"Back to the future: Beta radiation to treat recurrent in-stent restenosis".

When a patient presents with restenosis and two layers of previously place drug eluting stents this is a true treatment dilemma for the interventionist. Beta radiation has proven its efficacy to decrease in-stent restenosis compared to standard PCI. No drug-coated balloons are currently available in the United States for treatment of in-stent restenosis.

Premature, Opportune, and Delayed Weaning in Mechanically Ventilated Patients: A Call for Implementation of Weaning Protocols in Low- and Middle-Income Countries.

OBJECTIVES: Weaning protocols establish readiness-to-wean criteria to determine the opportune moment to conduct a spontaneous breathing trial. Weaning protocols have not been widely adopted or evaluated in ICUs in low- and middle-income countries. We sought to compare clinical outcomes between participants whose weaning trials were retrospectively determined to have been premature, opportune, or delayed based on when they met readiness-to-wean criteria. DESIGN: Prospective, multicenter observational study. SETTING: Five medical ICUs in four public hospitals in Lima, Perú. SUBJECTS: Adults with acute respiratory failure and at least 24 hours of invasive mechanical ventilation (n = 1,657). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We established six readiness-to-wean criteria and retrospectively categorized our sample into three weaning groups: 1) premature: if the weaning trial took place before fulfilling all criteria, 2) opportune: if the weaning trial took place within 24 hours after fulfilling the criteria, and 3) delayed: if the weaning trial took place over 24 hours after fulfilling criteria. We compared 90-day mortality, ventilator-free days, ICU-free days, and hospital-free days between premature, opportune, and delayed weaning groups. In our sample, 761 participants (60.8%) were classified as having a premature weaning trial, 196 underwent opportune weaning (15.7%), and 295 experienced delayed weaning (23.6%). There was no significant difference in 90-day mortality between the groups. Both the premature and delayed weaning groups had poorer clinical outcomes with fewer ventilator-free days (-2.18, p = 0.008) and (-3.49, p < 0.001), ICU-free days (-2.25, p = 0.001) and (-3.72, p < 0.001), and hospital-free days (-2.76, p = 0.044) and (-4.53, p = 0.004), respectively, compared with the opportune weaning group. CONCLUSIONS: Better clinical outcomes occur with opportune weaning compared with premature and delayed weaning. If readiness-to-wean criteria can be applied in resource-limited settings, it may improve ICU outcomes associated with opportune weaning.

Mean Airway Pressure As a Predictor of 90-Day Mortality in Mechanically Ventilated Patients.

OBJECTIVES: To determine the association between mean airway pressure and 90-day mortality in patients with acute respiratory failure requiring mechanical ventilation and to compare the predictive ability of mean airway pressure compared with inspiratory plateau pressure and driving pressure. DESIGN: Prospective observational cohort. SETTING: Five ICUs in Lima, Peru. SUBJECTS: Adults requiring invasive mechanical ventilation via endotracheal tube for acute respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of potentially eligible participants (n = 1,500), 65 (4%) were missing baseline mean airway pressure, while 352 (23.5%) were missing baseline plateau pressure and driving pressure. Ultimately, 1,429 participants were included in the analysis with an average age of 59 ± 19 years, 45% female, and a mean PaO2/FIO2 ratio of 248 ± 147 mm Hg at baseline. Overall, 90-day mortality was 50.4%. Median baseline mean airway pressure was 13 cm H2O (interquartile range, 10-16 cm H2O) in participants who died compared to a median mean airway pressure of 12 cm H2O (interquartile range, 10-14 cm H2O) in participants who survived greater than 90 days (p < 0.001). Mean airway pressure was independently associated with 90-day mortality (odds ratio, 1.38 for difference comparing the 75th to the 25th percentile for mean airway pressure; 95% CI, 1.10-1.74) after adjusting for age, sex, baseline Acute Physiology and Chronic Health Evaluation III, baseline PaO2/FIO2 (modeled with restricted cubic spline), baseline positive end-expiratory pressure, baseline tidal volume, and hospital site. In predicting 90-day mortality, baseline mean airway pressure demonstrated similar discriminative ability (adjusted area under the curve = 0.69) and calibration characteristics as baseline plateau pressure and driving pressure. CONCLUSIONS: In a multicenter prospective cohort, baseline mean airway pressure was independently associated with 90-day mortality in mechanically ventilated participants and predicts mortality similarly to plateau pressure and driving pressure. Because mean airway pressure is readily available on all mechanically ventilated patients and all ventilator modes, it is a potentially more useful predictor of mortality in acute respiratory failure.

Implementing Autonomous Driving Behaviors Using a Message Driven Petri Net Framework.

Most autonomous car control frameworks are based on a middleware layer with several independent modules that are connected by an inter-process communication mechanism. These modules implement basic actions and report events about their state by subscribing and publishing messages. Here, we propose an executive module that coordinates the activity of these modules. This executive module uses hierarchical interpreted binary Petri nets (PNs) to define the behavior expected from the car in different scenarios according to the traffic rules. The module commands actions by sending messages to other modules and evolves its internal state according to the events (messages) received. A programming environment named RoboGraph (RG) is introduced with this architecture. RG includes a graphical interface that allows the edition, execution, tracing, and maintenance of the PNs. For the execution, a dispatcher loads these PNs and executes the different behaviors. The RG monitor that shows the state of all the running nets has proven to be very useful for debugging and tracing purposes. The whole system has been applied to an autonomous car designed for elderly or disabled people.

Risk factors for the development of acute respiratory distress syndrome in mechanically ventilated adults in Peru: a multicenter observational study.

BACKGROUND: Clinical and epidemiological differences between acute respiratory distress syndrome (ARDS) that presents at the initiation of mechanical ventilation [MV] (ARDS at MV onset) and that which develops during the course of MV (ARDS after MV onset) are not well understood. We conducted an observational study in five Peruvian ICUs to characterize differences between ARDS at MV onset and after MV onset and identify risk factors for the development of ARDS after MV onset. METHODS: We consecutively enrolled critically ill patients with acute respiratory failure requiring at least 24 h of mechanical ventilation and followed them prospectively during the first 28 days and compared baseline characteristics and clinical outcomes by ARDS status. RESULTS: We enrolled 1657 participants on MV (mean age 60.0 years, 55% males) of whom 334 (20.2%) had ARDS at MV onset and 180 (10.9%) developed ARDS after MV onset. Average tidal volume at the initiation of MV was 8.7 mL/kg of predicted body weight (PBW) for participants with ARDS at MV onset, 8.6 mL/kg PBW for those who developed ARDS after MV onset, and 8.5 mL/kg PBW for those who never developed ARDS (p = 0.23). Overall, 90-day mortality was 56% and 55% for ARDS after MV onset and ARDS at MV onset, respectively, as compared to 46% among those who never developed ARDS (p < 0.01). Adults with ARDS had a higher body mass index (BMI) than those without ARDS (27.3 vs 26.5 kg/m2, p < 0.01). Higher peak pressure (adjusted interquartile OR = 1.51, 95% CI 1.21-1.88), higher mean airway pressure (adjusted interquartile OR = 1.41, 95% CI 1.13-1.76), and higher positive end-expiratory pressure (adjusted interquartile OR = 1.29, 95% CI 1.10-1.50) at MV onset were associated with a higher odds of developing ARDS after MV onset. CONCLUSIONS: In this study of mechanically ventilated patients, 31% of study participants had ARDS at some point during their ICU stay. Optimal lung-protective ventilation was not used in a majority of patients. Patients with ARDS after MV onset had a similar 90-day mortality as those with ARDS at MV onset. Higher airway pressures at MV onset, higher PEEP, and higher BMI were associated with the development of ARDS after MV onset.

Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort.

OBJECTIVES: We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. DESIGN: A longitudinal study of critically ill participants on mechanical ventilation. SETTING: Five intensive care units (ICUs) in four public hospitals in Lima, Peru. PATIENTS: One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. RESULTS: After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001). CONCLUSIONS: Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.

Distributed and Modular CAN-Based Architecture for Hardware Control and Sensor Data Integration.

In this article, we present a CAN-based (Controller Area Network) distributed system to integrate sensors, actuators and hardware controllers in a mobile robot platform. With this work, we provide a robust, simple, flexible and open system to make hardware elements or subsystems communicate, that can be applied to different robots or mobile platforms. Hardware modules can be connected to or disconnected from the CAN bus while the system is working. It has been tested in our mobile robot Rato, based on a RWI (Real World Interface) mobile platform, to replace the old sensor and motor controllers. It has also been used in the design of two new robots: BellBot and WatchBot. Currently, our hardware integration architecture supports different sensors, actuators and control subsystems, such as motor controllers and inertial measurement units. The integration architecture was tested and compared with other solutions through a performance analysis of relevant parameters such as transmission efficiency and bandwidth usage. The results conclude that the proposed solution implements a lightweight communication protocol for mobile robot applications that avoids transmission delays and overhead.

In a Setting of Esophageal Replacement, Total Gastric Pull-Up has Fewer Complications than Partial Gastric Pull-Up.

AIM: The main indications for an esophageal replacement (ER) are unresolved complex esophageal atresia (EA) and caustic strictures (CS). The use of different organs for replacement has been described. When the stomach is chosen, there are two ways to do a gastric pull-up: a partial (PGP) or a total pull-up (TGP). Few studies have been published comparing the different techniques. The aim of this study was to compare the outcomes of patients who underwent ER by PGP or by TGT. METHODS: The medical records of all patients who underwent gastric pull-up for ER in the last 18 years at the National Pediatric Hospital Prof. Dr. Juan P. Garrahan were reviewed. The study is comparative, retro-prospective and longitudinal. Patients were divided in two groups according to the ER technique (PGP or TGP). We compared the following outcomes: duration of the operation, days of hospitalization in the intensive care unit (ICU), days of total hospitalization, time to initiation of oral feedings and rate of anastomosis dehiscence, incidence of anastomotic stenosis, need for re-operations, incidence of gastroesophageal reflux disease (GERD), incidence of tracheo-esophageal fistulas (TEF), incidence of dumping syndrome, incidence of gastric necrosis and mortality. RESULTS: There were 92 patients included in the study: 70 in the PGP group (76%) and 26 in the TGP group (24%). The two groups were demographically equivalent. Patients in the TGP group had a statistically significant lower incidence of anastomotic dehiscence (22,7% versus 54,3%; p = 0.01) and dumping syndrome (13,6% versus 37,1%; p = 0.038). Patients in the TGP had lower incidence of anastomotic stenosis, although the difference was not statistically significant. There were no statistically significant differences between the groups in terms of duration of the operation, postoperative days in the ICU, time to oral feedings, GERD, TEF or overall hospital stay. There were no cases of gastric necrosis. There were 3 deaths in the PGP group and one in the TGP group. CONCLUSIONS: We observed benefits in the TGP group versus the PGP approach in terms of anastomotic dehiscence and dumping syndrome, as well as a trend toward a lower incidence of anastomotic stenosis. Based on this experience, we recommend the TGP approach for patients who need an esophageal replacement by a gastric pull-up. LEVELS OF EVIDENCE: According to the Journal of Pediatric Surgery this research corresponds to type of study level III for retrospective comparative study.

Outcome of renal transplant in patients with abnormal urinary tract.

PURPOSE: To determine whether surgical procedures of the lower urinary tract in patients with uropathies affect evolution of the graft in renal transplantation. METHODS: 156 kidney transplantations were performed in 150 patients with end-stage renal failure due to urologic disorders. The patients were classified into three groups: A, patients who did not require surgery in the lower urinary tract; B, required surgery and preserved adequate bladder function, and C, required surgery due to vesical dysfunction. RESULTS: Graft survival rates at 1 year were 93.38% in group A, 95.45% in group B and 93% in group C. Rates at 5 years post-transplantation were 82.45, 79.85 and 86.58% for each group, respectively (not significant). Complications were vesicoureteral stenosis: 2 in group A, 3 in B and 1 in C; vesicoureteral reflux: 1 in group A, 1 in B and 10 in C; distal ureteral necrosis: 2 cases in group A, 2 in B and 1 in C; upper urinary tract infection: 12, 23.1 and 42.2% in each group, respectively. CONCLUSION: Children with reconstructed urinary tract may be good candidates for kidney transplantation despite the higher frequency of urinary infections. Thus, careful and strict post-surgical urologic follow-up is mandatory.

High flow priapism: diagnosis and treatment in pediatric population.

PURPOSE: To present three cases of arterial high flow priapism (HFP) and propose a management algorithm for this condition. MATERIALS AND METHODS: We studied three children with post-traumatic arterial HFP (two patients with perineal trauma and one with penis trauma). RESULTS: Spontaneous resolution was observed in all the patients. The time of resolution by a return to a completely flaccid penis was different: 14, 27 and 36 days in each case. CONCLUSIONS: Absence of long-term damaging effects of arterial HFP on erectile tissue combined with the possibility of spontaneous resolution associated with blunt perineal trauma are suggestive signs for the introduction of an observation period in the management algorithm of HFP. Such a period may help to avoid unnecessary surgical intervention. Thus, these cases reinforce the decision to manage these patients conservatively and avoid angiographic embolization as a first therapeutic choice.

Outcomes of event-free survival in patients with Wilms tumor undergoing preoperative chemotherapy. Analysis of lymph-node yield in a single-center cohort.

INTRODUCTION: The clinical value of lymph node sampling in Wilms tumor (WT) lies in its ability to accurately determine lymph node (LN) involvement. LN yield (LNY) is used as a valuable tool to measure LN retrieval, and a minimum of 6 LNs is one of the current recommendations. In patients who are managed with the SIOP strategy, preoperative chemotherapy decreases the retrieval of LN during surgery resulting in lower LNY values. PURPOSE: To determine the mean LNY and to analyze survival outcomes in patients with WT who underwent preoperative chemotherapy at a single center. METHODS: We performed a retrospective chart review of all patients between 6 months and 12 years of age with unilateral WT who underwent preoperative chemotherapy between 2010 and 2018. Patients with bilateral WT or without preoperative chemotherapy were excluded. Collected data included: demographics, tumor volume, tumor histopathology, number of LNs collected (LNY), presence or absence of tumor in the retrieved LNs, and disease stage according to these results. Kaplan Meier curves were calculated to estimate 5-year event-free survival (EFS) and overall survival (OS). RESULTS: 95 patients with a median follow-up of 25 months were included in the study. A total of 19 patients underwent laparoscopic surgery. Mean LNY for the entire cohort was 3.26 (95% CI, 2.4-3.6; SD, 3.62). Six patients (6.3%) had at least one positive LN. The estimated 5-year OS was 89.3% (95% CI, 82.1%-96.5%). EFS was 79.8 (95% CI, 74.8%-84.8%). Recurrence rate was 20% (n: 19). Four patients (4.2%) developed local recurrence and 15 patients (15.7%) developed pulmonary recurrence. The initial mean LNY in patients that relapsed was 4.16 (95% CI, 2.2-5.8; SD: 4.18), which was higher than in patients who did not relapse (LNY: 3; 95% CI, 2.33-3.67; SD, 3.39). No recurrences or deaths occurred in the laparoscopic group. DISCUSSION: The identification of a minimum LNY (i.e. threshold) to minimize the risk of harboring occult metastatic disease has been proposed to standardize the surgical procedure. Preliminary results in this study suggest that a limited LNY with acceptable survival outcomes is a possible scenario in patients treated according to the SIOP protocol. Systematic LN sampling to reduce the rate of false negatives is still strongly recommended. CONCLUSION: Our cohort presented with a relatively low LNY compared to standard recommendations. Our EFS, however, remained acceptable. Multivariate analysis would be necessary to determine the actual role of LN sampling as an isolated prognostic factor in unilateral WT.

[Recommendations for the diagnosis and treatment of persistent postsurgical symptoms in Hirschsprung disease]. / Recomendaciones para el diagnóstico y el tratamiento de los síntomas posquirúrgicos persistentes en la enfermedad de Hirschsprung.

Hirschsprung disease is characterized by the lack of migration of intrinsic parasympathetic ganglia from neural crest and consequently absence of them at varying length of the bowel, resulting in functional obstruction. The incidence is 1 per 5000 births. After surgery, short term and long term comorbidity commonly occurs. The aim of this article is to revise the main causes of ongoing symptoms after surgery in Hirschsprung disease patients and to show a diagnostic and therapeutic algorithm that can be developed in our community.

La enfermedad de Hirschsprung ocurre en 1 de cada 5000 nacimientos. La falla de migración de las células ganglionares desde la cresta neural en dirección cefalocaudal genera su ausencia en parte o todo el colon. Se manifiesta con falta de eliminación de meconio, distensión abdominal y dificultades en la evacuación. Luego del tratamiento quirúrgico, existen complicaciones a corto y largo plazo. El objetivo de esta publicación es describir las principales causas de síntomas persistentes en los pacientes operados por enfermedad de Hirschsprung y presentar un algoritmo diagnóstico-terapéutico factible de ser realizado en nuestro medio.

Ciencia perdida: un debate latinoamericano

La presente contribución analiza las formas en que se construye la ciencia en América Latina y el Caribe. Su objetivo principal es destacar las particularidades de esta región y cómo estas diferencias afectan el desarrollo científico en comparación con otras áreas del mundo, desde la perspectiva de la ciencia perdida e invisible. Se argumenta que la ciencia en América Latina y el Caribe se ha desarrollado principalmente a través de la colaboración y la cooperación entre países, pero sus revistas científicas se encuentran en desventaja a partir de la ciencia globalizada que limita el acceso a temáticas locales. Este enfoque se ha impulsado por la necesidad de superar las limitaciones económicas y tecnológicas presentes en la región. Como resultado, se han creado iniciativas propias que destacan la importancia de las aportaciones y el conocimiento local en la construcción de la ciencia. Tener una perspectiva propia y contextualizada es fundamental para abordar los desafíos y necesidades específicas de la región. Esto se refleja en la diversidad de temas de investigación y enfoques científicos. El artículo también menciona algunos de los desafíos y obstáculos que enfrenta la ciencia en América Latina y el Caribe, a pesar los cuales se destaca la resiliencia y creatividad de los científicos latinoamericanos y caribeños, quienes han logrado hacer contribuciones significativas a nivel mundial.

ABTRASCT This contribution analyzes the ways in which science is constructed in Latin America and the Caribbean. Its main objective is to highlight the particularities of this region and how these differences affect scientific development compared to other areas of the world, from the lost and invisible science's perspective. It is argued that science in Latin America and the Caribbean has developed mainly through collaboration and cooperation between countries, but its scientific journals are at a disadvantage due to globalized science that limits access to local topics. This approach has been driven by the need to overcome the economic and technological limitations present in the region. As a result, own initiatives have been created that highlight the importance of contributions and local knowledge in the construction of science. Having its own and contextualized perspective is essential to address the specific challenges and needs of the region. This is reflected in the diversity of research topics and scientific approaches. The article also mentions some of the challenges and obstacles faced by science in Latin America and the Caribbean, despite which the resilience and creativity of Latin American and Caribbean scientists stands out, who have managed to make significant contributions worldwide.

Bi-directional drones to strengthen healthcare provision: experiences and lessons from Madagascar, Malawi and Senegal.

Drones are increasingly being used globally for the support of healthcare programmes. Madagascar, Malawi and Senegal are among a group of early adopters piloting the use of bi-directional transport drones for health systems in sub-Saharan Africa. This article presents the experiences as well as the strengths, weaknesses, opportunities and threats (SWOT analysis) of these country projects. Methods for addressing regulatory, feasibility, acceptability, and monitoring and evaluation issues are presented to guide future implementations. Main recommendations for governments, implementers, drone providers and funders include (1) developing more reliable technologies, (2) thorough vetting of drone providers' capabilities during the selection process, (3) using and strengthening local capacity, (4) building in-country markets and businesses to maintain drone operations locally, (5) coordinating efforts among all stakeholders under government leadership, (6) implementing and identifying funding for long-term projects beyond pilots, and (7) evaluating impacts via standardised indicators. Sharing experiences and evidence from ongoing projects is needed to advance the use of drones for healthcare.

Laparoscopic total nephrectomy for Wilms tumor: Towards new standards of care.

INTRODUCTION: Laparoscopic total nephrectomy (LN) in malignant pediatric tumors remains controversial. For selected patients undergoing pre-operative chemotherapy in referral centers, LN has so far shown comparable results to the standard open technique. PURPOSE: To describe the inclusion criteria and preliminary results of laparoscopic nephrectomies (LN) for the treatment of unilateral Wilms tumors (WT). MATERIAL AND METHODS: Between November 2010 and January 2016, a retrospective study of patients with WT and undergoing pre-operative chemotherapy was performed. Inclusion criteria for candidates for LN were: unilateral tumors without venous invasion and central kidney localization. Tumor size and vascular thrombus were estimated with pre-operative computed tomography (CT) scan. Overall survival and recurrence rates were evaluated. RESULTS: Among 105 patients with WT, 14 underwent LN. Tumor bleeding or the lack of response to chemotherapy were not exclusion criteria. Median tumor volume for the patients undergoing LN was 71.5 cc (range 7-169). Patients with small tumors localized near the renal pole and candidates for nephron sparing surgery (NSS) were excluded. Estimated 5-year overall survival for all patients with WT during this period was 88.7% (88.1-103.1). Two patients underwent conversion. No recurrence or related death was found at a mean 32- month follow-up period. DISCUSSION: Reproducing the steps of the open nephrectomy when performing LN for malignant tumors allowed comparable oncologic results to the conventional procedure. However, upstaging of the tumor was not admissible and has become the main goal when approaching these patients laparoscopically. Preliminary results showed that the incidence of intraoperative rupture and incomplete node sampling were not an issue when comparing LN to open nephrectomy. On the other hand, LN for malignant tumors requires experience in advanced laparoscopy and oncologic surgery. Pre-operative chemotherapy changes the tumor's consistency and this is the key point as to why these patients are amenable to be approached laparoscopically. Lifting the tumor along with the fat to avoid capsule fraction, as well as changing the lens to the lateral port to achieve a correct view for lymph node sampling are some of the considerations when performing LN. CONCLUSIONS: Preliminary data suggest that LN for WT is feasible and has promising results in terms of event-free and overall survival. In patients undergoing pre-operative chemotherapy the correct selection for LN is crucial. Following the basic oncological precepts and in experienced centers, LN represents a plausible modality in the care of these patients.