Intraoperative goal directed hemodynamic therapy in noncardiac surgery: a systematic review and meta-analysis

Background: The goal directed hemodynamic therapy is an approach focused on the use of cardiac output and related parameters as end-points for fluids and drugs to optimize tissue perfusion and oxygen delivery. Primary aim: To determine the effects of intraoperative goal directed hemodynamic therapy on postoperative complications rates. Methods: A meta-analysis was carried out of the effects of goal directed hemodynamic therapy in adult noncardiac surgery on postoperative complications and mortality using Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. A systematic search was performed in Medline PubMed, Embase, and the Cochrane Library (last update, October 2014). Inclusion criteria were randomized clinical trials in which intraoperative goal directed hemodynamic therapy was compared to conventional fluid management in noncardiac surgery. Exclusion criteria were trauma and pediatric surgery studies and that using pulmonary artery catheter. End-points were postoperative complications (primary) and mortality (secondary). Those studies that fulfilled the entry criteria were examined in full and subjected to quantifiable analysis, predefined subgroup analysis (stratified by type of monitor, therapy, and hemodynamic goal), and predefined sensitivity analysis. Results: 51 RCTs were initially identified, 24 fulfilling the inclusion criteria. 5 randomized clinical trials were added by manual search, resulting in 29 randomized clinical trials in the final analysis, including 2654 patients. A significant reduction in complications for goal directed hemodynamic therapy was observed (RR: 0.70, 95% CI: 0.62-0.79, p < 0.001). No significant decrease in mortality was achieved (RR: 0.76, 95% CI: 0.45-1.28, p = 0.30). Quality sensitive analyses confirmed the main overall results. Conclusions: Intraoperative goal directed hemodynamic therapy with minimally invasive monitoring decreases postoperative complications in noncardiac surgery, although it was not able to show a significant decrease in mortality rate

Embedded bleeding detector into a PMMA applicator for electron intraoperative radiotherapy

Purpose: The aim of this work is to present a ready to industrialize low-cost and easy-to-install bleeding detector for use in intraoperative electron radiation therapy (IOERT). The detector works in stand-alone mode and is embedded into a translucent polymethylmethacrylate (PMMA) applicator avoiding any contact with the patient, which represent a novelty compared to previous designs. The use of this detector will prevent dose misadministration during irradiation in the event of accumulation of fluids in the applicator. Methods: The detector is based on capacitive sensor and wireless power-supply electronics. Both sensor and electronics have been embedded in the applicator, so that any contact with the patient would be avoided. Since access to the tumor can be done through different trajectories, the detector has been calibrated for different tilting angles. Results: The result of the calibration provides us with a fit curve that allows the interpolation of the results at any angle. Comparison of estimated fluid height vs real height gives an error of 1 mm for tilting angles less than 10º and 2 mm for tilting angles greater than 15º. This accuracy is better than the one required by clinic. Conclusions: The performance of the bleeding detector was evaluated in situ. No interference was observed between the detector and the beam. In addition, a user-friendly mobile application has been developed to help the surgical team making decisions before and during irradiation. The measurement provided by the mobile application was stable during the irradiation process

Impacto de un programa de recuperación intensificada en cistectomía radical. Estudio comparativo de cohortes

Objetivo: Evaluar los resultados de la instauración de un programa de recuperación intensificada (ERAS) para cistectomía radical en abordaje abierto con respecto a la cohorte histórica de un mismo hospital. Material y métodos: Estudio de análisis retrospectivo de 138 pacientes sometidos a cistectomía radical con derivación ileal tipo Bricker o Studer de forma consecutiva (97 históricos vs. 41 ERAS). Se compararon tasa de complicaciones a 30 días, complicaciones estadio Clavien-Dindo > 2, mortalidad, estancia y tasa de readmisión en el hospital y en cuidados críticos, reintervención y necesidad de sondaje nasogástrico, trasfusión o nutrición parenteral. Resultados: No se hallaron diferencias estadísticamente significativas en cuanto a la tasa de complicaciones globales tras 30 días de alta (73,171 vs. 77.32%; OR 1,25, IC 95% 0,54-2,981; p = 0,601) ni en Clavien-Dindo > 2 (41,463 vs. 42.268%; OR 1.033, IC 95% 0,492-2,167; p = 0,93), así como en mortalidad, estancias o tasas de readmisión y reintervención. La necesidad de sondaje nasogástrico fue menor en el grupo ERAS (43,902 vs. 78,351%; OR 4,624, IC 95% 2,112-10,123; p < 0,0001), así como la necesidad de nutrición parenteral total (26,829 vs. 34,021%; OR 12,234, IC 95% 5,165-28,92; p < 0,0001) y el tiempo bajo intubación orotraqueal desde la inducción anestésica (mediana [RIC] = 325 (285-355) vs. 540 (360-600) min; p < 0,0001). Conclusión: Los programas de recuperación intensificada en cistectomía radical disminuyen el intervencionismo sobre el paciente sin aumentar la morbimortalidad

Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial)

Background The aim of this study was to evaluate postoperative complications in patients having major elective surgery using oesophageal Doppler monitor-guided goal-directed haemodynamic therapy (GDHT), in which administration of fluids, inotropes, and vasopressors was guided by stroke volume, mean arterial pressure, and cardiac index. Methods The FEDORA trial was a prospective, multicentre, randomised, parallel-group, controlled patient- and observer-blind trial conducted in adults scheduled for major elective surgery. Randomization and allocation were carried out by a central computer system. In the control group, intraoperative fluids were given based on traditional principles. In the GDHT group, the intraoperative goals were to maintain a maximal stroke volume, with mean arterial pressure >70 mm Hg, and cardiac index ≥2.5 litres min−1 m−2. The primary outcome was percentage of patients with moderate or severe postoperative complications during the first 180 days after surgery. Results In total, 450 patients were randomized to the GDHT group (n=224) or control group (n=226). Data from 420 subjects were analysed. There were significantly fewer with complications in the GDHT group (8.6% vs 16.6%, P=0.018). There were also fewer complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections, etc.), and length of hospital stay was shorter in the GDHT group. There was no significant difference in mortality between groups. Conclusions Oesophageal Doppler monitor-guided GDHT reduced postoperative complications and hospital length of stay in low–moderate risk patients undergoing intermediate risk surgery, with no difference in mortality at 180 days

Cloud condensation nuclei activation properties of Mediterranean pollen types considering organic chemical composition and surface tension effects

Wind-dispersed pollen grains emitted from vegetation are directly injected into the atmosphere being an important source of natural aerosols globally. These coarse particles of pollen can rupture into smaller particles, known as subpollen particles (SPPs), that may act as cloud condensation nuclei (CCN) and affect the climate. In this study, we characterize and investigate the ability of SPPs of 10 Mediterranean-climate pollen types to activate as CCN. A continuous flow CCN counter (CCNC) was used to measure the activation of size-selected (80, 100 and 200 nm dry mobility diameter) particles at different supersaturations (SS). Hygroscopicity parameter (κ) for each SPP type and size has been calculated using κ-Köhler theory. Organic chemical speciation and protein content has been determined to further characterize pollen solutions. Furthermore, the surface activity of SPPs has also been investigated by using pendant drop tensiometry. All studied SPP samples show critical supersaturation (SSCrit) values that are atmospherically relevant SS conditions. Hygroscopicity κ values are in the range characteristic of organic compounds (0.1–0.3). We found that organic speciation and protein content vary substantially among pollen types, with saccharides and fatty acids being the only organic compounds found in all pollen types. A clear relationship between SPP activation and its organic composition was not observed. This study also reveals that all SPPs investigated reduce the surface tension of water at high concentrations but at diluted concentrations (such as those of activation in the CCNC), the water surface tension value is a good approximation in Köhler theory. Overall, this analysis points out that pollen particles might be an important source of CCN in the atmosphere and should be considered in aerosol-cloud interactions processes.This work was supported by BioCloud project (RTI2018.101154.A.I00) funded by MCIN/AEI/10.13039/501100011033, FEDER “Una manera de hacer Europa” and NUCLEUS project (PID2021-128757OB-I00) funded by MCIN/AEI/10.13039/501100011033 and NextGenerationEU/PRTR. This work received support from the European Union's Horizon 2020 research and innovation program through projects ACTRIS.IMP (grant agreement No 871115) and ATMO_ACCESS (grant agreement No 101008004), by the Spanish Ministry of Science and Innovation through projects ELPIS (PID2020-120015RB-I00) and ACTRIS-España (CGL2017-90884REDT)). By the Junta de Andalucía Excellence, project ADPANE (P20-00136), AEROPRE (P-18-RT-3820) and by University of Granada Plan Propio through Visiting Scholars (PPVS2018-04), Singular Laboratory (LS2022-1) programs and Pre-Competitive Research Projects Pre-Greenmitigation3 (PP2022.PP34). Funding for open access charge, University of Granada/CBUA. Andrea Casans is funded by Spanish ministry of research and innovation under the predoctoral program FPI (PRE2019-090827) funded by MCIN/AEI/10.13039/501100011033, FSE “El FSE invierte en tu futuro”. Fernando Rejano is funded by Spanish ministry of universities through predoctoral grant FPU19/05340. Juan Andrés Casquero-Vera is funded by FJC2021-047873-I, MCIN/AEI/10.13039/501100011033 and NextGenerationEU/PRTR. Elisabeth Andrews is funded in part by NOAA cooperative agreements NA17OAR4320101. Thanks to the NOAA Global Monitoring Laboratory for the use of the CCN counter.Peer reviewe

Phenomenology of ultrafine particle concentrations and size distribution across urban Europe

The 2017-2019 hourly particle number size distributions (PNSD) from 26 sites in Europe and 1 in the US were evaluated focusing on 16 urban background (UB) and 6 traffic (TR) sites in the framework of Research Infrastructures services reinforcing air quality monitoring capacities in European URBAN & industrial areaS (RI-URBANS) project. The main objective was to describe the phenomenology of urban ultrafine particles (UFP) in Europe with a significant air quality focus. The varying lower size detection limits made it difficult to compare PN concentrations (PNC), particularly PN10-25, from different cities. PNCs follow a TR > UB > Suburban (SUB) order. PNC and Black Carbon (BC) progressively increase from Northern Europe to Southern Europe and from Western to Eastern Europe. At the UB sites, typical traffic rush hour PNC peaks are evident, many also showing midday-morning PNC peaks anti-correlated with BC. These peaks result from increased PN10-25, suggesting significant PNC contributions from nucleation, fumigation and shipping. Site types to be identified by daily and seasonal PNC and BC patterns are: (i) PNC mainly driven by traffic emissions, with marked correlations with BC on different time scales; (ii) marked midday/morning PNC peaks and a seasonal anti-correlation with PNC/BC; (iii) both traffic peaks and midday peaks without marked seasonal patterns. Groups (ii) and (iii) included cities with high insolation. PNC, especially PN25-800, was positively correlated with BC, NO2, CO and PM for several sites. The variable correlation of PNSD with different urban pollutants demonstrates that these do not reflect the variability of UFP in urban environments. Specific monitoring of PNSD is needed if nanoparticles and their associated health impacts are to be assessed. Implementation of the CEN-ACTRIS recommendations for PNSD measurements would provide comparable measurements, and measurements of <10 nm PNC are needed for full evaluation of the health effects of this size fraction

Impact of desert dust on new particle formation events and the cloud condensation nuclei budget in dust-influenced areas

Detailed knowledge on the formation of new aerosol particles in the atmosphere from precursor gases, and their subsequent growth, commonly known as new particle formation (NPF) events, is one of the largest challenges in atmospheric aerosol science. High pre-existing particle loadings are expected to suppress the formation of new atmospheric aerosol particles due to high coagulation and condensation (CS) sinks. However, NPF events are regularly observed in conditions with high concentrations of pre-existing particles and even during intense desert dust intrusions that imply discrepancies between the observations and theory. In this study, we present a multi-site analysis of the occurrence of NPF events under the presence of desert dust particles in dust-influenced areas. Characterization of NPF events at five different locations highly influenced by desert dust outbreaks was done under dusty and non-dusty conditions using continuous measurements of aerosol size distribution in both fine and coarse size fractions. Contrary to common thought, our results show that the occurrence of NPF events is highly frequent during desert dust outbreaks, showing that NPF event frequencies during dusty conditions are similar to those observed during non-dusty conditions. Furthermore, our results show that NPF events also occur during intense desert dust outbreaks at all the studied sites, even at remote sites where the amounts of precursor vapours are expected to be low. Our results show that the condensation sink associated with coarse particles (CSC) represents up to the 60 % of the total CS during dusty conditions, which highlights the importance of considering coarse-fraction particles for NPF studies in desert-dust-influenced areas. However, we did not find a clear pattern of the effect of desert dust outbreaks on the strength of NPF events, with differences from site to site. The particle growth rate (GR) did not present a clear dependence on the CS during dusty and non-dusty conditions. This result, together with the fact that desert dust has different effects on the growth and formation rates at each site, suggests different formation and growth mechanisms at each site between dusty and non-dusty conditions, probably due to differences in precursor vapours' origins and concentrations as well as changes in the oxidative capacity of pre-existing particles and their effectiveness acting as CS. Further investigation based on multiplatform measurement campaigns and chamber experiments with state-of-the-art gaseous and particulate physical and chemical properties measurements is needed to better understand the role of catalyst components present in desert dust particles in NPF. Finally, our results reveal a significant impact of NPF events on the cloud condensation nuclei (CCN) budget during desert dust outbreaks at the studied sites. Therefore, since desert dust contributes to a major fraction of the global aerosol mass load, and since there is a foreseeable increase in the frequency, duration and intensity of desert dust episodes due to climate change, it is imperative to improve our understanding of the effect of desert dust outbreaks on NPF and the CCN budget for better climate change prediction.Juan Andrés Casquero-Vera is funded by FJC2021-047873-I, by MCIN/AEI/10.13039/501100011033 and NextGenerationEU/PRTR, by Spanish Ministry of Universities and the European Union – NextGenerationEU, and by the Academy of Finland through ACCC Flagship (Atmosphere and Climate Competence Center, project no. 337549). This research has been partially supported by the Spanish Ministry of Science and Innovation (grant nos. PID2020-120015RB-I00, RED2022-134824-E, PID2019-108990RB-I00 and PID2021-128757OB-I00 funded by MCIN/AEI/10.13039/501100011033) and by the European Union's Horizon 2020 Research and Innovation programme through projects ACTRIS IMP (grant no. 871115) and ATMO ACCESS (grant no. 101008004) and via Horizon Europe through “Non-CO2 Forcers and their Climate, Weather, Air Quality and Health Impacts”, FOCI (project no. 101056783). This research was also partially supported by Plan Propio of University of Granada through EMERALD project (PPJIA2022-15) and the Singular Laboratory AGORA programme (LS2022-1) and Scientific Units of Excellence Program (grant no. UCE-PP2017-02) and by the Consejo Superior de Investigaciones Científicas (CSIC) under project 202030E261. Measurements at Hada Al Sham were funded by the Deanship of Scientific Research (DSR; grant no I-122-430) at King Abdulaziz University (KAU).Peer reviewe

Sensing Wood Moisture in Heritage and Wooden Buildings: A New Sensing Unit With an Integrated LoRa-Based Monitoring System

The rapid development of LoRa and LoRaWAN received a wide interest in research in order to understand the performance of this technologies for various Internet of Things (IoT) applications. In this article, we propose an IoT system for smart buildings based on LoRa and LoRaWAN. The main aim of this system is monitoring the moisture of wood in buildings; specifically, in cultural heritage buildings. Monitoring uses wireless sensor nodes that are digitally controlled and low power. The wireless sensor node includes a moisture sensor that relies on a novel resistance measurement method which is developed and tested, including a new printed circuit board (PCB). The sensor comprises an LoRa communication module in order to be used as the end node of the proposed system. To complete the monitoring system, a cloud-based application was developed to provide remote visualization and control for all LoRa sensor nodes in a building. The proposed system is scalable and represents a practical solution for the early detection of wood moisture due to heavy rain, leaks, etc. The path loss is evaluated, showing that the proposed LoRa system can be applied for preservation of heritage buildings despite the attenuation of thick walls and complex architectural structures

Coloides versus cristaloides em fluidoterapia guiada por objetivos, revisão sistemática e metanálise. Demasiadamente cedo ou demasiadamente tarde para obter conclusões [Colloids versus crystalloids in objective-guided fluid therapy, systematic review and meta-analysis. Too early or too late to draw

Introdução: Foram feitos múltiplos ensaios clínicos em fluidoterapia guiada por objetivos (FGO), muitos deles com o uso de coloides para aprimoramento da pré-carga. Após a decisão da Agência Europeia de Medicamentos, existe ainda controvérsia sobre seu uso, seus benefícios e sua possível contribuição para a falência renal. O objetivo desta revisão sistemática e metanálise é comparar o uso de coloides de última geração, derivados de milho, com cristaloides em FGO para determinar as complicações e a mortalidade associadas. Métodos: Busca bibliográfica em Medline, Pubmed, Embase e Biblioteca Cochrane de ensaios clínicos aleatórios nos quais se comparam cristaloides com coloides dentro de FGO para cirurgia não cardíaca de grande porte em adultos. Resultados: Foram obtidas 130 referências das quais se selecionaram 38 e 29 foram analisadas; dessas, seis foram incluídas para revisão sistemática e metanálise, incluindo 390 pacientes. Observou-se que o uso de coloides não está associado a um aumento de complicações, mas sim a uma tendência a maior mortalidade (RR [IC 95%] 3,87 [1,121-13,38]; I2 = 0,0%; p = 0,635). Conclusões: Devido às limitações desta metanálise em decorrência do número escasso de ensaios clínicos aleatórios e pacientes incluídos, os resultados devem ser usados com cautela e propõe-se a feitura de novos ensaios clínicos aleatórios, com potência estatística suficiente naqueles em que se comparam coloides balanceados e não balanceados com cristaloides balanceados e não balanceados, dentro de protocolos de FGO, que respeitem as indicações atuais e as sugestões emitidas pelos grupos de especialistas. Introduction: Several clinical trials on Goal directed fluid therapy (GDFT) were carried out, many of those using colloids in order to optimize the preload. After the decision of European Medicines Agency, there is such controversy regarding its use, benefits, and possible contribution to kidney failure. The objective of this systematic review and meta-analysis is to compare the use of last-generation colloids, derived from corn, with crystalloids, in GDFT, to determine complications and mortality associated associated. Methods: A bibliographic research was carried out in Medline, Pubmed, Embase and Cochrane Library, corroborating randomized clinical trials in those crystalloids are compared to colloids in GDFT for mayor non-cardiac surgery in adults. Results: One hundred thirty references were found, among those 38 were selected, and 29 analyzed; of these, 6 were included for systematic review and meta-analysis, including 390 patients. It was perceived that the use of colloids it not associated with the increase of complications, but rather with a tendency to a higher mortality (RR 95% IC] 3.87 1.121, 13, 38]); I2=0.0%; p=0.635). Conclusiones: Due to this meta-analysis'' limitations for small number of randomized clinical trials and patients included, the results should be taken cautiously, and it is proposed to carry out new randomized clinical trials, with enough statistical power, comparing balanced and non-balanced colloids to balanced and non-balanced crystalloids, following the protocols of GDFT, respecting current guidelines and suggestions made by groups of experts