Use of carotid artery cannulation during redo sternotomy in congenital cardiac surgery: a single-centre experience.

OBJECTIVES: Management of resternotomy is often a difficult challenge in patients with congenital diseases who have undergone multiple sternotomies. Our goal was to report our single-centre experience with carotid cannulation using a graft interposed during redo sternotomy in complex cardiac reintervention procedures. METHODS: We performed a retrospective review of all patients who had undergone complex redo sternotomies between January 2019 and May 2020 utilizing a cervical cannulation technique with a Gore-Tex graft interposed on the carotid artery. We classified our population study on the basis of the primary diagnosis and the type of surgery. The primary outcomes of our analysis were the evaluation of the safety of the procedure in terms of survival and freedom from neurological events. RESULTS: We analysed 22 patients who had undergone previous complex operations. The median age and weight at the time of reintervention were 130.35 (range 0.46-435) months and 31.5 (range 2.2-85) kg, respectively. Composite graft carotid cannulation provided adequate arterial flow in all patients with a median arterial flow of 3.5 l/min/m2 (range 0.6-6). One major cardiac injury occurred during sternotomy when emergency cardiopulmonary bypass (CPB) was initiated. Moreover, during their hospital stays, all patients had an uneventful recovery without neurological or vascular complications and no cervical wound infections. CONCLUSIONS: Carotid cannulation using interposition of a side graft on the common carotid artery for arterial inflow is a reliable and safe method for initiation of CPB in complex redo surgeries in patients with congenital disease. Complications directly associated with this type of cannulation are uncommon and allow surgical re-entry with overall low risks.

Outcome for Conservative Surgery for the Correction of Severe Mitral Valve Regurgitation in Children: A Single-Center Experience.

Evolving reconstructive techniques have progressively become the preferred approach for treatment of pediatric mitral valve regurgitation. We present our experience in a cohort of patients undergoing surgical correction for severe mitral regurgitation. Fifty-five patients (age 1 month-18 years; median 5 years) were included in the present analysis. Different surgical techniques were used (posterior leaflet augmentation in 25, isolated cleft closure in 12, Alfieri-type procedure in 10, annuloplasty in 5, with artificial chordae in 2, and quadrangular resection with chordal transposition in 1). Follow-up time ranged from 1 to 192 months (median 38[IQR 12-54] months). Operative and follow-up mortality was 0%. Reintervention in the whole population occurred in 31% of patients. However, when first surgery was performed under 2 years of age (no = 17), reintervention reached nearly 50%. The degree of residual mitral regurgitation at follow-up remained stable after surgery, while a significant increase in mean transmitral gradient was observed over time (paired t test = 0.03). In multivariable Cox-regression analysis, post-surgical transmitral gradient was the only independent predictor for reintervention (p = 0.017; HR 2.4; 95%CI 1.2-5.1), after correcting for differences in age at surgery, type of reintervention, mitral annulus dimension, and BSA at the first surgery. ROC curve demonstrated that a post-surgical transmitral mean gradient value > 5 mmHg, was predictive for reintervention (AUC = 0.89; Youden index = 0.44). Our study suggests that the use of conservative technique strategy achieves satisfactory functional results in infants and children with severe MR, although the rate of reoperation in younger patients remains substantial. Post-operative moderate mitral stenosis was the strongest predictor for reoperation.

Long-Term Outcomes After Extracardiac Fontan Takedown to an Intermediate Palliative Circulation.

BACKGROUND: Acute failure of the Fontan circulation is rare but remains associated with high morbidity and mortality rates. Little is known about the long-term outcome of patients who underwent Fontan takedown to an intermediate palliative circulation and their potential candidacy for redo Fontan completion. METHODS: Patients followed up at a single institution who underwent takedown of a Fontan circulation to an intermediate palliative circulation within 2 months of extracardiac Fontan completion were reviewed. RESULTS: Between October 1990 and December 2015, 18 patients underwent Fontan takedown to a superior cavopulmonary connection (with or without an additional shunt) at a median age of 3.3 years (range, 1.8 to 8.0) and median weight of 13.8 kg (range, 8.0 to 27.0 kg). Takedown was required during the Fontan procedure itself in 2 patients, and within the first 2 postoperative months in 16 patients (median time to takedown, 3 days). Seventeen patients survived the post-takedown period and 3 ultimately underwent successful redo Fontan. Four patients required heart transplantation, with 2 deaths. In patients with extended intermediate palliation, median arterial oxygen saturation was 84% (range, 76% to 92%) at a median follow-up of 6.3 years (range, 0.7 to 25.9). CONCLUSIONS: Takedown to a superior cavopulmonary connection is an effective treatment option and, in some patients, acts as a bridge to subsequent redo Fontan completion or heart transplantation. An extended intermediate palliative circulation is tolerated for several years with reasonable oxygen saturation levels at rest. In our experience, an early takedown strategy to a superior cavopulmonary connection is the treatment of choice for acute Fontan failure.

Atrial septal defect morphology and stenting in hypoplastic left heart syndrome after hybrid palliation.

Aims The aim of this study was to describe atrial septal defect morphology in hypoplastic left heart syndrome, to report the incidence of restrictiveness and its relationship with defect morphology, to correlate restriction with midterm outcome, and to describe our interventional approach to restrictive defect. Methods and results From 2011 to 2015, 31 neonates with hypoplastic left heart syndrome underwent hybrid procedure with pulmonary artery banding and ductal stenting at our Institution. Restrictive physiology of the atrial septal defect was based on Doppler gradient >6 mmHg through the defect and on clinical signs of pulmonary hypertension. The mean gradient was then measured invasively. Restrictive defect occurred in 11/27 patients (40%). The restrictive group showed three ostium secundum defects (27%) and eight complex morphologies (73%). Conversely, in the non-restrictive group, we observed 11 ostium secundum defects (69%) and five complex morphologies (31%). Early balloon atrioseptostomy was required in three cases. Late restriction occurred in eight patients and was dealt with balloon dilation, stenting, or atrioseptectomy. There was no significant difference between restrictive and non-restrictive groups in terms of early or 12-month survival. CONCLUSIONS: Complex morphologies were more frequently related to restrictiveness. Stenting technique has a crucial role, as the procedure carries a significant risk for stent migration. Effective treatment of restrictive atrial septal defect is related to a better outcome, as it leads to equalisation of survival between patients with and those without restrictive atrial septal defect.

Early hybrid approach and enteral feeding algorithm could reduce the incidence of necrotising enterocolitis in neonates with ductus-dependent systemic circulation.

BACKGROUND: The reported incidence of necrotising enterocolitis in neonates with complex CHD with ductus-dependent systemic circulation ranges from 6.8 to 13% despite surgical treatment; the overall mortality is between 25 and 97%. The incidence of gastrointestinal complications after hybrid palliation for neonates with ductus-dependent systemic circulation still has to be defined, but seems comparable with that following the Norwood procedure. METHODS: We reviewed the incidence of gastrointestinal complications in a series of 42 consecutive neonates with ductus-dependent systemic circulation, who received early hybrid palliation associated with a standardised feeding protocol. RESULTS: The median age and birth weight at the time of surgery were 3 days (with a range from 1 to 10 days) and 3.07 kg (with a range from 1.5 to 4.5 kg), respectively. The median ICU length of stay was 7 days (1-70 days), and the median hospital length of stay was 16 days (6-70 days). The median duration of mechanical ventilation was 3 days. Hospital mortality was 16% (7/42). In the postoperative period, 26% of patients were subjected to early extubation, and all of them received treatment with systemic vasodilatory agents. Feeding was started 6 hours after extubation according to a dedicated feeding protocol. After treatment, none of our patients experienced any grade of necrotising enterocolitis or major gastrointestinal adverse events. CONCLUSIONS: Our experience indicates that the combination of an "early hybrid approach", systemic vasodilator therapy, and dedicated feeding protocol adherence could reduce the incidence of gastrointestinal complications in this group of neonates. Fast weaning from ventilatory support, which represents a part of our treatment strategy, could be associated with low incidence of necrotising enterocolitis.

Isolated limb perfusion for the management limb threatening soft tissue sarcomas: The role of histological type on clinical outcomes.

BACKGROUND: Hyperthermic isolated limb perfusion (HILP) is an effective neoadjuvant treatment to avoid amputation in patients with locally advanced extremity soft tissue sarcomas (STS). We aimed to investigate whether STS histological type plays a role in predicting clinical outcomes. METHODS: This study reports a retrospective analysis of 125 patients with limb threatening STS (liposarcoma, n = 41; malignant peripheral nerve sheath tumor, n = 20; leiomyosarcoma, n = 20; miscellany, n = 44), who underwent HILP from 1990 through 2015 at our institution. The following endpoints were evaluated: tumor response (assessed by radiological imaging and histology), limb sparing rate, local progression-free survival (LPFS) and overall survival (OS). RESULTS: On average, overall (complete + partial) tumor response was significantly greater in patients affected with liposarcoma as compared to those with other histotypes (radiological response rate: 38/41, 92.7% vs 66/84, 78.6%, P-value: 0.048; mean histological necrosis: 83.6% vs 52.9%, P < 0.0001). Limb sparing rate was also higher among patients with liposarcoma as compared to other histotypes (39/41, 95.1% vs 62/84, 73.8%, P-value: 0.005). As regards survival, LPFS was similar across tumor types, whereas OS resulted significantly worse in patients with limb leiomyosarcoma (log-rank P-value: 0.009). CONCLUSIONS: HILP is a very effective treatment modality for limb threatening STS. In our series, liposarcoma appears to be the histological type most sensitive to HILP in terms of tumor response and thus limb sparing, which might help clinicians in the patient selection process.

Aerosol composition and properties variation at the ground and over the column under different air masses advection in South Italy.

Aerosol composition and properties variation under the advection of different air masses were investigated, as case studies, by contemporary measurements over the atmospheric column and at the ground in a semi-rural site in South Italy. The absence of local strong sources in this area allowed to characterize background aerosol and to compare particle mixing effects under various atmospheric circulation conditions. Aerosol optical depth (AOD) and Ǻngström parameters from radiometric measurements allowed the detection and identification of polluted, dust, and volcanic atmospheric conditions. AODs were the input for a suitable model to evaluate the columnar aerosol composition, according to six main atmospheric components (water-soluble, soot, sea salt accumulation, sea salt coarse, mineral dus,t and biological). Scanning electron microscope (SEM) analysis of particulate sampled with a 13-stage impactor at the ground showed not only fingerprints typical of the different air masses but also the effects of transport and aging on atmospheric particles, suggesting processes that changed their chemical and optical properties. Background columnar aerosol was characterized by 72% of water-soluble and soot, in agreement with ground-based findings that highlighted 60% of contribution from anthropogenic carbonate particles and soot. In general, a good agreement between ground-based and columnar results was observed. Under the advection of trans-boundary air masses, water-soluble and soot were always present in columnar aerosol, whereas, in variable percentages, sea salt and mineral particles characterized both dust and volcanic conditions. At the ground, sulfates characterized the amorphous matrix produced in finer stages by the evaporation of solutions of organic and inorganic aerosols. Sulfates were also one of the key players involved in heterogeneous chemical reactions, producing complex secondary aerosol, as such clay-sulfate internally mixed particle externally mixed with soot chains.

Characterization of crumb rubber from end-of-life tyres for paving applications.

Crumb rubber (CR) derived from grinding of end-of-life tyres (ELTs) may be successfully used as a bitumen modifier or as a supplementary component in the production of bituminous mixtures employed for the construction and maintenance of road pavements. However, CRs deriving from different sources and production processes yield effects on performance of corresponding paving mixtures under traffic loading and on gaseous emissions produced during laying on site which may change considerably depending upon their physical and chemical properties. In order to quantitatively assess the possible variability of CR characteristics, 16 samples were taken from 9 Italian and 2 foreign ELT processing plants. Investigation activities included field surveys, during which plants were examined in detail, and laboratory tests, which focused on physical and chemical characterization of CR. Based on the analysis of available technical information and experimental data, it was possible to find relationships between the peculiar characteristics of treatment cycles and corresponding CR properties.

Sporadic isolation of sabin-like polioviruses and high-level detection of non-polio enteroviruses during sewage surveillance in seven Italian cities, after several years of inactivated poliovirus vaccination.

Sewage surveillance in seven Italian cities between 2005 and 2008, after the introduction of inactivated poliovirus vaccination (IPV) in 2002, showed rare polioviruses, none that were wild-type or circulating vaccine-derived poliovirus (cVDPV), and many other enteroviruses among 1,392 samples analyzed. Two of five polioviruses (PV) detected were Sabin-like PV2 and three PV3, based on enzyme-linked immunosorbent assay (ELISA) and PCR results. Neurovirulence-related mutations were found in the 5'noncoding region (5'NCR) of all strains and, for a PV2, also in VP1 region 143 (Ile>Thr). Intertypic recombination in the 3D region was detected in a second PV2 (Sabin 2/Sabin 1) and a PV3 (Sabin 3/Sabin 2). The low mutation rate in VP1 for all PVs suggests limited interhuman virus passages, consistent with efficient polio immunization in Italy. Nonetheless, these findings highlight the risk of wild or Sabin poliovirus reintroduction from abroad. Non-polio enteroviruses (NPEVs) were detected, 448 of which were coxsackievirus B (CVB) and 294 of which were echoviruses (Echo). Fifty-six NPEVs failing serological typing were characterized by sequencing the VP1 region (nucleotides [nt] 2628 to 2976). A total of 448 CVB and 294 Echo strains were identified; among those strains, CVB2, CVB5, and Echo 11 predominated. Environmental CVB5 and CVB2 strains from this study showed high sequence identity with GenBank global strains. The high similarity between environmental NPEVs and clinical strains from the same areas of Italy and the same periods indicates that environmental strains reflect the viruses circulating in the population and highlights the potential risk of inefficient wastewater treatments. This study confirmed that sewage surveillance can be more sensitive than acute flaccid paralysis (AFP) surveillance in monitoring silent poliovirus circulation in the population as well as the suitability of molecular approaches to enterovirus typing.

Measurement of charged particle yields from PMMA irradiated by a 220 MeV/u (12)C beam.

The radiation used in hadrontherapy treatments interacts with the patient body producing secondary particles, either neutral or charged, that can be used for dose and Bragg peak monitoring and to provide a fast feedback on the treatment plans. Recent results obtained from the authors on simplified setups (mono-energetic primary beams interacting with homogeneous tissue-like target) have already indicated the correlation that exists between the flux of these secondaries coming from the target (e.g. protons and photons) and the position of the primary beam Bragg peak. In this paper, the measurements of charged particle fluxes produced by the interaction of a 220 MeV/u carbon ion beam at GSI, Darmstadt, with a polymethyl methacrylate target are reported. The emission region of protons (p), deuterons (d) and tritons (t) has been characterized using a drift chamber while the particle time-of-flight, used to compute the kinetic energy spectra, was measured with a LYSO scintillator. The energy released in the LYSO crystal was used for particle identification purposes. The measurements were repeated with the setup at 60° and 90° with respect to the primary beam direction. The accuracy on the fragments emission profile reconstruction and its relationship with the Bragg peak position have been studied. Based on the acquired experimental evidence, a method to monitor the dose profile and the position of the Bragg peak inside the target is proposed.

A novel radioguided surgery technique exploiting ß(-) decays.

The background induced by the high penetration power of the radiation is the main limiting factor of the current radio-guided surgery (RGS). To partially mitigate it, a RGS with ß(+)-emitting radio-tracers has been suggested in literature. Here we propose the use of ß(-)-emitting radio-tracers and ß(-) probes and discuss the advantage of this method with respect to the previously explored ones: the electron low penetration power allows for simple and versatile probes and could extend RGS to tumours for which background originating from nearby healthy tissue makes probes less effective. We developed a ß(-) probe prototype and studied its performances on phantoms. By means of a detailed simulation we have also extrapolated the results to estimate the performances in a realistic case of meningioma, pathology which is going to be our first in-vivo test case. A good sensitivity to residuals down to 0.1 ml can be reached within 1 s with an administered activity smaller than those for PET-scans thus making the radiation exposure to medical personnel negligible.

Review of Italian experience on automotive shredder residue characterization and management.

Automotive Shredder Residue (ASR) is a special waste that can be classified as either hazardous or non hazardous depending on the amount of hazardous substances and on the features of leachate gathered from EN12457/2 test. However both the strict regulation concerning landfills and the EU targets related to End-of-Life Vehicles (ELVs) recovery and recycling rate to achieve by 2015 (Directive 2000/53/EC), will limit current landfilling practice and will impose an increased efficiency of ELVs valorization. The present paper considers ELVs context in Italy, taking into account ASRs physical-chemical features and current processing practice, focusing on the enhancement of secondary materials recovery. The application in waste-to-energy plants, cement kilns or metallurgical processes is also analyzed, with a particular attention to the possible connected environmental impacts. Pyrolysis and gasification are considered as emerging technologies although the only use of ASR is debatable; its mixing with other waste streams is gradually being applied in commercial processes. The environmental impacts of the processes are acceptable, but more supporting data are needed and the advantage over (co-)incineration remains to be proven.

An automatized system for the assessment of nutritive sucking behavior in infants: a preliminary analysis on term neonates.

Nutritive Sucking (NS) is a highly organized process that can reflect infants' maturation during the early post-natal period. The assessment of NS may provide a sensitive means of evaluating early motor skills and their development. Thus, a reliable tool for assessing sucking behavior may benefit diagnostics and treatment of newborns since the first days of life. The aim of this work is to propose an automatized system to measure sucking ability and calculate a set of objective and quantitative indices for its assessment. We focused on the analysis of the Intraoral Pressure (IP) generated by infants while feeding: an ad-hoc designed software application was developed to analyze the signal obtained by a pressure transducer connected with a catheter placed through a standard bottle teat into the oral cavity during feeding. Automatic algorithms for suck and burst identification and for their characterization are described. We carried out a preliminary test of the system, analyzing data from two healthy term newborns, tested twice over time (1-2 days old and 6-10 weeks later). We calculated a set of different sucking parameters (e.g. sucking amplitude, frequency and area), and proposed some indices, that are typically used for the assessment of motor control, in order to assess the smoothness of IP. Results encourage further investigation of the proposed system for monitoring the development of early sucking skills.

Detection and distribution of culturable Human Enteroviruses through environmental surveillance in Milan, Italy.

AIMS: Human Enteroviruses (HEVs) infections have a significant impact on public health, being implicated in outbreaks of meningitis, encephalitis, hand-foot-mouth disease and other acute and chronic manifestation. In the strategic plan for poliomyelitis eradication, the environmental surveillance of poliovirus (PV) has been identified by the World Health Organization (WHO) as an activity that can complement the surveillance of polio. Having wastewater samples available for PV surveillance allows us to study nonpolio enteroviruses (NPEVs) circulating in the study population, which are widely spread. METHODS AND RESULTS: This study was carried out according to the WHO guidelines for environmental surveillance of PV and analysed the circulation of PV and NPEVs through the isolation of viruses in cell cultures in Milan area; from 2006 to 2010, 321 wastewater samples were collected, regularly over time, at the inlet of three diverse waste water treatment plants (WWTPs). Culturable HEVs were isolated in 80% of sewage samples: all isolates belonged to the HEV-B group and those circulating more intensely were CVB5 and Echo 6, while CVB4 was the predominant serotype found in 2010. In this study, two type 2 PVs were isolated, both characterized as Sabin like. CONCLUSION: Environmental monitoring of HEVs in Milan has proved to be an interesting tool to investigate the circulation and distribution of viruses. SIGNIFICANCE AND IMPACT OF THE STUDY: The detection of PV and other NPEV could be predictive of possible re-emergence of these viruses with an impact on public health. NPEV monitoring could also be a powerful public health tool to investigate the possible role of NPEV in different clinical manifestations.

Charged particle's flux measurement from PMMA irradiated by 80 MeV/u carbon ion beam.

Hadrontherapy is an emerging technique in cancer therapy that uses beams of charged particles. To meet the improved capability of hadrontherapy in matching the dose release with the cancer position, new dose-monitoring techniques need to be developed and introduced into clinical use. The measurement of the fluxes of the secondary particles produced by the hadron beam is of fundamental importance in the design of any dose-monitoring device and is eagerly needed to tune Monte Carlo simulations. We report the measurements carried out with charged secondary particles produced from the interaction of a 80 MeV/u fully stripped carbon ion beam at the INFN Laboratori Nazionali del Sud, Catania, with a poly-methyl methacrylate target. Charged secondary particles, produced at 90° with respect to the beam axis, have been tracked with a drift chamber, while their energy and time of flight have been measured by means of a LYSO scintillator. Secondary protons have been identified exploiting the energy and time-of-flight information, and their emission region has been reconstructed backtracking from the drift chamber to the target. Moreover, a position scan of the target indicates that the reconstructed emission region follows the movement of the expected Bragg peak position. Exploiting the reconstruction of the emission region, an accuracy on the Bragg peak determination in the submillimeter range has been obtained. The measured differential production rate for protons produced with E(Prod)(kin) > 83 MeV and emitted at 90° with respect to the beam line is dN(P)/(dN(C)dΩ) (E(Prod)(kin) > 83 MeV, θ = 90°) = (2.69 ± 0.08(stat) ± 0.12(sys)) × 10⁻4 sr⁻¹.

Automobile Shredder Residues in Italy: characterization and valorization opportunities.

At the moment Automobile Shredder Residue (ASR) is usually landfilled worldwide, but European draft Directive 2000/53/CE forces the development of alternative solutions, stating the 95%-wt recovery of an End of Life Vehicle (ELV) weight to be fulfilled by 2015. This work describes two industrial tests, each involving 250-300 t of ELVs, in which different pre-shredding operations were performed. The produced ASR materials underwent an extended characterization and some post-shredding processes, consisting of dimensional, magnetic, electrostatic and densimetric separation phases, were tested on laboratory scale, having as main purpose the enhancement of ASR recovery/recycling and the minimization of the landfilled fraction. The gathered results show that accurate depollution and dismantling operations are mandatory to obtain a high quality ASR material which may be recycled/recovered and partially landfilled according to the actual European Union regulations, with particular concern for Lower Heating Value (LHV), heavy metals content and Dissolved Organic Carbon (DOC) as critical parameters. Moreover post-shredding technical solutions foreseeing minimum economic and engineering efforts, therefore realizable in common European ELVs shredding plants, may lead to multi-purposed (material recovery and thermal valorization) opportunities for ASR reuse/recovery.

[Exposure to asbestos in buildings in areas of Basilicata characterized by the presence of rocks containing tremolite]. / Esposizione ad amianto in edilizia in aree della Basilicata caratterizzate dalla presenza di rocce contaminate da tremolite.

Lucania, in southern Italy, is characterized by areas with natural outcrops of rocks containing tremolite. The study aims to assess the risk of exposure to asbestos in the building workers in these areas through environmental sampling near sites for implementation of safety of roads built on serpentinite rocks and personal sampling in a group of persons who work in the building industry and a group of residents engaged in activities without contact with the ground. Near road sites was found the presence of airborne tremolite in 66% of environmental samples with peaks up to 31 ff/l. The analysis of personal samples showed the presence of tremolite in doses higher than the natural background in 100% of the building workers, while there were no fibers in the samples of residents employed in activities without soil disturbance. The study shows that the building in areas with naturally occurring asbestos determines a condition of significant occupational exposure to asbestos. Adequate safety measures for workers exposed are needed.

Importance of accurate diagnosis using real-time three-dimensional echocardiography in the surgical treatment of congenital intramitral ring in infants.

Congenital mitral ring is a rare type of congenital mitral stenosis. There are two types of mitral ring: the intramitral ring and the supramitral ring. Intramitral rings are often associated with complex valve pathology, and therefore have a worse prognosis than supramitral rings, in which the mitral apparatus is usually normal. The role of echocardiography in the evaluation of the mitral valve apparatus is crucial, because it allows an identification of the types of malformation, their hemodynamic repercussion and early predictors of the outcome. We describe two cases of intramitral ring, the diagnostic challenge they provided, and the value of the information obtained using real-time three-dimensional echocardiography in such cases.

Linguistic correlates of self in deceptive oral autobiographical narratives.

The current study collected orally-delivered autobiographical narratives from a sample of 44 undergraduate students. Participants were asked to produce both deceptive and non-deceptive versions of their narrative to two specific autobiographical question prompts while standing in front of a video camera. Narratives were then analyzed with Coh-Metrix software on 33 indices of linguistic cohesion. Following a Bonferroni correction for the large number of linguistic variables (p<.002), results indicated that the deceptive narratives contained more explicit action verbs, less linguistic complexity, and less referential coherence (sentences being cohesive with each other). The results support a theory that, in deceptive narratives, there is greater narrative distance between the self that narrates and the self that is narrated about. This suggests that narrative selves are constituted not as autonomous selves, but are subject to processes (e.g., psychological, linguistic, social) that are likely operating on a subconscious level.