traffic was also increased in Child class A subjects (41.6 +/- 2 bursts/min, P <.01 vs. controls) although to a lesser extent (P <.05 vs. Child class C patients). Skin sympathetic nerve traffic was within the normal range in all patients. Neurohormones were all markedly increased in Child class C subjects. Only norepinephrine was increased in Child class A patients. Our data show that sympathetic nerve traffic activation (1) is already detectable in Child class A cirrhosis when clinically significant portal hypertension is present but ascites never developed and (2) is not generalized because although muscle traffic is increased, skin traffic is within normal range. The role of drugs modulating sympathoactivation should be investigated in preascitic cirrhosis.

Structural analysis of families with a polydrug-dependent, bulimic, or normal adolescent daughter.

This study compared perceived relationships and interaction patterns among 44 families with externalizing (polydrug-dependent), internalizing (bulimic), or normal adolescent daughters. Data from L.S. Benjamin's (1974) structural analysis of social behavior rating scales and observational coding system were subjected to a pattern analysis of effect sizes. Results revealed that families of polydrug-dependent girls were less well attached and less autonomous than were families of daughters with bulimia who were, in turn, less attached and autonomous than controls. Observed interactions also showed that parents of drug-dependent teenagers communicated a mixed message of blaming the daughter while pseudo-affirming her. The findings were interpreted as evidence for specific disturbances in the critical elements of attachment and autonomy in both clinical disorders, with more pronounced and pervasive problems in the families of polydrug-dependent girls.

Sequenced scintigraphy: a morphological and functional study of the salivary glands.

The use of scintigraphy in sequenced registration shows that there are three fundamental stages in the intraglandular turnover of the radionuclide: 1. At very early stage (between 3 min. and 15 min.), the major salivary glands could be clearly distinguished; 2. At the stage immediately following (between 20 min. and 35 min.), both the parotid and submaxillary glands were already less well defined; while in the mouth projection zone, quite intense radioactivity, connected with a progressive accumulation of the radionuclide in the minor salivary glands, was seen; 3. Within an hour after injection, maximum captation took place in the minor salivary glands, while both the parotid and the submaxillary glands were hardly distinct. These three stages are strictly related to the three phases of behavior of the radionuclide in each salivary gland; arrival, accumulation, dismissal. Then, each documented variation from the normal pattern will indicate a determined functional anomaly related to defined disease of the salivary glands. The sequenced scintigrraphy offers a functional study of the salivary glands from which it is possible to obtain many elements of practical clinical utility.