The use of veno-arterial extracorporeal membrane oxygenation in the octogenarian population: A single-center experience.

INTRODUCTION: Advanced age is a known risk factor for poor outcomes after veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for cardiac support. The use of ECMO support in patients over the age of 80 is controversial, and sometimes its use is contraindicated. We aimed to assess the use of ECMO in octogenarian patients to determine survival and complication rates. METHODS: A single-center, retrospective analysis was completed at a large, urban academic medical center. Patients requiring V-A ECMO support between December of 2012 and November of 2019 were included as long as the patient was at least 80 years of age at the time of cannulation. Post cardiotomy shock patients were excluded. RESULTS: A total of 46 patients met eligibility criteria; all received V-A ECMO support. Overall, the majority of patients (71.7%; 33/46) survived to decannulation, and 43.5% (20/46) survived to discharge. Patients who were previously rescued from percutaneous interventions tend to have a better survival than other patients (p = .06). The most common complications were renal and hemorrhagic. CONCLUSIONS: We demonstrated that advanced age alone should not disqualify patients from cannulating and supporting with V-A ECMO.

Acute humoral rejection in an infant without risk factors after heart transplantation.

Graft rejection is the most common factor that limits graft survival after transplantation. During infancy, the humoral immune system is partially suppressed and humoral rejection of a cardiac allograft has not been reported in the absence of risk factors such as prior transplantation, blood transfusions, ventricular assist devices, and elevation of panel reactive antibodies. We present a case of an infant with dilated cardiomyopathy who developed multiple episodes of acute humoral rejection after heart transplantation in the absence of risk factors.

Prehabilitation Maximizing Functional Mobility in Patients With Cardiogenic Shock Supported on Axillary Impella.

Physical therapy (PT) benefits for critically ill patients are well recognized; however, little data exist on PT in patients receiving temporary mechanical circulatory support. In this single-center retrospective study (February 2017-January 2022), we analyzed 37 patients who received an axillary Impella device (Abiomed, Danvers, MA) and PT to "prehabilitate" them before durable left ventricular assist device (dLVAD) implantation. The Activity Measure for Post-Acute Care (AM-PAC) Basic Mobility tool assessed the functional status at different points during admission. Immediately after Impella placement, the median AM-PAC score was 12.7 (interquartile range [IQR], 9-15), and the scores continued to significantly increase to 18.4 (IQR, 16-23) before dLVAD and up to 20.7 (IQR, 19-24) at discharge, indicating improved independence. No PT-related complications were reported. Thus, we hypothesize that critically ill patients initially deemed equivocal candidates may safely participate in PT while maximizing functional activities before dLVAD placement.

Intrapericardial delivery of amiodarone rapidly achieves therapeutic levels in the atrium.

BACKGROUND: Amiodarone is widely used worldwide as an important drug for managing supraventricular arrhythmias, regardless of its association with potentially severe side effects due to systemic toxicity. Amiodarone reduces the incidence of atrial fibrillation after cardiac surgery, but oral therapy requires a presurgery loading period, lasting from 1 to 4 weeks. In this study, we showed that it is possible to rapidly obtain therapeutic cardiac tissue levels of the drug by infusing aqueous amiodarone intrapericardially, without appreciable systemic exposure. We also examined the long-term histologic safety of intrapericardial infusion. METHODS: In this observational study, 9 adult sheep, randomized into 3 groups of 3 animals each, were given low (2.5 -mg/h), medium (10-mg/h), or high (50-mg/h) dosages of amiodarone by continuous infusion intrapericardially for 72 hours. An intrapericardial drain prevented tamponade from fluid build-up. Levels of amiodarone and its active metabolite, desethylamiodarone (DEA), were assessed both in plasma and in transmural biopsy specimens taken from the left atrial appendage and left and right ventricular myocardium. Cardiac, hepatic, and renal functions were also assessed. Humane euthanization was performed after 3 months, and cardiac and thoracic tissues were assessed for evidence of epicarditis, severe fibrotic changes, or other adverse effects potentially caused by the local amiodarone administration. RESULTS: Pericardial infusion resulted in rapid uptake and high concentrations of amiodarone and DEA in the myocardial tissues, without an appreciable systemic presence of either drug. The highest and lowest levels of these agents were observed in the left atrium and left ventricle, respectively. Drug concentrations in all cardiac biopsy specimens were similar to, or higher than, those reportedly observed in patients taking long-term oral amiodarone. At 90 days, postmortem microscopic, biochemical, and hematologic evaluation of end-organ tissues from the 8 surviving sheep showed no adverse effects. Excessive inflammation or fibrotic changes were not observed in these 8 sheep. The ninth sheep died prematurely, and its death was deemed not to be related to this study. CONCLUSIONS: Short-term intrapericardial delivery of amiodarone is a safe method for rapidly obtaining therapeutic atrial-tissue drug levels. When begun perioperatively, this method may prevent postoperative atrial fibrillation similarly to oral or intravenous amiodarone therapy. However, we have shown that pericardial administration avoids systemic drug distribution and thus may greatly decrease the systemic complicationsresulting from this drug.

Perioperative Impella 5.5 Support for Surgical Aortic Valve Replacement: Pull Back/Push Through Technique, Safeguards, and Pitfalls.

In patients undergoing aortic valve surgery, preoperative reduced left ventricular ejection fraction is not uncommon and is associated with poor outcomes. Mechanical circulatory support (MCS) may be preemptively used in patients presenting with high periprocedural risk. The Impella 5.5 is a percutaneous left ventricular assist device that has been increasingly used in various cardiac surgeries. In this article, we present a step-by-step guide, safeguards, and pitfalls on how to replace the aortic valve and preserve this transaortic MCS device for postoperative support in patients with concomitant aortic valve pathology and left ventricular dysfunction.

Surgical Explantation of Impella 5.5 With Inflow Thrombus in Patients Undergoing Durable Left Ventricular Assist Device Implantation.

The Impella 5.5® (Abiomed, Danvers, MA, USA) is a microaxial flow pump that promotes left ventricular unloading and improves end-organ perfusion before durable left ventricular assist device (LVAD) implantation. Thrombus formation after Impella 5.5 insertion can occur and represents a significant challenge to device explantation. Durable LVAD implantation is typically performed without aortic cross-clamping, so a dislodged thrombus can potentially embolize and lead to catastrophic events. We describe our technique to safely explant an Impella 5.5 in patients who develop a thrombus on the inflow portion of the device before surgical LVAD implantation.

Use of Percutaneous Left Ventricular Assist Device Before Durable Device Implantation in Patients With Cardiac Cachexia: Case Series.

Frailty and malnutrition in patients with heart failure are barriers to durable left ventricular assist device (D-LVAD) support and heart transplantation. Moreover, cachexia in patients with advanced heart failure carries a high mortality risk. There are no guidelines for these patients other than increased caloric intake and rehabilitation. Patients suffering from cardiac cachexia and heart failure may benefit from temporary, percutaneous assist device support to improve the underlying heart disease and reverse the catabolic state. We retrospectively reviewed patients from January 2017 to January 2022. All patients who received Impella support (5.0 or 5.5, Abiomed) before D-LVAD implantation were screened. Those who met the criteria for cardiac cachexia were included. Patient demographics, nutritional and biochemical markers, and survival data were collected. A total of 14 patients were included. The majority of patients were male (85.7%) with ischemic cardiomyopathy (64.3%). Caloric intake, physical strength, and ambulation improved. Prealbumin levels improved from a median of 13.7-18.0 mg/dl ( p < 0.006) while on Impella 5.0 or 5.5 support. All patients survived to discharge and the 6 month follow-up. In conclusion, use of the Impella device improves cardiogenic shock symptoms and, consequently, may improve cachexia status prior to D-LVAD implantation.

Surgically Implanted Impella Device for Patients on Impella CP Support Experiencing Refractory Hemolysis.

The Impella CP (Abiomed Inc., Danvers, MA) is widely used in cardiac catheterization laboratories for patients presenting with cardiogenic shock, but it is also known to cause significant hemolysis. The risk of hemolysis can be reduced by properly positioning the device, ensuring an adequate volume status, and using full anticoagulation strategies; however, in some cases hemolysis persists. We present a case series of eight patients that were diagnosed with cardiogenic shock, underwent Impella CP placement, and then suffered from refractory hemolysis which was treated by upgrading the Impella device to the 5.0 or 5.5 version. Fifty percent (4/8) of the patients in this series were already receiving continuous renal replacement therapy, and the levels of plasma free hemoglobin (pFHb) and lactate dehydrogenase continued to increase after the implantation of the Impella CP. The median time between Impella CP placement and the diagnosis of refractory hemolysis was 16.5 hours (interquartile range [IQR], 8.0-26.0). The median time between the diagnosis of hemolysis to Impella upgrade was 6.0 hours (IQR, 4.0-7.0). A total of 87.5% (7/8) of patients experienced a drop in pFHb to below 40 mg/dl at 72 hours post-Impella upgrade, and they were discharged without any further need of dialysis. One patient expired due to irreversible multiple organ failure. We propose that early identification of hemolysis by close monitoring of pFHb and upgrading to the Impella 5.5 reduces hemolysis, prevents further kidney damage, and significantly improves clinical outcomes.

Transaortic Placement of Percutaneous Mechanical Support Device via Partial Sternotomy: Feasible Option for Unsuitable Axillary Artery Access.

Acute decompensated refractory cardiogenic shock is an emergency in which the prompt instauration of mechanical circulatory support improves outcomes. The typical, initial approach for device delivery is via femoral vessels due to easy access and safety. If longer support is needed, the femoral access will severely impair the patient's mobility and can also limit the amount of support given as the new-generation devices are too large for direct arterial insertion. Upper-body arterial conduits (UBACs) are used for the delivery of larger, percutaneous ventricular assist devices (pVADs). The Impella 5.5 (Abiomed, Danvers, MA, USA) is a pVAD that can be deployed through a UBAC by either axillary/subclavian access or a transaortic approach. The latter approach is typically used in cases of postcardiotomy shock, in which the ascending aorta is already exposed through a full sternotomy. However, in some cases, the axillary artery is not suitable due to size (<6 mm in diameter), and a smaller pVAD is delivered into the heart. To avoid providing suboptimal support, we present an alternative, minimally invasive approach in which the larger device is delivered through the ascending aorta. This article summarizes the details of this approach through a mini upper partial sternotomy and reviews the relevant technical considerations.

Left Ventricular Rupture After Impella® Placement During High-Risk Percutaneous Coronary Intervention.

Ventricular perforation is a rare complication during a high-risk percutaneous coronary intervention (PCI) when supported by Impella® (Abiomed). However, instrumentation of the left ventricle several days after transmural infarct potentially increases susceptibility for perforation. While a patient is on Impella support, physicians should review ventriculograms carefully to detect perforation and should consider the presence of a decompressed ventricle, the absence of normal systolic pressure and the movement of contrast from the ventricle into the aorta bypassing the left ventricular ejection. Immediate removal of the Impella if a perforation occurs must be avoided. Retrieving the device would risk a catastrophic bleed, while alternative repair techniques are available. Here, we describe a patient with a left ventricle perforation that occurred during a high-risk PCI supported by an Impella device. ANNOTATED SUMMARY: The repair of a left ventricle perforation during high-risk PCI in a patient who had an unrecognized left ventricular perforation is described. Physicians are encouraged to carefully review ventriculograms to identify the subtle changes that can indicate a perforation. Further, immediate removal of the temporary LVAD should be avoided to minimize the risk of catastrophic bleeds.

Resident training experience with robotic assisted transabdominal preperitoneal inguinal hernia repair.

BACKGROUND: General surgery is the fastest growing field in the adoption of robotic assisted laparoscopic surgery. Here, we present the results of one institution's experience in training surgical residents in robotic assisted transabdominal preperitoneal inguinal hernia repairs. METHODS: Data were prospectively collected on patients undergoing robotic assisted laparoscopic inguinal hernia repair with residents. Data points included patient age, gender, complications, hernia difficulty, resident technical competency as measured by GEARS, Zwisch scores, operative time, and the number of robotic console cases reported by residents as primary surgeon. RESULTS: Residents who performed >30 robotic cases had significantly higher mean modified GEARS scores (p ≤ .002). Residents who completed 10 or fewer robotic cases achieved significantly lower mean modified GEARS and Zwisch scores than those who completed 11 or more (p < .001). CONCLUSIONS: Resident competency and autonomy improve with increasing total robotic case load. Attending surgeons grant more autonomy to residents with higher competency scores.

Axillary Access TAVR: Entrapment of a Transcatheter Aortic Valve in the Innominate Artery With Aortic Dissection.

Non-femoral transcatheter aortic valve replacement (TAVR) is indicated when peripheral vascular disease is diagnosed. We describe the "double-stick" technique via the axillary artery. During the procedure, the pigtail coiled around the TAVR system. While retracting the TAVR sheath, the seam along system split dislodging the valve from the balloon. The valve was entrapped in the innominate artery, and an aortic dissection required surgery. With the double-stick technique, friction and resistance between the pigtail and delivery system must be avoided. Pre-procedural planning and early identification is paramount. Smaller and more seamless delivery systems may reduce risk for dissection and entrapment.

Classification of ADHD and Non-ADHD Subjects Using a Universal Background Model.

ADHD affects a major portion of our children, predominantly boys. Upon diagnosis treatment can be offered that is usually quite effective. Diagnosis is generally based on subjective observation and interview. As a result, an objective test for the detection or presence of ADHD is considered very desirable. Based on EEG, across multiple channels, using autoregressive model parameters as features, ADHD detection is approached here in analogy with the imposter problem known from speaker verification. Gaussian mixture models are used to define ADHD and universal background models so that a likelihood ratio detector can be designed. The efficacy of this approach is reflected in the traditional detector performance measures of the area-under-the-curve and equal-error-probability. The results - based on a limited database of males, approximately 6 years of age - indicate that high probability of detection and low equal error rate can be achieved simultaneously with the proposed approach, when using EEG collected during an attention network task. The effect of using contaminated data is investigated as well.

Microplásticos en la sardina Sardinella aurita (Teleostei: Clupeidae) en Sucre, Venezuela / Microplastics in the sardine Sardinella aurita (Teleostei: Clupeidae) in Sucre, Venezuela

Resumen Introducción: La creciente presencia de plásticos en los ecosistemas acuáticos ha sido considerada como un problema ambiental emergente global. Existen estudios que han demostrado que los microplásticos pueden ser ingeridos por una variedad de organismos acuáticos. La variabilidad natural e importancia del recurso sardina, son razones suficientes para evaluar la presencia de estas partículas en el contenido estomacal, y así generar información acerca de las implicaciones de ingestión de estos contaminantes emergentes. Objetivo: Evaluar la presencia de microplásticos en el contenido estomacal de la sardina y su correlación con la condición fisiológica y reproductiva de los peces estudiados. Metodología: Se evaluaron un total de 800 sardinas, entre abril y mayo del 2022. Se midieron las variables morfométricas longitud total y peso, se determinó el factor de condición y el índice gonadosomático. Se extrajo el tracto digestivo y se determinó el peso del estómago lleno y vacío, además del peso del contenido estomacal para determinar el índice de repleción y vacuidad. Las variables determinadas se correlacionaron con la abundancia de microplásticos. El contenido estomacal fue procesado para extraer los microplásticos y caracterizarlos de forma física. Resultados: El índice de repleción presentó diferencias mensuales; su promedio fue de 0.311. El índice de vacuidad promedio fue de 0.276. La abundancia de microplásticos promedio fue 3 066 ítems, con diferencias mensuales e interacción con respecto al sexo y una frecuencia de aparición de 70.125 %, con un total de 2 402 fibras y 57 fragmentos. Las fibras negras fueron las más abundantes (947 ítems). Encontramos correlaciones bajas y positivas entre la abundancia de microplásticos, el índice gonadosomático y el peso de los organismos. Conclusiones: Estos resultados no pueden ser concluyente con respecto a las consecuencias causadas por este contaminante emergente. Mas estudios son necesarios, incluyendo ensayos de laboratorios con metodologías estandarizadas.

Abstract Introduction: The increasing presence of plastics in aquatic ecosystems has been considered as an emerging global environmental problem. Studies have shown that microplastics can be ingested by a variety of aquatic organisms. The natural variability and importance of the sardine resource are sufficient reasons to evaluate the presence of these particles in stomach contents, and thus generate information about the ingestion implications of these emerging contaminants. Objective: To evaluate the presenc e of microplastics in the stomach contents of sardines and their correlation with the physiological and reproductive condition of the fish studied. Methodology: We evaluated a total of 800 sardines between April and May 2022. We measured total length and weight, and determined the condition factor and the gonadosomatic index. We removed the digestive tract and weighed the stomach both empty and full, as well as the stomach contents to determine the repletion and emptiness index. We correlated the determined variables with the abundance of microplastics. We extracted microplastics and characterized them physically. Results: The filling index presented monthly differences with an average of 0.311. The average vacancy index was 0.276. The average abundance of microplastics was 3 066 items, with monthly differences and interaction with respect to sex and a frequency of appearance of 70.125 %, with a total of 2 402 fibers and 57 fragments. Black fibers were the most abundant (947 items). Low and positive correlations were found between the abundance of microplastics, the gonadosomatic index and the weight of the organisms. Conclusions: These results cannot be conclusive as to the consequences caused by this emerging pollutant. Further study is necessary, including laboratory tests with standardized methodologies.

Classification of ADHD and non-ADHD using AR models.

Accurate and confident diagnosis of ADHD is highly dependent on subjective observations. Several quantitative methods have been proposed, posing it as a two-class classification problem (ADHD and non-ADHD). However, the results have not made it past the research stage yet, as misclassification rates must be close to 0%. This study aims to discriminate ADHD and non-ADHD subjects using autoregressive models, with a high level of accuracy (85-95%). In addition, a confidence metric is proposed, expressing with how much confidence the classification of ADHD and non-ADHD subjects is made.

Sensing and visualization tools for objective assessment and debriefing of high-risk neonatal resuscitation training scenarios.

We present TeamVis, a set of tools for sensing and visualization of objective team performance in a simulated medical scenario. TeamVis helps teams, instructors, and researchers in observation, analysis, and evaluation of team behavior. The current system supports analysis of team movements and verbal communication. The system has potential to provide deeper insight into team performance, enabling design of more effective simulation training scenarios. Furthermore, the observed metrics can aid trainee debriefings by providing another mechanism for learning through self-reflection.

Terapia de rehidratacion oral en pacientes deshidratados por diarrea aguda infantil / Oral rehydration therapy in children with acute diarrhea and dehydration

La Terapia de Rehidratación Oral (TRO) se ha convertido en las últimas décadas en la piedra angular del tratamiento de las enfermedades diarreicas, constituyendo un gran avance para tratar en forma segura y eficaz la deshidratación producida por diarrea de diversas etiologías en todas las edades, excepto cuando la deshidratación es grave. La composición de las soluciones de rehidratación oral (SRO) ha sido objeto de controversias relacionadas con el contenido de electrolitos, bicarbonato, osmolaridad, transportadores, y micronutrientes. Sin embargo, los resultados de investigaciones promovidas por la Organización Mundial de la Salud (OMS) y el Fondo para la Infancia de las Naciones Unidas (UNICEF) en el año 2001, recomiendan el uso de las SRO de Osmolaridad Reducida (SROOR) ya que estas muestran superioridad significativa, en los resultados clínicos, sobre las SRO estándar (SRO-S). En el texto, a continuación, se describen las bases fisiológicas de la terapia de la rehidratación oral, la composición y características de las SRO, la evaluación clínica de la deshidratación, los planes de hidratación en casos de diarrea, y la terapia de rehidratación oral en el niño desnutrido.

Oral rehydration therapy (ORT) has been in the last decades the corner stone of the therapy for diarrheic diseases, this type of treatment produced a great improvement in safety and efficiency in the therapy of diarrheas of diverse etiologies, in all ages, with the only exception of serious dehydration. The therapy of diarrheas with oral rehydration solutions (ORS) has triggered numerous controversies related to the composition of the solutions on the basis of electrolytes content, sodium bicarbonate, osmolality, transporters, and micronutrients. However, the results of the research conducted, in 2001, by the World Health Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF), recommend the use of the ORS of reduced osmolality (ORS-R), because this kind of therapy shows a meaningful superiority in the clinical outcome of the patients, when compared with the ORS of standard osmolality (ORS-S). In the text, we describe the physiological basis for oral therapy rehydration, the composition and characteristics of ORS, the clinical evaluation of dehydration, different therapy treatments for hydration in diarrheic disease, and the use of therapy of oral rehydration in malnourished infant.

Manejo nutricional del prematuro / Nutritional manaement of preterm newborn

La nutrición del recién nacido prematuro o de bajo peso constituye un desafío para el pediatra y el neonatólogo desde el nacimiento y hasta bien avanzada la infancia. Uno de los mayores retos es mantener una ganancia de peso similar al crecimiento fetal hasta que el neonato alcance las 40 semanas de edad postconcepcional, y luego lograr un crecimiento que garantice eventualmente, una talla acorde a la edad cronológica, adecuada mineralización ósea y un óptimo neurodesarrollo. Todas estas metas se pueden alcanzar con el inicio precoz de la alimentación enteral, incluso nutrición trófica, en aquellos neonatos difíciles de alimentar y sin contraindicación de la vía oral; así como con el empleo de leche humana, la suplementación y/o fortificación cuando los requerimientos sean mayores y/o la ganancia de peso sea insuficiente, y el adecuado seguimiento de las variables antropométricas y bioquímicas que evidencian un crecimiento saludable.

The nutrition of the premature or low birth weight newborn is a challenge for the pediatrician and neonatologist from birth and up to advanced childhood. One of the biggest challenges is to keep a weight gain similar to fetal growth until the neonate achieves 40 weeks of postconcepcional age, and subsequently achieve a growth rate that guarantees, eventually, the goal of a length according to chronological age, proper bone mineralization and an optimal neurodevelopment. All these goals can be reached with the early commencement of enteral feeding, even with trophic nutrition in those hard-to-feed infants without contraindication to eat; the use of human milk, supplementation or fortification when the requirements are higher, and/or weight gain is too low and with the appropriate follow-up of the anthropometric and biochemical measurements that evidence a healthy growth.