Diagnostic Value of Endotracheal Aspirates Sonication on Ventilator-Associated Pneumonia Microbiologic Diagnosis

Microorganisms are able to form biofilms within respiratory secretions. Methods to disaggregate such biofilms before utilizing standard, rapid, or high throughput diagnostic technologies may aid in pathogen detection during ventilator associated pneumonia (VAP) diagnosis. Our aim was to determine if sonication of endotracheal aspirates (ETA) would increase the sensitivity of qualitative, semi-quantitative, and quantitative bacterial cultures in an animal model of pneumonia caused by Pseudomonasaeruginosa or by methicillin resistant Staphylococcusaureus (MRSA). MATERIAL AND METHODS: P.aeruginosa or MRSA was instilled into the lungs or the oropharynx of pigs in order to induce severe VAP. Time point assessments for qualitative and quantitative bacterial cultures of ETA and bronchoalveolar lavage (BAL) samples were performed at 24, 48, and 72 h after bacterial instillation. In addition, at 72 h (autopsy), lung tissue was harvested to perform quantitative bacterial cultures. Each ETA sample was microbiologically processed with and without applying sonication for 5 min at 40 KHz before bacterial cultures. Sensitivity and specificity were determined using BAL as a gold-standard. Correlation with BAL and lung bacterial burden was also determined before and after sonication. Assessment of biofilm clusters and planktonic bacteria was performed through both optical microscopy utilizing Gram staining and Confocal Laser Scanning Microscopy utilizing the LIVE/DEAD®BacLight kit. RESULTS: 33 pigs were included, 27 and 6 from P.aeruginosa and MRSA pneumonia models, respectively. Overall, we obtained 85 ETA, 69 (81.2%) from P.aeruginosa and 16 (18.8%) from MRSA challenged pigs. Qualitative cultures did not significantly change after sonication, whereas quantitative ETA cultures did significantly increase bacterial counting. Indeed, sonication consistently increased bacterial burden in ETAs at 24, 48, and 72 h after bacterial challenge. Sonication also improved sensitivity of ETA quantitative cultures and maintained specificity at levels previously reported and accepted for VAP diagnosis. CONCLUSION: The use of sonication in ETA respiratory samples needs to be clinically validated since sonication could potentially improve pathogen detection before standard, rapid, or high throughput diagnostic methods used in routine microbial diagnostics

Achieving Sender Anonymity in Tor against the Global Passive Adversary

Tor is the de facto standard used for anonymous communication over the Internet. Despite its wide usage, Tor does not guarantee sender anonymity, even in a threat model in which the attacker passively observes the traffic at the first Tor router. In a more severe threat model, in which the adversary can perform traffic analysis on the first and last Tor routers, relationship anonymity is also broken. In this paper, we propose a new protocol extending Tor to achieve sender anonymity (and then relationship anonymity) in the most severe threat model, allowing a global passive adversary to monitor all of the traffic in the network. We compare our proposal with Tor through the lens of security in an incremental threat model. The experimental validation shows that the price we have to pay in terms of network performance is tolerable

Fenestrated Adipofascial Reverse Flap: A Modified Technique for the Reconstruction of Fingertip Amputations.

4sireservedAims of the Study: Fingertip injuries can be treated in different ways, including shortening with primary closure, skin graft, and local or distant flaps. Several local flaps for the reconstruction of the amputated fingertip were described. We present our experience with a new concept of homodigital adipofascial reverse flap that avoids the second surgical stage and allows a complete and anatomically perfect reconstruction of nail bed, with preservation of the nail lamina. Materials and Methods: Between March 2014 and February 2015, five patients with digital amputations (distally to the nail matrix) were treated using the Fenestrated Adipofascial Reverse (F.A.R.) flap. The patients were evaluated measuring 2-point discrimination (2PD) value and range of motion of the distal interphalangeal joint (DIP). Scar evaluation was performed using the Vancouver Scar Scale (VSS). Results: All the flaps completely survived. A normal nail grow has been observed in first two-three months of post operatory follow-up. Length of the digits was preserved and good aesthetic as functional outcome were archive. The F.A.R. flap provided excellent coverage of fingertip defects and preserved finger length. After 1 year of follow, the mean static 2PD value at the reconstructed finger was 4.2 mm (range 3-5 mm), reconstructed fingers' mean range of motion for the DIP joint was 78 degrees and the VSS score ranged from 0 to 2 (mean score: 0.6). No complications were reported. Conclusions: F.A.R. flap is one of the most useful techniques in order to achieve all the goals in fingertip reconstructionmixedIdone, F; Sisti, A; Tassinari, J; Nisi, G.Idone, F; Sisti, Andrea; Tassinari, Juri; Nisi, Giusepp

A diagnostic study on folium and orchil dyes with non-invasive and micro-destructive methods

Folium and orchil are dyes of vegetal origin. Folium is obtained from Chrozophora tinctoria (L.) A. Juss., whereas orchil is obtained from Roccella and other genera of lichens. These dyes were used in the past to impart purple hue to paintings and textiles as substitutes for the more prised Tyrian purple dye, obtained from shellfish. Despite several citations in ancient technical treatises dating back at least to the Greek-Roman age, the identification of these dyes in artworks is rare. In the case of folium, an additional drawback is that its composition is presently unknown. In this work different non-invasive (FT-IR, FT-Raman, fibre optic reflectance spectrophotometry, spectrofluorimetry, X-ray fluorescence spectrometry) and micro-invasive (surface enhanced Raman spectroscopy, matrix assisted laser desorption ionisation-time of flight-mass spectrometry, inductively coupled plasma-mass spectrometry) techniques were used in order to increase the diagnostic information available on these dyes. Measurements were carried out on the dyes extracted from raw materials and on painted or dyed parchments. The possibility to distinguish between folium and orchil by chemical analysis is discussed

A Rare Case of Left Ventricular Non-Compaction with Coronary Artery Anomaly Complicated by ST-Elevation Myocardial Infarction and Subcutaneous Defibrillator Implantation

Left ventricular non-compaction (LVNC) is a rare congenital cardiomyopathy caused by arrest of normal endomyocardial embryogenesis and characterized by the persistence of ventricular hypertrabeculation, isolated or associated to other congenital defects. A 33-year-old male, with family history of sudden cardiac death (SCD), presented to our ER with typical chest pain and was diagnosed with anterior STEMI. Coronary angiography showed an anomalous origin of the circumflex artery from the right coronary artery and a critical stenosis on the proximal left anterior descending artery, treated with primary percutaneous coronary intervention. The echocardiogram documented left ventricular severe dysfunction with lateral wall hypertrabeculation, strongly suggestive for non-compaction, confirmed by cardiac MRI. At 3 months follow up, for the persistence of the severely depressed EF (30%) and the family history for SCD, the patient underwent subcutaneous ICD (sICD) implantation for primary prevention. To the best of our knowledge, this is the first case of LVNC associated with anomalous coronary artery origin and STEMI reported in the literature. Arrhythmias are common in LVNC due to endocardial hypoperfusion and fibrosis. sICD overcomes the risks of transvenous ICD, and it is a valuable option when there is no need for pacing therapy for bradycardia, cardiac resynchronization therapy and anti-tachycardia pacing

Lambl's excrescence in transcatheter aortic valve implantation: prevalence and risk of embolic events

The role of aortic valve Lambl's excrescence (LEs) in determining ischemic events has not been well clarified, but they can represent a potential embolic source during procedures with catheter/device manipulation through the aortic valve. Aim of our study was to assess the prevalence of LEs and the rate of embolism in patients with aortic valve stenosis scheduled for transcatheter aortic valve implantation (TAVI)

Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome

RATIONALE: Oxygen is commonly administered after extubation. Although several devices are available, data about their clinical efficacy are scarce. OBJECTIVES: To compare the effects of the Venturi mask and the nasal high-flow (NHF) therapy on PaO2/FiO2SET ratio after extubation. Secondary endpoints were to assess effects on patient discomfort, adverse events, and clinical outcomes. METHODS: Randomized, controlled, open-label trial on 105 patients with a PaO2/FiO2 ratio less than or equal to 300 immediately before extubation. The Venturi mask (n = 52) or NHF (n = 53) were applied for 48 hours postextubation. MEASUREMENTS AND MAIN RESULTS: PaO2/FiO2SET, patient discomfort caused by the interface and by symptoms of airways dryness (on a 10-point numerical rating scale), interface displacements, oxygen desaturations, need for ventilator support, and reintubation were assessed up to 48 hours after extubation. From the 24th hour, PaO2/FiO2SET was higher with the NHF (287 \ub1 74 vs. 247 \ub1 81 at 24 h; P = 0.03). Discomfort related both to the interface and to airways dryness was better with NHF (respectively, 2.6 \ub1 2.2 vs. 5.1 \ub1 3.3 at 24 h, P = 0.006; 2.2 \ub1 1.8 vs. 3.7 \ub1 2.4 at 24 h, P = 0.002). Fewer patients had interface displacements (32% vs. 56%; P = 0.01), oxygen desaturations (40% vs. 75%; P < 0.001), required reintubation (4% vs. 21%; P = 0.01), or any form of ventilator support (7% vs. 35%; P < 0.001) in the NHF group. CONCLUSIONS: Compared with the Venturi mask, NHF results in better oxygenation for the same set FiO2 after extubation. Use of NHF is associated with better comfort, fewer desaturations and interface displacements, and a lower reintubation rate. Clinical trial registered with www.clinicaltrials.gov (NCT 01575353)

Quantification of Extracellular Volume in CT in Neoadjuvant Chemotherapy in Breast Cancer: New Frontiers in Assessing the Cardiotoxicity of Anthracyclines and Trastuzumab

: Breast cancer patients undergoing neoadjuvant chemotherapy with anthracyclines or trastuzumab can suffer cardiotoxic issues. Nowadays, the markers of cardiac damage are still not reliable, and extracellular volume (ECV) calculated from CT could be a promising cardiotoxic marker. Eighty-two patients, treated with two different chemotherapy regimens based on doxorubicin (DOX) or epirubicin-trastuzumab (EPI-TRAS), were retrospectively selected and the variations in extracellular volume (ECV) values were measured and analyzed. Whole Body CT (WB-CT) scans were acquired after 1 min, in the portal phase (PP), and after 5 min, in the delayed phases (DP), at the baseline (T0), after one year (T1) and after five years (T5) from the end of chemotherapies. The values measured by two radiologists with different levels of experience were evaluated in order to assess the inter-reader reproducibility assessment (ICC = 0.52 for PP and DP). Further, we performed a population-based analysis and a drug-oriented subgroup analysis in 54 DOX-treated and 28 EPI-TRAS-treated patients. In the general cohort of women treated with any of the two drugs, we observed in the lapse T0-T1 a relative increase (RI) of 25% vs. 20% (PP vs. DP, p &lt; 0.001) as well as in the lapse T0-T5 an RI of 17% vs. 15% (PP vs. DP, p &lt; 0.01). The DOX-treated patients reported in the lapse T0-T1 an RI of 22% (p &lt; 0.0001) in PP and an RI of 16% (p = 0.018) in the DP, with ECV values remaining stably high at T5 both in PP (RI 14.0%, p &lt; 0.0001) and in DP (RI 17%, p = 0.005) highlighting a possible hallmark of a persisting CTX sub-damage. On the other hand, ECV measured in EPI-TRAS-treated women showed an RI in T0-T1 of 18% (p = 0.001) and 29% (p = 0.006) in PP and DP, respectively, but the values returned to basal levels in T5 both in the PP (p = 0.12) and in DP setting (p = 0.13), suggesting damage in the first-year post-treatment and a possible recovery over time. For the 82 patients, an echocardiography was performed at T0, T1= 12 m + 3 m and T5 = 60 m + 6 m with LVEF values at T0 (64% ± 5%), T1 (54% ± 6%) and T5 (53% ± 8%). WB-CT-derived ECV values could provide a valid imaging marker for the early diagnosis of cardiotoxic damage in BC patients undergoing oncological treatments. We detected different patterns during the follow-up, with stably high values for DOX, whereas EPI-TRAS showed a peak within the first year, suggesting different mechanisms of cardiac damage

Tidal Volume Lowering by Instrumental Dead Space Reduction in Brain-Injured ARDS Patients: Effects on Respiratory Mechanics, Gas Exchange, and Cerebral Hemodynamics

Background: Limiting tidal volume (VT), plateau pressure, and driving pressure is essential during the acute respiratory distress syndrome (ARDS), but may be challenging when brain injury coexists due to the risk of hypercapnia. Because lowering dead space enhances CO2 clearance, we conducted a study to determine whether and to what extent replacing heat and moisture exchangers (HME) with heated humidifiers (HH) facilitate safe VT lowering in brain-injured patients with ARDS. Methods: Brain-injured patients (head trauma or spontaneous cerebral hemorrhage with Glasgow Coma Scale at admission &lt; 9) with mild and moderate ARDS received three ventilatory strategies in a sequential order during continuous paralysis: (1) HME with VT to obtain a PaCO2 within 30-35 mmHg (HME1); (2) HH with VT titrated to obtain the same PaCO2 (HH); and (3) HME1 settings resumed (HME2). Arterial blood gases, static and quasi-static respiratory mechanics, alveolar recruitment by multiple pressure-volume curves, intracranial pressure, cerebral perfusion pressure, mean arterial pressure, and mean flow velocity in the middle cerebral artery by transcranial Doppler were recorded. Dead space was measured and partitioned by volumetric capnography. Results: Eighteen brain-injured patients were studied: 7 (39%) had mild and 11 (61%) had moderate ARDS. At inclusion, median [interquartile range] PaO2/FiO2 was 173 [146-213] and median PEEP was 8 cmH2O [5-9]. HH allowed to reduce VT by 120 ml [95% CI: 98-144], VT/kg predicted body weight by 1.8 ml/kg [95% CI: 1.5-2.1], plateau pressure and driving pressure by 3.7 cmH2O [2.9-4.3], without affecting PaCO2, alveolar recruitment, and oxygenation. This was permitted by lower airway (- 84 ml [95% CI: - 79 to - 89]) and total dead space (- 86 ml [95% CI: - 73 to - 98]). Sixteen patients (89%) showed driving pressure equal or lower than 14 cmH2O while on HH, as compared to 7 (39%) and 8 (44%) during HME1 and HME2 (p &lt; 0.001). No changes in mean arterial pressure, cerebral perfusion pressure, intracranial pressure, and middle cerebral artery mean flow velocity were documented during HH. Conclusion: The dead space reduction provided by HH allows to safely reduce VT without modifying PaCO2 nor cerebral perfusion. This permits to provide a wider proportion of brain-injured ARDS patients with less injurious ventilation