Enhanced intra-operative grading of ascending aorta atheroma by epiaortic ultrasound vs echocardiography

Aims Intra-operative grading of atheromatous plaques in the ascending aorta by epiaortic ultrasound (EAU) and transesophageal echocardiography (TEE) in patients who have undergone CABG. Methods and results Sixty patients scheduled for elective CABG were prospectively enrolled to undergo intra-operative TEE and EAU ultrasound scanning of the ascending aorta. The ascending aorta was divided into three sections; proximal, middle and distal, and four segments; anterior, posterior, medial and lateral. Degree of atherosclerosis was graded according to a modified Montgomery scale. Epiaortic ultrasound was unable to provide images for a reliable assessment in 56 areas (7.7%; 56/720) vs 322 non-visualized areas by TEE (44.7%; 298/720) (p < 0.01). Out of 563 areas that scored ≥ 2, EAU visualized 379/720 areas (52.6%), whereas TEE visualized 184/720 areas (25.5%) (p < 0.01). EAU mean scores were significantly higher for the mid (p = 0.0001) and distal (p = 0.05) sections and for the posterior segment (p < 0.01) vs TEE. TEE had a higher mean score than EAU in the anterior segment. When all EAU areas were grouped the posterior segment reached a significantly higher mean score (p < 0.01), and the anterior segment was the second mostly diseased. Conclusions EAU is the intra-operative investigation of choice because it allowed a detailed grading of atheromatous lesions over the entire length of the ascending aorta. Accurate grading by TEE was restricted only to those areas that could be sufficiently visualized. TEE has a reduced power of investigation that limits its use, especially in the distal ascending aorta, a site of great surgical manipulation

Phylogeography of the white-tailed eagle, a generalist with large dispersal capacity

Aim  Late Pleistocene glacial changes had a major impact on many boreal and temperate taxa, and this impact can still be detected in the present-day phylogeographic structure of these taxa. However, only minor effects are expected in species with generalist habitat requirements and high dispersal capability. One such species is the white-tailed eagle, Haliaeetus albicilla, and we therefore tested for the expected weak population structure at a continental level in this species. This also allowed us to describe phylogeographic patterns, and to deduce Ice Age refugia and patterns of postglacial recolonization of Eurasia. Location  Breeding populations from the easternmost Nearctic (Greenland) and across the Palaearctic (Iceland, continental Europe, central and eastern Asia, and Japan). Methods  Sequencing of a 500 base-pair fragment of the mitochondrial DNA control region in 237 samples from throughout the distribution range. Results  Our analysis revealed pronounced phylogeographic structure. Overall, low genetic variability was observed across the entire range. Haplotypes clustered in two distinct haplogroups with a predominantly eastern or western distribution, and extensive overlap in Europe. These two major lineages diverged during the late Pleistocene. The eastern haplogroup showed a pattern of rapid population expansion and colonization of Eurasia around the end of the Pleistocene. The western haplogroup had lower diversity and was absent from the populations in eastern Asia. These results suggest survival during the last glaciation in two refugia, probably located in central and western Eurasia, followed by postglacial population expansion and admixture. Relatively high genetic diversity was observed in northern regions that were ice-covered during the last glacial maximum. This, and phylogenetic relationships between haplotypes encountered in the north, indicates substantial population expansion at high latitudes. Areas of glacial meltwater runoff and proglacial lakes could have provided suitable habitats for such population growth. Main conclusions  This study shows that glacial climate fluctuations had a substantial impact on white-tailed eagles, both in terms of distribution and demography. These results suggest that even species with large dispersal capabilities and relatively broad habitat requirements were strongly affected by the Pleistocene climatic shifts

Intensive care doctors' preferences for arterial oxygen tension levels in mechanically ventilated patients

Background: Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors’ preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors’ preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients. Methods: In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016. Results: The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO2) the most important parameter; 24% a combination of PaO2 and arterial oxygen saturation (SaO2); and 23% preferred SaO2. Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO2 of 8 kPa or lower and 77% would accept a PaO2 of 12 kPa or higher in a clinical trial of oxygenation targets. Conclusion: Intensive care unit doctors preferred PaO2 to SaO2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients

Intensive care doctors’ preferences for arterial oxygen tension levels in mechanically ventilated patients

Background: Oxygen is liberally administered in intensive care units (ICUs). Nevertheless, ICU doctors’ preferences for supplementing oxygen are inadequately described. The aim was to identify ICU doctors’ preferences for arterial oxygenation levels in mechanically ventilated adult ICU patients. Methods: In April to August 2016, an online multiple-choice 17-part-questionnaire was distributed to 1080 ICU doctors in seven Northern European countries. Repeated reminder e-mails were sent. The study ended in October 2016. Results: The response rate was 63%. When evaluating oxygenation 52% of respondents rated arterial oxygen tension (PaO2) the most important parameter; 24% a combination of PaO2 and arterial oxygen saturation (SaO2); and 23% preferred SaO2. Increasing, decreasing or not changing a default fraction of inspired oxygen of 0.50 showed preferences for a PaO2 around 8 kPa in patients with chronic obstructive pulmonary disease, a PaO2 around 10 kPa in patients with healthy lungs, acute respiratory distress syndrome or sepsis, and a PaO2 around 12 kPa in patients with cardiac or cerebral ischaemia. Eighty per cent would accept a PaO2 of 8 kPa or lower and 77% would accept a PaO2 of 12 kPa or higher in a clinical trial of oxygenation targets. Conclusion: Intensive care unit doctors preferred PaO2 to SaO2 in monitoring oxygen treatment when peripheral oxygen saturation was not included in the question. The identification of PaO2 as the preferred target and the thorough clarification of preferences are important when ascertaining optimal oxygenation targets. In particular when designing future clinical trials of higher vs lower oxygenation targets in ICU patients

Performance of a capnodynamic method estimating effective pulmonary blood flow during transient and sustained hypercapnia

The capnodynamic method is a minimally invasive method continuously calculating effective pulmonary blood flow (COEPBF), equivalent to cardiac output when intra pulmonary shunt flow is low. The capnodynamic equation joined with a ventilator pattern containing cyclic reoccurring expiratory holds, provides breath to breath hemodynamic monitoring in the anesthetized patient. Its performance however, might be affected by changes in the mixed venous content of carbon dioxide (CvCO2). The aim of the current study was to evaluate COEPBF during rapid measurable changes in mixed venous carbon dioxide partial pressure (PvCO2) following ischemia-reperfusion and during sustained hypercapnia in a porcine model. Sixteen pigs were submitted to either ischemia-reperfusion (n = 8) after the release of an aortic balloon inflated during 30 min or to prolonged hypercapnia (n = 8) induced by adding an instrumental dead space. Reference cardiac output (CO) was measured by an ultrasonic flow probe placed around the pulmonary artery trunk (COTS). Hemodynamic measurements were obtained at baseline, end of ischemia and during the first 5 min of reperfusion as well as during prolonged hypercapnia at high and low CO states. Ischemia-reperfusion resulted in large changes in PvCO2, hemodynamics and lactate. Bias (limits of agreement) was 0.7 (-0.4 to 1.8) L/min with a mean error of 28% at baseline. COEPBF was impaired during reperfusion but agreement was restored within 5 min. During prolonged hypercapnia, agreement remained good during changes in CO. The mean polar angle was -4.19A degrees (-8.8A degrees to 0.42A degrees). Capnodynamic COEPBF is affected but recovers rapidly after transient large changes in PvCO2 and preserves good agreement and trending ability during states of prolonged hypercapnia at different levels of CO