Understanding cardiopulmonary interactions through esophageal pressure monitoring

Esophageal pressure is the closest estimate of pleural pressure. Changes in esophageal pressure reflect changes in intrathoracic pressure and affect transpulmonary pressure, both of which have multiple effects on right and left ventricular performance. During passive breathing, increasing esophageal pressure is associated with lower venous return and higher right ventricular afterload and lower left ventricular afterload and oxygen consumption. In spontaneously breathing patients, negative pleural pressure swings increase venous return, while right heart afterload increases as in passive conditions; for the left ventricle, end-diastolic pressure is increased potentially favoring lung edema. Esophageal pressure monitoring represents a simple bedside method to estimate changes in pleural pressure and can advance our understanding of the cardiovascular performance of critically ill patients undergoing passive or assisted ventilation and guide physiologically personalized treatments

Distinguishing the Mélange-forming processes in subduction-accretion complexes: constraints from the Anisotropy of Magnetic Susceptibility (AMS).

The strong morphological similitude of the block-in-matrix fabric of chaotic rock units (mélanges and broken formations) makes problematic the recognition of their primary forming-processes. We present results of the comparison between magnetic fabric and mesoscale structural investigations of non-metamorphic tectonic, sedimentary, and polygenetic mélanges in the exhumed Late Cretaceous to early Eocene Ligurian accretionary complex and overlying wedge-top basin succession in the Northern Apennines (northwest Italy). Our findings show that the magnetic fabric reveals diagnostic configurations of principal anisotropy of magnetic susceptibility (AMS) axes orientation that are well comparable with the mesoscale block-in-matrix fabric of mélanges formed by different processes. Broken formations and tectonic mélanges show prolate and neutral-to-oblate ellipsoids, respectively, with magnetic fabric elements being consistent with those of the mesoscale anisotropic “structurally ordered” block-in-matrix fabric. Sedimentary mélanges show an oblate ellipsoid with a clear sedimentary magnetic fabric related to downslope gravitational emplacement. Polygenetic mélanges show the occurrence of a cumulative depositional and tectonic magnetic fabric. The comparison of field and laboratory investigations validate the analysis of magnetic features as a diagnostic tool suitable to analytically distinguish the contribution of different mélange forming-processes and their mutual superposition, and to better understand the geodynamic evolution of subduction-accretion complexes

Anatomy and kinematic evolution of an ancient passive margin involved into an orogenic wedge (Western Southern Alps, Varese area, Italy and Switzerland)

We make use of own geological mapping, interpretations of seismic reflection profiles and deep geophysical data to build a lithospheric-scale cross-section across the European Western Southern Alps (Varese area) and to model a progressive restoration from the end of Mesozoic rifting to present-day. Early phases of Alpine orogeny were characterized by Europe-directed thrusting, whereas post-Oligocene shortening led to basement-involving crustal accretion accompanied by backfolding, and consistent with the kinematics of the adjoining Ivrea Zone. Wedging was favored by a significant component of reactivation of the inherited Adriatic rifted margin. Our results also suggest that, during the collisional and post-collisional tectonics, lithosphere dynamics drove diachronically the onset of tectonic phases (i.e., wedging and slab retreat), from east to west, across the Western Southern Alps

Ambulatory surgery for perianal Crohn’s disease. Study of feasibility

Background. One-third of Crohn’s disease (CD) patients present perianal fistula. The gold standard in the diagnosis and treatment of symptomatic perianal disease (PAD) in CD is the exploration of the anal canal and distal rectum under anesthesia (EUA). This procedure is mainly conducted as a day case surgery. Unfortunately, it is not always possible to proceed within the ideal timing and any delay may well represent a relevant clinical issue. The aim of this study was to evaluate the feasibility of outpatient treatment of symptomatic perianal fistulas in CD patients. Methods. All CD patients under regular follow-up at our inflammatory bowel disease referral center, presenting with symptomatic perianal fistulas, were offered surgical consultation. The data of patients were prospectively collected for three years (February 2014 to February 2017) for the purpose of the study. All clinical information, including previous EUA and/or records from MRI and endoscopic ultrasound, was included. Outpatient anal canal and distal rectum exploration and treatment (OE) were undertaken during the specialist surgical consultation. Fistulas were classified according to Parks’s classification; the type of outpatient treatment and compliance of patients were recorded. Pain was assessed by VAS at the time of the procedure and during the first control. Patients were followed up in the surgical clinic in relation to the study. Results. Ninety-two CD patients with symptomatic perianal fistulas had surgical consultation during the study period. OE was offered to all but 18 patients who fulfilled the exclusion criteria or had an extremely severe disease; six patients refused the OE (8.11%). Of the 68 patients undergoing OE, eleven (16.18%) had previous surgery for perianal disease. The OE was accomplished in sixty-one patients (89.71%), while in 7 patients, it was abandoned for scarce compliance. Nine patients (14.75%) underwent drainage of perianal abscess; in 3 of them, it was possible to probe the fistula tract, find the internal orifice, and pass a loose seton. Overall, setonage was performed in 50 patients (81.97%). Rectovaginal setons were placed in 3 patients and more than one seton (up to 3) in 6 cases. Fistulotomy was performed in 4 simple subcutaneous fistulous tracts. Concordance with the preoperative findings was found in 54 out of 61 patients. EUA was scheduled at the time of OE for the 7 patients who did not complete the procedure. All sixty-one patients who had the OE were followed up for a minimum of 12 months. Conclusions. This preliminary study indicates that OE in CD patients with symptomatic perianal fistulas is safe and feasible in a high-volume referral center. It might provide several benefits, including patients’ logistics, reduce or remove patients’ symptoms and discomfort, allow for a timely start of medical therapy, and avoid further complications

Anatomy and kinematic evolution of an ancient passive margin involved into an orogenic wedge (Western Southern Alps, Varese area, Italy and Switzerland)

We make use of own geological mapping, interpretations of seismic reflection profiles and deep geophysical data to build a lithospheric-scale cross-section across the European Western Southern Alps (Varese area) and to model a progressive restoration from the end of Mesozoic rifting to present-day. Early phases of Alpine orogeny were characterized by Europe-directed thrusting, whereas post-Oligocene shortening led to basement-involving crustal accretion accompanied by backfolding, and consistent with the kinematics of the adjoining Ivrea Zone. Wedging was favored by a significant component of reactivation of the inherited Adriatic rifted margin. Our results also suggest that, during the collisional and post-collisional tectonics, lithosphere dynamics drove diachronically the onset of tectonic phases (i.e., wedging and slab retreat), from east to west, across the Western Southern Alps

The Impact of an Introductory Course on Ph.D. Students: A Qualitative Analysis of Student Perceptions

This qualitative case study examined Ph.D. students’ perceptions of the impact of a full semester introductory course at a Tier-1 research institution. Results from multiple data sources including open-coded interviews and reflective entries yielded three overarching perceptions of the impact of the introductory class by its first-year students: (1) the establishment of community; (2) contributions to students’ knowledge base through cultivation of academic tools within a Ph.D. program, both departmentally and programmatically; and (3) addressing and relieving “imposter syndrome.” Results indicated participants benefited from a semester-long introductory course as it contributed to community building and socialization, acquisition of needed skills and dispositions of the field, and assisted in managing imposter syndrome. Additionally, participants offered suggestions regarding course improvement. The study contributes to the body of post-secondary literature, as little work has been conducted on semester-long introductory courses at the doctoral level

catheter and laryngeal mask endotracheal surfactant therapy the calmest approach as a novel mist technique

AbstractPurpose: Neonatal respiratory distress syndrome (RDS) is a major cause of mortality and morbidity among preterm infants. Although the INSURE (INtubation, SURfactant administration, Estubation) technique for surfactant replacement therapy is so far the gold standard method, over the last years new approaches have been studied, i.e. less invasive surfactant administration (LISA) or minimally invasive surfactant therapy (MIST). Here we propose an originally modified MIST, called CALMEST (Catheter And Laryngeal Mask Endotracheal Surfactant Therapy), using a particular laryngeal mask as a guide for a thin catheter to deliver surfactant directly in the trachea.Materials and methods: We performed a preliminary study on a mannequin and a subsequent in vivo pilot trial.Results and conclusions: This novel procedure is quick, effective and well tolerated and might represent an improvement in reducing neonatal stress. Ultimately, CALMEST offers an alternative approach that could be extremely useful for medica..

Fetal oxygenation in the last weeks of pregnancy evaluated through the umbilical cord blood gas analysis

IntroductionEmbryo and fetus grow and mature over the first trimester of pregnancy in a dynamic hypoxic environment, where placenta development assures an increased oxygen availability. However, it is unclear whether and how oxygenation changes in the later trimesters and, more specifically, in the last weeks of pregnancy.MethodsObservational study that evaluated the gas analysis of the umbilical cord blood collected from a cohort of healthy newborns with gestational age >= 37 weeks. Umbilical venous and arterial oxygen levels as well as fetal oxygen extraction were calculated to establish whether oxygenation level changes over the last weeks of pregnancy. In addition, fetal lactate, and carbon dioxide production were analyzed to establish whether oxygen oscillations may induce metabolic effects in utero.ResultsThis study demonstrates a progressive increase in fetal oxygenation levels from the 37th to the 41st weeks of gestation (mean venous PaO2 approximately from 20 to 25 mmHg; p < 0.001). This increase is largely attributable to growing umbilical venous PaO2, regardless of delivery modalities. In neonates born by vaginal delivery, the increased oxygen availability is associated with a modest increase in oxygen extraction, while in neonates born by cesarean section, it is associated with reduced lactate production. Independently from the type of delivery, carbon dioxide production moderately increased. These findings suggest a progressive shift from a prevalent anaerobic metabolism (Warburg effect) towards a growing aerobic metabolism.ConclusionThis study confirms that fetuses grow in a hypoxic environment that becomes progressively less hypoxic in the last weeks of gestation. The increased oxygen availability seems to favor aerobic metabolic shift during the last weeks of intrauterine life; we hypothesize that this environmental change may have implications for fetal maturation during intrauterine life

Lung ultrasound in young children with neurological impairment: A proposed integrative clinical tool for deaeration-detection related to feeding

Infants and children with neurological impairment, such as cerebral palsy (CP), often experience abnormal ingestion functions, including oropharyngeal dysphagia and gastroesophageal reflux disease, which led to aspiration-related respiratory complications, morbidity, hospitalization, or death. There is a lack of evidence-based, repeatable, infant-friendly instrumental procedures to assess aspiration-risk in infants with CP or other neurological disorders, with also a lack of clinical assessment measures to support the use of more invasive diagnostic techniques. To this purpose, in the current study we explore the feasibility of lung ultrasound (LUS), to assess lung deaeration possibly related to aspiration during meal, in a cohort of 35 subjects affected by CP or other encephalopathies, and 10 controls in the same age-range. We coupled LUS procedure with meal caregiver administration for each child. Our results support the feasibility of this innovative approach in the clinical setting. Exploratory findings revealed a number of lung abnormalities likely related to abnormal ingestion function in subjects. Subgroup analyses revealed possible differences in LUS abnormalities between CP and other encephalopathies, possibly related to different mechanism of disease or dysfunction. Also, some evidences arose about the possible relationship between such LUS abnormalities and feeding and swallowing abilities in CP or other encephalopathies. LUS showed preliminarily feasibility and effectiveness in detecting meal-related LUS abnormalities in a dynamic manner in the clinical setting. This approach demonstrated usefulness as a potential tool for improving assessment and management in complex care of infants and young children with severe neurological disorders