A plea for an early ultrasound-clinical integrated approach in patients with acute heart failure. A proactive comment on the ESC Guidelines on Heart Failure 2016.

BACKGROUND: The European Association of Cardiology (ESC) Guidelines on the diagnosis and treatment of acute heart failure (AHF) indicate prompt therapy initiation and performance of relevant investigations as paramount. Specifically, echocardiography prior to treatment is advocated only with hemodynamic instability, and the evaluation of clinical signs of peripheral perfusion and congestion is suggested as guidance for early interventions. Given the growing body of evidence on the diagnostic/monitoring capabilities of bedside ultrasound (including focused cardiac ultrasound, comprehensive echocardiography, lung ultrasound), we discuss the potential benefit of an integrated clinical/ultrasound approach at the very early stages of acute heart failure. METHODS AND RESULTS: We proposed a narrative review of the current evidence on the clinical-ultrasound integrated approach to AHF, with special emphasis on the components of the early diagnostic-therapeutic workup where cardiac, inferior vena cava and lung ultrasound showed high diagnostic accuracy and the capability of substantially changing an exclusively clinically-oriented patient management. A proactive comment to the ESC guidelines is made, suggesting an integration of clinical and biochemical assessment, as defined by guidelines, with combined bedside ultrasound on may help in the definition of AHF pathophysiology and treatment. CONCLUSION: A multi-organ integrated clinical-ultrasound approach should be advocated as part of the clinical-diagnostic workup at AHF very early phase. Whenever competence and technology available, bedside ultrasound, along with clinical and biochemical assessment, should target AHF profiling, identify the cause of AHF, and subsequently aid disease course and response to treatment monitoring.

Competition between Superconductor - Ferromagnetic stray magnetic fields in YBa2Cu3O7-x films pierced with Co nano-rods.

Superconductivity and ferromagnetism are two antagonistic phenomena that combined can lead to a rich phenomenology of interactions, resulting in novel physical properties and unique functionalities. Here we propose an original hybrid system formed by a high-temperature superconducting film, patterned with antidots, and with ferromagnetic nano-rods grown inside them. This particular structure exhibits the synergic influence of superconductor (SC) - ferromagnetic (FM) stray fields, in both the superconducting behaviour of the film and the three-dimensional (3D) magnetic structure of nano-rods. We show that FM stray fields directly influence the critical current density of the superconducting film. Additional functionalities appear due to the interaction of SC stray fields, associated to supercurrent loops, with the non-trivial 3D remanent magnetic structure of FM nano-rods. This work unravels the importance of addressing quantitatively the effect of stray magnetic fields from both, the superconductor and the ferromagnet in hybrid magnetic nano-devices based on high temperature superconductors.

Lung ultrasound in the ICU: from diagnostic instrument to respiratory monitoring tool.

Imaging has greatly contributed to the understanding of lung disease in the critically ill and currently serves as a tool to diagnose lung pathology, monitor its course, and guide clinical management. Lung ultrasound is a real-time imaging modality that is simple, non-invasive, potentially ubiquitous, and free of ionizing radiation. Its increasing popularity and supporting research data substantiate its role as an emerging technique for bedside chest imaging in critical care. Furthermore, the International Consensus Conference on Lung ultrasound (ICC-LUS) promoted by the World Interactive Network Focused on Critical UltraSound (WINFOCUS) recently standardized the nomenclature and technique for lung ultrasound, and provided recommendations supporting its use in clinical practice. While the utility of lung ultrasound in the emergency setting is unquestioned, its potential role in the more complex and resource-rich intensive care environment is still under investigation. The purpose of this paper was to describe current and potential uses of lung ultrasound in the specific setting of adult intensive care, with an emphasis on respiratory monitoring, and to provide a framework for the practical application of this tool at the bedside.

Focused echocardiography entry level: new concept of a 1-day training course.

AIM: We describe a training programme for non-specialists in focused echocardiography in the periresuscitation setting which represents an entry level in echocardiography training (FEEL) for emergency and critical care medicine physicians. METHODS: A prospective observational study based upon the development of a periresuscitation echocardiography training programme developed for novice practitioners (N=15 courses). RESULTS: The programme enables novice echocardiographers to be able to perform a focused echocardiogram in an ALS-compliant manner, and interpret the findings in the context of the clinical scenario. It is based on the concept of blended learning, incorporating a combination of e-learning, web-based teaching and reading selected literature, and attendance at a course. The course comprises 4-hours of theory and 4-hours of hands-on training. CONCLUSIONS: Periresuscitation echocardiography, performed safely, within the competence of practitioners in an ALS-compliant manner is a potentially valuable skill to be acquired by physicians caring for the critically ill, regardless of the environment in which they work, or their level of seniority. This newly-developed blended learning periresuscitation echocardiography programme (FEEL) may serve as entry level in peri-resuscitation echocardiography for both emergency physicians and critical care practitioners.

Echocardiographic assessment of cardiovascular failure.

In the last few years echocardiography has gained an increasing role in critical care settings as invaluable tool for hemodynamic assessment of the unstable patient, due to its unique features of dynamic bedside imaging technique which can yield both morphologic and functional information. The main characteristics of cardiovascular function can be thoroughly explored, and a practical clinically-oriented approach can lead to answer the crucial questions of patient management, integrating (and often substituting) invasive monitoring, and allowing invasive monitoring pitfalls correction. Therapeutic impact of transesophageal echocardiography (TEE) has proven to be substantial in intensive care unit (ICU) population, although large randomized controlled studies are currently missing. Echocardiography requires specific training, but short training focused on the key hemodynamic information obtained from the shocked patient is proving to be effective. Echocardiographic hemodynamic evaluation should become part of routine assessment in the ICU soon, and critical care teams could achieve a hierarchic organization with respect to echocardiographic skills, with all members being at least able to perform a basic ultrasound examination of the heart, and a fewer who have gone through higher level formal training and board certification.

Pathophysiology of severe pulmonary hypertension in the critically ill patient.

Pulmonary hypertension (PH) is a threatening condition that can be associated with a great variety of both pulmonary and extrapulmonary diseases. In all forms of severe PH the pulmonary vascular bed looses its physiological features of a "high flow-low pressure system", putting an increased afterload on the right ventricle (RV). Acute pulmonary hypertension in the intensive care unit often represents a clinical problem secondary to acute respiratory failure, left heart failure, pulmonary embolism, or decompensation of prior PH by concurrent pulmonary or cardiovascular disease. Right ventricular failure (acute cor pulmonale) occurs when relevant increases in pulmonary vascular resistance overwhelm its compensatory mechanisms, both abruptly on a previously normal RV, or gradually on a chronic cor pulmonale. This review addresses the main pathophysiological aspects of severe PH, focusing on the hemodynamic derangements occurring in the setting of acute cor pulmonale, and emphasizing the role of ventricular interdependence (the way right ventricular failure greatly affects diastolic and systolic function of the left ventricle), the risk of RV ischemia (the end stage of RV failure) and systemic organ hypoperfusion (caused by antegrade and retrograde heart failure). The understanding of the peculiar features of this type of cardiovascular insufficiency is necessary to both provide effective monitoring and adequate supportive therapy.

Effect of hypothyroidism on hormone profiles in virgin, pregnant and lactating rats, and on lactation.

Thyroid dysfunctions can produce reproductive problems. Untreated maternal hypothyroidism has serious consequences on development of offspring, resulting in stunted growth and mental retardation. The effects of propylthiouracyl-induced hypothyroidism (0.1 g l(-1) in drinking water starting 8 days before mating, or given to virgin rats for 30 or 50 days) on the serum profiles of hormones related to reproduction and mammary function (prolactin, growth hormone (GH), progesterone, corticosterone, oestradiol, insulin-like growth factor I (IGF-I), thyroid-stimulating hormone (TSH), triiodothyronine and tetraiodothyronine), and on mammary function in virgin, pregnant and lactating rats, were investigated. Propylthiouracyl treatment severely decreased circulating triiodothyronine and tetraiodothyronine concentrations, and increased serum TSH concentrations. Virgin rats showed prolonged periods of vaginal dioestrus, increased circulating progesterone concentrations and afternoon peaks of prolactin concentration, which are indicative of prolactin-induced pseudopregnancy. Propylthiouracyl-treated virgin rats had mammary development comparable to that of midpregnancy, and half of these rats had increased mammary casein and lactose concentrations. Serum prolactin concentrations were decreased on the afternoon of day 5 of pregnancy, increased during late pregnancy (days 15-21) and were normal during lactation. Circulating GH concentrations decreased on days 15-21 of pregnancy, whereas progesterone concentrations increased during late pregnancy and early lactation. Circulating oestradiol (measured in late pregnancy and in virgin rats), IGF-I and corticosterone concentrations were decreased. Although assessment of mammary histology showed no differences in extent of development, casein content was increased in propylthiouracyl-treated rats on day 21 of pregnancy; litter growth was severely reduced and at day 20 of age the pups were hypothyroid, with decreased GH serum concentrations. An acute suckling experiment was performed on days 10-12 of lactation to determine whether some impairment in mammary function or the suckling reflex might account for these differences. After an 8 h separation of mothers from their litters and 30 min of suckling, circulating prolactin values were not affected by propylthiouracyl treatment, but serum oxytocin concentration and milk excretion were reduced. In conclusion, hypothyroidism induces various alterations in the hormone profiles of virgin and pregnant rats, and induces pseudopregnancies and mammary development in virgin rats. These alterations do not appear to have an overt impact on the outcome of pregnancy and on mammary function during lactation, with the exception of the milk ejection reflex, which may account at least partially for the reduced litter growth.