Nephrologists' perceptions regarding dialysis withdrawal and palliative care in Europe: lessons from a European Renal Best Practice survey

Background. There is a variation in dialysis withdrawal rates, but reasons for this variation across European countries are largely unknown. We therefore surveyed nephrologists' perceptions of factors concerning dialysis withdrawal and palliative care and explored relationships between these perceptions and reports of whether withdrawal actually occurred in practice. Methods. We developed a 33-item electronic survey, disseminated via an email blast to all European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) members. In our data analyses, we distinguished those respondents who reported occurrence from those reporting no dialysis withdrawal in their unit. With multilevel logistic regression, we investigated the association between respondents' characteristics and perceptions and whether they reported occurrence of dialysis withdrawal or not. Results. Five hundred and twenty-eight nephrologists from 45 countries completed the questionnaire; 42% reported occurrence of withdrawal in their unit in the past year, and 56% perceived that stopping life-prolonging treatment in terminally ill patients was allowed. Few respondents reported presence in their unit of protocols on withdrawal decision making (7%) or palliative care (10%) or the common involvement of a geriatrician in withdrawal decisions (10%). The majority stated that palliative care had not been part of their core curriculum (74%) and that they had not recently attended continuous medical education sessions on this topic (73%). Respondents from Eastern and Southern Europe had a 42 and 40% lower probability, respectively, of reporting withdrawal compared with those from North European countries. Working in a public centre [odds ratio (OR), 2.41; 95% confidence interval (CI), 1.36-4.25] and respondents' perception that stopping life-prolonging treatment in terminally ill patients was allowed (OR, 1.96; 95% CI, 1.23-3.12), that withdrawal decisions were commonly shared between doctor and patient (OR, 1.97; 95% CI, 1.26-3.08) and that palliative care was reimbursed (OR, 1.81; 95% CI, 1.16-2.83) increased the odds of reporting occurrence of withdrawal. Conclusion. Reports of dialysis withdrawal occurrence varied between European countries. Occurrence reports were more likely if respondents worked in a public centre, if stopping life-prolonging treatments was perceived as allowed, if withdrawal decisions were considered shared between doctors and patients and if reimbursement of palliative care was believed to be in place. There is room for improvement regarding protocols on withdrawal and palliative care processes and regarding nephrologists' training and education on end-of-life care.

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When deception becomes easy: the effects of task switching and goal neglect on the truth proportion effect

Lying is typically more cognitively demanding than truth telling. Yet, recent cognitive models of lying propose that lying can be just as easy as truth telling, depending on contextual factors. In line with this idea, research has shown that the cognitive cost of deception decreases when people frequently respond deceptively, while it increases when people rarely respond deceptively (i.e., the truth proportion effect). In the present study, we investigated two possible underlying mechanisms of the truth proportion effect. In Experiment 1 (N = 121), we controlled for the impact of switch costs by keeping the number of switches between deceptive and truthful responses constant. We found that people who often responded deceptively made fewer errors when responding deceptively than people who only occasionally responded deceptively, replicating the truth proportion effect. Thus, while the truth proportion effect in earlier studies may be partially driven by the cost of switching between truthful and deceptive responses, we still found evidence for the truth proportion effect while controlling for switch costs. In Experiment 2 (N = 68), we assessed whether the truth proportion effect is influenced by goal neglect. According to this view, the truth proportion effect should be reduced if participants are cued to maintain the task goals, while it should be larger when participants are allowed to neglect the task goals. In line with this hypothesis, we found a smaller truth proportion effect when participants were cued with the task goals compared to when they were not cued. This study shows that the truth proportion effect is influenced by goal neglect, implying that frequent deceptive responding strengthens the goal of responding deceptively. Our findings imply that the accuracy of lie detection tests could be increased by using a majority of truth items (i.e., induce the truth proportion effect), and that the truth proportion effect should be maximized

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Selecting a strategy for prevention of contrast-induced nephropathy in clinical practice: an evaluation of different clinical practice guidelines using the AGREE tool

Background. Contrast-induced acute kidney injury (CI-AKI) is a potential complication of radio-contrast investigations. Many organisations have published guidance documents on the prevention of CI-AKI. Our aim is to explore the scope, content, consistency, practicality in clinical practice and reasons for eventual underlying discrepancies of these documents. Methods. We searched the literature for guidance documents developed to guide prevention of CI-AKI up to 09/2014. Four reviewers appraised guideline quality using the 23-item AGREE-II instrument, which rates reporting of the guidance development process across six domains: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence. Total scores were calculated as standardised averages by domain. Results. Twenty-four guidance documents were evaluated. The guidance documents were produced by radiologists (N = 7), intensivists (N = 2), nephrologists (N = 6) or multidisciplinary teams (N = 9). One document did not mention the background of the authors. Only guidance documents (N = 15) that were not mere adaptations of existing guidelines were evaluated more in depth, using the AGREE tool. Overall, quality was mixed: only one clinical practice guidance document obtained an average score of >50% for all domains. The evidence was rated in a systematic way in only 11, and only 7 graded the strength of the recommendations. The Kidney Diseases Improving Global Outcomes guideline was the only one recommended without adaptions by all assessors. The guidance documents agreed in recommending pre-hydration as the main preventive measure, but there was difference in recommended total volumes, composition, rate and duration of the infused solutions. There was no consensus on the use of NaHCO3, with eight recommending it, six considering it and one not. Five guidance documents mentioned oral pre-hydration as a possibility, and none recommended N-acetylcysteine as solitary preventive-measure. More recent guidance documents recommend avoiding hypertonic contrast media, but did not recommend preference of iso-osmolar over low-osmolar contrast media. Most guidance documents recognised pre-existing chronic kidney disease, diabetes, age and cardiovascular comorbidity as risk factors. Conclusions. There seems to be a relative consensus on the need for adequate pre-hydration to avoid CI-AKI, but recommendations to define at-risk populations for whom these measures should be applied and how they should be implemented differ substantially. Based on accumulating evidence, more recent guidelines do not recommend iso-osmolar over low-osmolar contrast media, whereas all recommend avoiding hypertonic agents.

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Generalizing attentional control across dimensions and tasks: evidence from transfer of proportion-congruent effects

Three experiments investigated transfer of list-wide proportion congruent (LWPC) effects from a set of congruent and incongruent items with different frequency (inducer task) to a set of congruent and incongruent items with equal frequency (diagnostic task). Experiments 1 and 2 mixed items from horizontal and vertical Simon tasks. Tasks always involved different stimuli that varied on the same dimension (colour) in Experiment 1 and on different dimensions (colour, shape) in Experiment 2. Experiment 3 mixed trials from a manual Simon task with trials from a vocal Stroop task, with colour being the relevant stimulus in both tasks. There were two major results. First, we observed transfer of LWPC effects in Experiments 1 and 3, when tasks shared the relevant dimension, but not in Experiment 2. Second, sequential modulations of congruency effects transferred in Experiment 1 only. Hence, the different transfer patterns suggest that LWPC effects and sequential modulations arise from different mechanisms. Moreover, the observation of transfer supports an account of LWPC effects in terms of list-wide cognitive control, while being at odds with accounts in terms of stimulus–response (contingency) learning and item-specific control.

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Chronic kidney disease prevalence: variation across thirteen European countries

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21st century education, care and support for children and adults with a disability in Flanders (Belgium)

At the turn of the 2l st century, substantial changes are taking place in Flanders (Belgium) with regard to the organization of education, care and support for people with disabiliîies. Overall, these changes are the result of new theoreticat insighr ãnd changed perspectives on disabilities: shift towards q social-ecological approach, supports paradigm and quality of life. The so-called "M-Decree" and Perspective 2020 qre the two most important reforms currently taking place in Flanders. The "M-Decree", a reþrm plan for special education which was approved in the Flemish Parliament in 2014, now wants to make a radical shift and aims at mainstreaming students with special needs in primary and se:condary education. Untilt now, the r"gr"gãrcd rpecial school remained the dominant type of education. Second, Perspective 2020, a policy plan lounched in 2010, aims at the active inclusion andfull participation of peopte with disabilities in society. This plan contains a centralfocus on the client and his/her network, stimulates person-centered support processes and plans through more individualizedfunding and induces a shiftfrom a supply-oriented model of care and support towards a demand-oriented model. Both ìeþrms are currently being implemented and will result in important changes, opportunities and challenges during the coming years.

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Gezinnen en hun functioneren: instrumentarium gesignaleerd

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Effects of Roux-en-Y gastric bypass surgery on postprandial fructose metabolism

Obesity

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Modelling the impact of deferring HCV treatment on liver-related complications in HIV coinfected men who have sex with men

Journal of Hepatology

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[18F]FPRGD2 PET/CT imaging of integrin ?v?3 levels in patients with locally advanced rectal carcinoma

European Journal of Nuclear Medicine & Molecular Imaging

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Prognostic role of 25-hydroxyvitamin D in patients with liver metastases from colorectal cancer treated with radiofrequency ablation

Journal of Gastroenterology and Hepatology

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Histone deacetylase 2 regulates doxorubicin (Dox) sensitivity of colorectal cancer cells by targeting ABCB1 transcription

Cancer Chemotherapy and Pharmacology

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A phase II study of adjuvant S-1/cisplatin chemotherapy followed by S-1-based chemoradiotherapy for D2-resected gastric cancer

Cancer Chemotherapy and Pharmacology

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Phase I/II study of nab-paclitaxel plus gemcitabine for chemotherapy-naive Japanese patients with metastatic pancreatic cancer

Cancer Chemotherapy and Pharmacology

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Risk of recurrence of Barrett’s esophagus after successful endoscopic therapy: a systematic review and meta-analysis

Gastrointestinal Endoscopy

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Loss of visceral adipose tissue precedes subcutaneous adipose tissue and associates with n-6 fatty acids content

Clinical Nutrition

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Tropheryma whipplei infection and Whipple's disease

The Lancet Infectious Diseases

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Objective prediction of pharyngeal swallow dysfunction in dysphagia through artificial neural network modeling

Neurogastroenterology & Motility

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Fecal calprotectin in the prediction of postoperative recurrence of Crohn's disease in children and adolescents

Journal of Pediatric Surgery

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Adrenomedullin therapy in patients with refractory ulcerative colitis

Digestive Diseases and Sciences

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Obese patients with type 2 diabetes on conventional versus intensive insulin therapy: Efficacy of low-calorie dietary intervention

Advances in Therapy

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Frequency and features of duodenal adenomas in patients with mutyh-associated polyposis

Clinical Gastroenterology and Hepatology

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Evidence-based clinical practice guidelines for peptic ulcer disease 2015

Journal of Gastroenterology

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Rare Variants of the Serotonin Transporter Are Associated With Psychiatric Comorbidity in Irritable Bowel Syndrome

Biological Research For Nursing

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A multicenter, randomized, double-blind, placebo-controlled trial of shuangbai san for treating primary liver cancer patients with cancer pain

Journal of Pain and Symptom Management

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Management of branch-duct intraductal papillary mucinous neoplasms: a large single-center study to assess predictors of malignancy and long-term outcomes

Gastrointestinal Endoscopy

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Depression, fatigue, and qol in colorectal cancer patients during and after treatment

Western Journal of Nursing Research

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Perioperative considerations in children with autism spectrum disorder.

Purpose of review: Children with autism often present a challenge to the anesthesiologist. This review summarizes the current experiences and recommendations for the perioperative management of this unique group of patients. Recent findings: Autism is the fastest growing neurodevelopmental disorder in the world. Increased recognition and public awareness of the disease is driven largely by the advances in research. A large body of evidence exists that identifies the role of genetic, environmental, biological, and developmental factors in the origin of autism. The anesthesia literature consists mostly of case reports. Recent publications are reporting management strategies and evaluation of this patient population's perioperative experiences. Summary: Patients with autism spectrum disorder are a heterogeneous group and often need general anesthesia for different procedures and studies. Familiarity with each patient's behavioral specifics and efforts to alleviate stress is of paramount importance for a smooth perioperative course with minimal adverse events. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Surgical treatment of craniosynostosis in infants: open vs closed repair.

Purpose of review: Correction of craniosynostosis may require extensive surgical interventions with related intra and postoperative complications especially hemorrhage. To reduce the intervention's impact and associated complications, less invasive surgical alternatives have evolved. The present review comprehensively summarizes surgical techniques, perioperative anesthesia management, success rates, complications, the results of outcome evaluations, and predictors of intra and postoperative complications. Recent findings: Recent evaluations suggest that less invasive methods represent valuable techniques with comparable cosmetic and volumetric results but reduced overall impact and complications. Furthermore, risk stratification based on predictors might optimize safety and guide decision-making concerning the required level of postoperative clinical care. Summary: Neuroendoscopic techniques, designed to minimize surgical incision, dissection, and blood loss, are becoming efficacious and valuable alternative therapeutic options reducing the need for fluid replacement and invasive hemodynamic monitoring. Since hemorrhage represents the most important complication in open craniosynostosis repair, prevention strategies such as the use of tranexamic acid should be considered. Sufficient correction of entailed coagulopathies is crucial. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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L-Cysteine protects intestinal integrity, attenuates intestinal inflammation and oxidant stress, and modulates NF-{kappa}B and Nrf2 pathways in weaned piglets after LPS challenge

In this study we investigated whether L-cysteine (L-cys) could alleviate LPS-induced intestinal disruption and its underlying mechanism. Piglets fed with an L-cys-supplemented diet had higher average daily gain. L-cys alleviated LPS-induced structural and functional disruption of intestine in weanling piglets, as demonstrated by higher villus height, villus height (VH) to crypt depth (CD) ratio, and transepithelial electrical resistance (TER) and lower FITC-dextran 4 (FD4) kDa flux in jejunum and ileum. Supplementation with L-cys up-regulated occludin and claudin-1 expression, reduced caspase-3 activity and enhanced proliferating cell nuclear antigen expression of jejunum and ileum relative to LPS group. Additionally, L-cys suppressed the LPS-induced intestinal inflammation and oxidative stress, as demonstrated by down-regulated TNF-α, IL-6 and IL-8 mRNA levels, increased catalase, superoxide dismutase, glutathione peroxidase activity, glutathione (GSH) contents and the ratio of GSH and oxidized glutathione in jejunum and ileum. Finally, a diet supplemented with L-cys inhibited NF-B(p65) nuclear translocation and elevated NF erythroid 2-related factor 2 (Nrf2) translocation compared with the LPS group. Collectively, our results indicated the protective function of L-cys on intestinal mucosa barrier may closely associated with its anti-inflammation, antioxidant and regulating effect on the NF-B and Nrf2 signaling pathways.

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Enhancing actions of peptides derived from the {gamma}-chain of fetal human hemoglobin on the immunostimulant activities of monophosphoryl lipid A

Hemoglobin and its structures have been described since the 1990s to enhance a variety of biological activities of endotoxins (LPS) in a dose-dependent manner. To investigate the interaction processes in more detail, the system was extended by studying the interactions of newly designed peptides from the -chain of human hemoglobin with the adjuvant monophosphoryl lipid A (MPLA), a partial structure of lipid A lacking its 1-phosphate. It was found that some selected Hbg peptides, in particular two synthetic substructures designated Hbg32 and Hbg35, considerably increased the bioactivity of MPLA, which alone was only a weak activator of immune cells. These findings hold true for human mononuclar cells, monocytes and T lymphocytes. To understand the mechanisms of action in more detail, biophysical techniques were applied. These showed a peptide-induced change of the MPLA aggregate structure from multilamellar into a non-lamellar, probably inverted, cubic structure. Concomitantly, the peptides incorporated into the tightly packed MPLA aggregates into smaller units down to monomers. The fragmentation of the aggregates was an endothermic process, differing from a complex formation but rather typical for a catalytic reaction.

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Heat shock proteins and chronic fatigue in primary Sjögrens syndrome

Fatigue occurs frequently in patients with cancer, neurological diseases and chronic inflammatory diseases, but the biological mechanisms that lead to and regulate fatigue are largely unknown. When the innate immune system is activated, heat shock proteins (HSPs) are produced to protect cells. Some extracellular HSPs appear to recognize cellular targets in the brain, and we hypothesize that fatigue may be generated by specific HSPs signalling through neuronal or glial cells in the central nervous system. From a cohort of patients with primary Sjögren's syndrome, 20 patients with high and 20 patients with low fatigue were selected. Fatigue was evaluated with a fatigue visual analogue scale. Plasma concentrations of HSP32, HSP60, HSP72 and HSP90α were measured and analysed to determine if there were associations with the level of fatigue. Plasma concentrations of HSP90α were significantly higher in patients with high fatigue compared with those with low fatigue, and there was a tendency to higher concentrations of HSP72 in patients with high fatigue compared with patients with low fatigue. There were no differences in concentrations of HSP32 and HSP60 between the high- and low-fatigue groups. Thus, extracellular HSPs, particularly HSP90α, may signal fatigue in chronic inflammation. This supports the hypothesis that fatigue is generated by cellular defence mechanisms.

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The ultrasonic polar scan for composite characterization and damage assessment: past, present and future

In the early 1980's, the ultrasonic polar scan (UPS) technique was developed to assess the fiber direction of composites in a nondestructive way. In spite of the recognition by several researchers as being a sophisticated and promising methodology for nondestructive testing (NDT) and materials science, little advance was made during the following 30 years. Recently however, the UPS technique experienced a strong revival and various modifications to the original UPS setup have been successfully implemented. This revival has exposed several powerful capabilities and interesting applications of the UPS technique for material characterization and damage assessment. This paper gives a short historical overview of the UPS technique for characterizing and inspecting (damaged) fiber-reinforced plastics. In addition, a few future research lines are given, which will further expand the applicability and potential of the UPS method to a broader range of (damaged) materials, bringing the UPS technique to the next level of maturity.

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Ligand addition energies and the stoichiometry of colloidal nanocrystals

Experimental nonstoichiometries of colloidal nanocrystals such as CdSe and PbS are accounted for by attributing to each constituent atom and capping ligand a formal charge equal to its most common oxidation state to obtain an overall neutral nano crystal. In spite of its apparent simplicity, little theoretical support of this approach called here the oxidation-number sum rule is present in the current literature. Here, we introduce the ligand addition energy, which we define as the energy gained or expended upon the transfer of one ligand from a reference state to a metal-rich solid surface. For the combination of CdSe, ZnSe and InP with either chalcogen, halogen or hydrochalcogen ligands, we compute successive ligand addition energies using ab initio methods and determine the thermodynamically stable surface composition as that composition where ligand addition turns endothermic. We find that the oxidation-number sum rule is valid in many situations, although exceptions occur for each material studied, most notably when exposed to small oxidative ligands. In the case of InP, however, violations are more severe, extending toward the entire chalcogen ligand family. In addition, we find that electronegativity rather than chemical hardness is a reasonable predictor for ligand addition energies, with the most electronegative ligands yielding the most exothermic addition energies. Finally, we argue that the ligand addition energy will be a most useful quantity for future computational studies on the structure, stability and reactivity of nanocrystal surfaces.

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CFD analysis of melting process in a shell-and-tube latent heat storage for concentrated solar power plants

A latent heat storage system for concentrated solar plants (CSP) is numerically examined by means of CFD simulations. This study aims at identifying the convective flows produced within the melted phase by temperature gradients and gravity. Simulations were carried out on experimental devices for applications to high temperature concentrated solar power plants. A shell-and-tube geometry composed by a vertical cylindrical tank, filled by a Phase Change Material (PCM) and an inner steel tube, in which the heat transfer fluid (HTF) flows, from the top to the bottom, is considered. The conjugate heat transfer process is examined by solving the unsteady Navier–Stokes equations for HTF and PCM and conduction for the tube. In order to take into account the buoyancy effects in the PCM tank the Boussinesq approximation is adopted. The results show that the enhanced heat flux, due to natural convective flow, reduce of about 30% the time needed to charge the heat storage. A detailed description of the convective motion in the melted phase and the heat flux distribution between the HTF and PCM are reported. The effect of the mushy zone constant is also investigated.

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Methodology used in studies reporting chronic kidney disease prevalence: a systematic literature review

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Exploring mechanisms of protein binding of uraemic toxins in CKD2-5 and haemodialysis patients

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Corporate giants provide fertility benefits: have they got it wrong?

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Antologías del cuento dominicano de la última década (2000-2010)

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Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care

Abstract

Background

European roundtable meeting recommendations on bathing and cleansing of infants were published in 2009; a second meeting was held to update and expand these recommendations in light of new evidence and the continued need to address uncertainty surrounding this aspect of routine care.

Methods

The previous roundtable recommendations concerning infant cleansing, bathing, and use of liquid cleansers were critically reviewed and updated and the quality of evidence was evaluated using the Grading of Recommendation Assessment, Development and Evaluation system. New recommendations were developed to provide guidance on diaper care and the use of emollients. A series of recommendations was formulated to characterize the attributes of ideal liquid cleansers, wipes, and emollients.

Results

Newborn bathing can be performed without harming the infant, provided basic safety procedures are followed. Water alone or appropriately designed liquid cleansers can be used during bathing without impairing the skin maturation process. The diaper area should be kept clean and dry; from birth, the diaper area may be gently cleansed with cotton balls/squares and water or by using appropriately designed wipes. Appropriately formulated emollients can be used to maintain and enhance skin barrier function. Appropriately formulated baby oils can be applied for physiologic (transitory) skin dryness and in small quantities to the bath. Baby products that are left on should be formulated to buffer and maintain babies' skin surface at approximately pH 5.5, and the formulations and their constituent ingredients should have undergone an extensive program of safety testing. Formulations should be effectively preserved; products containing harsh surfactants, such as sodium lauryl sulfate, should be avoided.

Conclusion

Health care professionals can use these recommendations as the basis of their advice to parents.

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Lipid-Rich Carcinoma of the Breast With Unusual Clinical and Histopathological Features

Lipid-rich carcinoma of the breast is a rare form of invasive breast carcinoma of special type. Most cases are grade 3, hormone receptor negative, and associated with aggressive clinical behavior. We report an unusual case of lipid-rich carcinoma with morphological and immunophenotypical features different from those of cases reported so far in the literature. The index case underscores the fact that there is no consensus with regard to the exact nature of this tumor. Hence, larger studies are needed to draw meaningful conclusions.

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Fluid Overload Is Associated With Higher Mortality and Morbidity in Pediatric Patients Undergoing Cardiac Surgery.

Objectives: Fluid overload after pediatric cardiac surgery is common and has been shown to increase both mortality and morbidity. This study explores the risk factors of early postoperative fluid overload and its relationship with adverse outcomes. Design: Secondary analysis of the prospectively collected data of children undergoing open-heart surgery between 2004 and 2008. Setting: Tertiary national cardiac center. Patients: One thousand five hundred twenty consecutive pediatric patients (

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Clonidine as a First-Line Sedative Agent After Neonatal Cardiac Surgery: Retrospective Cohort Study.

Objectives: To determine the cardiovascular tolerance of clonidine used as a first-line sedative after cardiac surgery in small infants. Design: Retrospective chart review. Setting: A tertiary and quaternary referral cardiac PICU. Patients: All infants younger than 2 months who received a clonidine infusion for sedation after cardiac surgery from October 2011 to July 2013. Interventions: None. Measurement and Main Results: Heart rate, blood pressure, central venous and left atrial pressure, vasoactive inotropic score, volume of fluid bolus, and lactate and central mixed venous saturation were assessed. Preinfusion values were compared with postinfusion values. Of 224 potentially eligible patients, only 23 infants met inclusion criteria, as most patients only received high doses of morphine and some received midazolam instead of clonidine. Clonidine administration was started at a median of 12 hours after surgery (Q1-Q3, 5-23), and infusion rate was 0.5-2 [mu]g/kg/hr for a median duration of 30 hours (Q1-Q3, 12-54). Heart rate decreased (maximal mean decrease: 12% [149 beats/min (SD, 17) to 131 beats/min (SD, 17)]; p

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Patient-Ventilator Asynchrony During Assisted Ventilation in Children.

Objective: To describe the frequency and type of patient-ventilator asynchrony in mechanically ventilated children by analyzing ventilator flow and pressure signals. Design: Prospective observational study. Setting: Tertiary PICU in a university hospital. Patients: Mechanically ventilated children between 0 and 18 years old and who were able to initiate and maintain spontaneous breathing were eligible for inclusion. Patients with congenital or acquired neuromuscular disorders, those with congenital or acquired central nervous system disorders, and those who were unable to initiate and maintain spontaneous breathing from any other cause were excluded. Interventions: None. Measurements and Main Results: All patients were ventilated in a time-cycled, pressure-limited mode with flow triggering set at 1.0 L/min by using the Evita XL (Drager, Lubeck, Germany). Patient-ventilator asynchrony was identified by a random 30-minute continuous recording and an offline analysis of the flow and pressure signals. Patient-ventilator asynchrony was categorized and labeled into four different groups: 1) trigger asynchrony (i.e., insensitive trigger, double triggering, autotriggering, or trigger delay), 2) flow asynchrony, 3) termination asynchrony (i.e., delayed or premature termination), and 4) expiratory asynchrony. Flow and pressure signals were recorded in 45 patients for 30 minutes. A total number of 57,651 breaths were analyzed. Patient-ventilator asynchrony occurred in 19,175 breaths (33%), and it was seen in every patient. Ineffective triggering was the most predominant type of asynchrony (68%), followed by delayed termination (19%), double triggering (4%), and premature termination (3%). Patient-ventilator asynchrony significantly increased with lower levels of peak inspiratory pressure, positive end-expiratory pressure, and set frequency. Conclusions: Patient-ventilator asynchrony is extremely common in mechanically ventilated children, and the predominant cause is ineffective triggering. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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A Decline in Intraoperative Renal Near-Infrared Spectroscopy Is Associated With Adverse Outcomes in Children Following Cardiac Surgery.

Objectives: Renal near-infrared spectroscopy is known to be predictive of acute kidney injury in children following cardiac surgery using a series of complex equations and area under the curve. This study was performed to determine if a greater than or equal to 20% reduction in renal near-infrared spectroscopy for 20 consecutive minutes intraoperatively or within the first 24 postoperative hours is associated with 1) acute kidney injury, 2) increased acute kidney injury biomarkers, or 3) other adverse clinical outcomes in children following cardiac surgery. Design: Prospective single center observational study. Setting: Pediatric cardiac ICU. Patients: Children less than or equal to age 4 years who underwent cardiac surgery with the use of cardiopulmonary bypass during the study period (June 2011-July 2012). Interventions: None. Measurements and Main Results: A reduction in near-infrared spectroscopy was not associated with acute kidney injury. Nine of 12 patients (75%) with a reduction in renal near-infrared spectroscopy did not develop acute kidney injury. The remaining three patients had mild acute kidney injury (pediatric Risk, Injury, Failure, Loss, End stage-Risk). A reduction in renal near-infrared spectroscopy was associated with the following adverse clinical outcomes: 1) a longer duration of mechanical ventilation (p = 0.05), 2) longer intensive care length of stay (p = 0.05), and 3) longer hospital length of stay (p

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Accuracy of Pulse Oximeters Intended for Hypoxemic Pediatric Patients.

Objectives: Prior studies have shown inaccuracies in pulse oximetry readings at saturations less than 85%; however, no large studies have evaluated new sensors marketed for these low saturations. This study's purpose was to evaluate two sensors with claims of improved accuracy in children with saturations less than 85%. Design: Prospective observational study. Setting: Single institution; cardiac catheterization laboratory, and operating room. Patients: Fifty patients weighing 3-20 kg with baseline saturations less than 90% undergoing surgical or catheterization procedure. Measurements and Main Results: Data collected included demographics, diagnosis, continuous saturations from three different pulse oximeters (Masimo LNCS [Masimo, Irvine, CA], Masimo Blue [Masimo], and Nellcor Max-I [Medtronic, Dublin, Ireland]) and up to four blood samples for co-oximetry as the gold-standard arterial oxygen saturation. Analysis included scatter plots, smoothed regression estimates of mean continuous saturation levels plotted against corresponding arterial oxygen saturation values, and Bland-Altman plots. Bland-Altman analysis indicated increasing levels of bias and variability for decreasing arterial oxygen saturation levels for all three sensors, with a statistically significant increase in mean difference observed for decreasing arterial oxygen saturation level. The Masimo Blue sensor had the lowest mean difference, SD and Bland-Altman limits in patients with saturations less than or equal to 85%. At saturation range of less than or equal to 85% and greater than 75%, 14% of the samples obtained from Masimo Blue, 24% of the readings from the Nellcor, and 31% from the Masimo Standard sensors were greater than or equal to 5% points difference. All three sensors had a further increase in these differences for arterial oxygen saturation values less than 75%. Conclusions: The Masimo Blue sensor has improved accuracy at saturations 75-85% versus the Nellcor and Masimo Standard sensors. The accuracy of peripheral capillary oxygen saturation of the Masimo Blue sensor was within 5% points of the arterial oxygen saturation the majority of the time. Currently, at saturations less than or equal to 85%, pulse oximetry alone should not be relied on in making clinical decisions. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Outcomes Following Single and Recurrent In-Hospital Cardiac Arrests in Children With Heart Disease: A Report From American Heart Association's Get With the Guidelines Registry-Resuscitation.

Objectives: Little is known regarding patient characteristics and outcomes associated with cardiac arrest in hospitalized children with underlying heart disease. We described clinical characteristics and in-hospital outcomes in cardiac patients with both single and recurrent cardiac arrests. Design: Retrospective analysis evaluating characteristics and outcomes in single versus recurrent arrest groups in unadjusted and adjusted analyses. Setting: American Heart Association's Get with the Guidelines-Resuscitation registry (2000-2010). Patients: Children younger than 18 years, identified with medical or surgical cardiac disease and one or more in-hospital cardiac arrest. Interventions: None. Measurement and Main Results: One thousand eight hundred and eighty-nine patients with 2,387 cardiac arrests from 157 centers met inclusion criteria: 1,546 (82%) with a single arrest and 343 (18%) with a recurrent arrest. More than two thirds of recurrent cardiac arrests occurred in ICUs, and those with recurrent arrest had a higher prevalence of baseline comorbidities (e.g., more likely to be mechanically ventilated and receiving vasoactive infusions). Overall survival to hospital discharge was 51%, and was lower in the recurrent versus single arrest group (41% vs 53%; p

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Validation of a Pediatric Early Warning Score in Hospitalized Pediatric Oncology and Hematopoietic Stem Cell Transplant Patients.

Objectives: To evaluate the correlation of a Pediatric Early Warning Score with unplanned transfer to the PICU in hospitalized oncology and hematopoietic stem cell transplant patients. Design: We performed a retrospective matched case-control study, comparing the highest documented Pediatric Early Warning Score within 24 hours prior to unplanned PICU transfers in hospitalized pediatric oncology and hematopoietic stem cell transplant patients between September 2011 and December 2013. Controls were patients who remained on the inpatient unit and were matched 2:1 using age, condition (oncology vs hematopoietic stem cell transplant), and length of hospital stay. Pediatric Early Warning Scores were documented by nursing staff at least every 4 hours as part of routine care. Need for transfer was determined by a PICU physician called to evaluate the patient. Setting: A large tertiary/quaternary free-standing academic children's hospital. Patients: One hundred ten hospitalized pediatric oncology patients (42 oncology, 68 hematopoietic stem cell transplant) requiring unplanned PICU transfer and 220 matched controls. Interventions: None. Measurements and Main Results: Using the highest score in the 24 hours prior to transfer for cases and a matched time period for controls, the Pediatric Early Warning Score was highly correlated with the need for PICU transfer overall (area under the receiver operating characteristic = 0.96), and in the oncology and hematopoietic stem cell transplant groups individually (area under the receiver operating characteristic = 0.95 and 0.96, respectively). The difference in Pediatric Early Warning Score results between the cases and controls was noted as early as 24 hours prior to PICU admission. Seventeen patients died (15.4%). Patients with higher Pediatric Early Warning Score prior to transfer had increased PICU mortality (p = 0.028) and length of stay (p = 0.004). Conclusions: We demonstrate that our institution's Pediatric Early Warning Score is highly correlated with the need for unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant patients. Furthermore, we found an association between higher scores and PICU mortality. This is the first validation of a Pediatric Early Warning Score specific to the pediatric oncology and hematopoietic stem cell transplant populations, and supports the use of Pediatric Early Warning Score as a method of early identification of clinical deterioration in this high-risk population. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Can Monitoring Fetal Intestinal Inflammation Using Heart Rate Variability Analysis Signal Incipient Necrotizing Enterocolitis of the Neonate?.

Objective: Necrotizing enterocolitis of the neonate is an acute inflammatory intestinal disease that can cause necrosis and sepsis. Chorioamnionitis is a risk factor of necrotizing enterocolitis. The gut represents the biggest vagus-innervated organ. Vagal activity can be measured via fetal heart rate variability. We hypothesized that fetal heart rate variability can detect fetuses with incipient gut inflammation. Design: Prospective animal study. Setting: University research laboratory. Subjects: Chronically instrumented near-term fetal sheep (n = 21). Measurements and Main Results: Animals were surgically instrumented with vascular catheters and electrocardiogram to allow manipulation and recording from nonanesthetized animals. In 14 fetal sheep, inflammation was induced with lipopolysaccharide (IV) to mimic chorioamnionitis. Fetal arterial blood samples were drawn at selected time points over 54 hours post lipopolysaccharide for blood gas and cytokines (interleukin-6 and tumor necrosis factor-[alpha] enzymelinked immunosorbent assay). Fetal heart rateV was quantified throughout the experiment. The time-matched fetal heart rate variability measures were correlated to the levels of interleukin-6 and tumor necrosis factor-[alpha]. Upon necropsy, ionized calcium binding adaptor molecule 1+ (Iba1+), CD11c+ (M1), CD206+ (M2 macrophages), and occludin (leakiness marker) immunofluorescence in the terminal ileum was quantified along with regional Iba1+ signal in the brain (microglia). Interleukin-6 peaked at 3 hours post lipopolysaccharide accompanied by mild cardiovascular signs of sepsis. At 54 hours, we identified an increase in Iba1+ and, specifically, M1 macrophages in the ileum accompanied by increased leakiness, with no change in Iba1 signal in the brain. Preceding this change on tissue level, at 24 hours, a subset of nine fetal heart rate variability measures correlated exclusively to the Iba+ markers of ileal, but not brain, inflammation. An additional fetal heart rate variability measure, mean of the differences of R-R intervals, correlated uniquely to M1 ileum macrophages increasing due to lipopolysaccharide. Conclusions: We identified a unique subset of fetal heart rate variability measures reflecting 1.5 days ahead of time the levels of macrophage activation and increased leakiness in terminal ileum. We propose that such subset of fetal heart rate variability measures reflects brain-gut communication via the vagus nerve. Detecting such noninvasively obtainable organ-specific fetal heart rate variability signature of inflammation would alarm neonatologists about neonates at risk of developing necrotizing enterocolitis and sepsis. Clinical validation studies are required. (C)2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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A force-sensing surgical tool with a proximally located force/torque sensor

Abstract

Background

Robotic surgery has seen a rapid increase in popularity in the last few decades because advantages such as increased accuracy and dexterity can be realized. These systems still lack force-feedback, where such a capability is believed to be beneficial to the surgeon and can improve safety.

Method

In this paper a force-feedback enabled surgical robotic system is described in which the developed force-sensing surgical tool is discussed in detail. The developed surgical tool makes use of a proximally located force/torque sensor, which, in contrast to a distally located sensor, requires no miniaturization or sterilizability.

Results

Experimental results are presented, and indicate high force sensing accuracies with errors <0.09 N.

Conclusions

It is shown that developing a force-sensing surgical tool utilizing a proximally located force/torque sensor is feasible, where a tool outer diameter of 12 mm can be achieved. For future work it is desired to decrease the current tool outer diameter to 10 mm. Copyright © 2016 John Wiley & Sons, Ltd.

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