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Objectives Ultrasound-guided regional anesthesia (UGRA) relies on acquiring and interpreting an appropriate view of sonoanatomy. Artificial intelligence (AI) has the potential to aid this by applying a color overlay to key sonoanatomical structures.The primary aim was to determine whether an AI-generated color overlay was associated with a difference in participants’ ability to identify an appropriate block view over a 2-month period after a standardized teaching session (as judged by a blinded assessor). Secondary outcomes included the ability to identify an appropriate block view (unblinded assessor), global rating score and participant confidence scores.Design Randomized, partially blinded, prospective cross-over study.Setting Simulation scans on healthy volunteers. Initial assessments on 29 November 2022 and 30 November 2022, with follow-up on 25 January 2023 – 27 January 2023.Participants 57 junior anesthetists undertook initial assessments and 51 (89.47%) returned at 2 months.Intervention Participants performed ultrasound scans for six peripheral nerve blocks, with AI assistance randomized to half of the blocks. Cross-over assignment was employed for 2 months.Main outcome measures Blinded experts assessed whether the block view acquired was acceptable (yes/no). Unblinded experts also assessed this parameter and provided a global performance rating (0–100). Participants reported scan confidence (0–100).Results AI assistance was associated with a higher rate of appropriate block view acquisition in both blinded and unblinded assessments (p=0.02 and

Objective: Open decannulation from femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) carries high risk of morbidity, including groin wound infection. This study evaluated the impact of percutaneous decannulation on rates of groin wound infection in patients decannulated from femoral VA-ECMO. Methods: Between January 1, 2022, and April 30, 2023, 47 consecutive patients received percutaneous femoral VA-ECMO and survived to decannulation. A percutaneous suture-mediated closure device was used for decannulation in patients with relatively smaller arterial cannulas. Patients with larger arterial cannulas or unsuccessful percutaneous closures underwent surgical cutdown and repair of the femoral artery. The primary outcome was arterial site wound infection following decannulation. Results: Among the 47 patients who survived to decannulation from VA-ECMO, 21 underwent percutaneous decannulation and 27 underwent surgical cutdown. One patient underwent 2 VA-ECMO runs, one with percutaneous decannulation and one with surgical cutdown. Percutaneous decannulation was attempted in 22 patients, with 21 of 22 (95.5%) success rate. Decannulation procedure length was significantly shorter in the percutaneous group (79 minutes vs 148 minutes, P = .0001). The percutaneous group had significantly reduced rates of groin wound complications (0% vs 40.7%, P = .001) and groin wound infections (0% vs 22.2%, P = .03) when compared with the surgical cutdown group. Three patients (14.3%) in the percutaneous group experienced vascular complications, including pseudoaneurysm at the distal perfusion catheter site and nonocclusive thrombus of the common femoral artery. Conclusions: Percutaneous decannulation may reduce decannulation procedure length and rate of groin wound infection in patients who survive to decannulation from VA-ECMO.

Abstract Background Legionella remains underdiagnosed in the intensive care unit and can progress to acute respiratory distress syndrome (ARDS), multiorgan failure and death. In severe cases, venovenous extracorporeal membrane oxygenation (VV-ECMO) allows time for resolution of disease with Legionella-targeted therapy. VV-ECMO outcomes for Legionella are favorable with reported survival greater than 70%. Rapid molecular polymerase chain reaction (PCR) testing of the lower respiratory tract aids in diagnosing Legionella with high sensitivity and specificity. We present a unique case of a patient with a positive COVID-19 test and ARDS who suffered a cardiac arrest. The patient was subsequently cannulated for VV-ECMO, and after lower respiratory tract PCR testing, Legionella was determined to be the cause. She was successfully treated and decannulated from VV-ECMO after eight days. Case presentation A 53-year-old female presented with one week of dyspnea and a positive COVID-19 test. She was hypoxemic, hypotensive and had bilateral infiltrates on imaging. She received supplemental oxygen, intravenous fluids, vasopressors, broad spectrum antibiotics, and was transferred to a tertiary care center. She developed progressive hypoxemia and suffered a cardiac arrest, requiring ten minutes of CPR and endotracheal intubation to achieve return of spontaneous circulation. Despite mechanical ventilation and paralysis, she developed refractory hypoxemia and was cannulated for VV-ECMO. Dexamethasone and remdesivir were given for presumed COVID-19. Bronchoscopy with bronchoalveolar lavage (BAL) performed with PCR testing was positive for Legionella pneumophila and negative for COVID-19. Steroids and remdesivir were discontinued and she was treated with azithromycin. Her lung compliance improved, and she was decannulated after eight days on VV-ECMO. She was discharged home on hospital day 16 breathing room air and neurologically intact. Conclusions This case illustrates the utility of rapid PCR testing to diagnose Legionella in patients with respiratory failure and the early use of VV-ECMO in patients with refractory hypoxemia secondary to Legionella infection. Moreover, many patients encountered in the ICU may have prior COVID-19 immunity, and though a positive COVID-19 test may be present, further investigation with lower respiratory tract PCR testing may provide alternative diagnoses. Patients with ARDS should undergo Legionella-specific testing, and if Legionella is determined to be the causative organism, early VV-ECMO should be considered in patients with refractory hypoxemia given reported high survival rates.

Introduction: Approximately 55.52% of the Indian population had been fully vaccinated by Jan. 2022, since its first roll out on January 16, 2021. A few concerns were raised concerning the Covishield vaccination related to thrombotic thrombocytopenia. Apheresis-derived platelet concentrates are frequently required in a plethora of clinical situations and post-vaccination decrement of platelet counts might lead to increased deferral of the platelet-pheresis donors. Objectives. The aim of the study was to discover the effect of the Covishield vaccination on deferral rates of plateletpheresis donors. Methods: Blood samples were collected from the potential platelet donors for the completion of the standard questionnaire for the complete blood count. The data collected were tabulated in the MS Excel spreadsheet and the biostatistical analysis was performed with the SPSS v23. A p-value of < 0.05 was taken as significant. We compared this data with age- and sex-matched controls. Results: The mean age of cases and controls was 29.69 ± 8.57 and 30.15 ± 7.11, respectively. There was a significant difference in platelet counts of cases (188496.35 ± 72065.66/cumm) and controls (269524.50 ± 53981.60/cumm). Furthermore, donors who received one dose had higher platelet counts of 248676.47 ± 80075.24/cumm than those who received both doses of vaccine (179970.83 ± 66773.73/cumm) . The difference in deferral rates between the two groups was remarkable (34.7% vs. 0.9%, with the p-value < 0.001). Conclusion: Vaccination certainly increased the deferral rates of plateletpheresis donors due to low platelet counts. Average platelet counts were low in fully vaccinated individuals, however, the platelets returned to normal counts as the post-vaccination days progressed.

Context: There is an ever-growing concern for the safety of blood transfusion with regard to the transmission of human immunodeficiency virus (HIV), hepatitis C (HCV) virus, and hepatitis B virus (HBV). About 11 million blood units are being collected in India every year. Instances of viral transmission through transfusion still occur as a result of donations that take place while a donor is in the pre-seroconversion window phase. Aim: The aim of the study is to analyze 4 years data of nucleic acid testing (NAT) for our blood donor population and validate the benefits of implementing individual donor NAT (ID-NAT). Subjects and Methods: A total of 54,895 blood donor samples were tested by ID-NAT method between January 2016 and December 2019. ID-NAT results and corresponding serological test results were collected and correlated for the identification of ID-NAT yield cases (seronegative/NAT positive) to identify the potential infected samples which may not be detected by the serological testing. Results: Of the 54,895 samples tested, there were total 71 samples which were serologically negative but detected by ID-NAT (ID-NAT yield). Among these 71 ID-NAT Yields, 3 were HIV, 12 were HCV, 46 were HBV, and 10 cases were reactive for HBV-HCV co-infections. Our combined ID-NAT yield rate was estimated to be 1 in 773 donations tested. Conclusion: Higher incidence of NAT only reactive donors poses a risk of transfusion transmissible infections in blood centers not adopting NAT. HBV NAT displays the highest yield, thereby recommending the universal adoption of NAT for all three viral markers, namely HIV, HBV, and HCV in our country.

BACKGROUND Fibrinogen is an important component of hemostasis and clot formation. Replacement therapy with a human Fibrinogen concentrate is the preferred therapeutic option for patients with congenital or acquired Fibrinogen insufficiency. To make the Fibrinogen available for treatment of such patients, Fibrogen-I®, a lyophilized product purified from pooled human plasma was developed and extensively characterized. The product quality attributes were assessed by different biochemical, functional and structural analytical methods. MATERIAL AND METHODS Functional activity of Fibrinogen in the Fibrogen-I® was demonstrated by determination of its clottable protein activity. Purity profiling of Fibrogen-I® was evaluated by SE-HPLC method. Activation and fibrinolysis markers like D-dimer, plasminogen was determined by automated coagulometer and fibrinopeptide A activity by ELISA. Far UV CD analysis was also performed by CD Spectrometer. RESULTS The product exhibited high purity 89.7% by SE-HPLC. Activation and Fibrinolysis marker proteins in the drug product were negligible. The high purity and integrity of Fibrogen-I® is underlined by the ratio of Fibrinogen activity by Clauss/clottable protein with mean calculated value of 0.9 which is in close proximity with theoretical value 1 indicating fully native Fibrinogen. The results of far-UV CD spectroscopy revealed that Fibrogen-I® exists mostly as a β-sheet secondary structure, which is in accordance with the three-dimensional structure of human Fibrinogen. Downscaling experiments for the two dedicated orthogonal pathogen inactivation steps, ie solvent detergent treatment and dry heat treatment, exhibited pathogen safety. DISCUSSION Fibrogen-I® exhibited specific functional activity, desirable quality attributes, pathogen safety and the ability to be made available to patients requiring fast and effective Fibrinogen replacement.

The utilization of venovenous bypass in liver transplantation (LT) has become less frequent and more center dependent over time. Unfortunately, this has left many transplant surgeons, particularly younger trainees, unfamiliar with the techniques and indications for its utilization. We present a case of LT in a patient with complete superior vena cava (SVC) occlusion prohibiting direct vascular access. A multi-disciplinary approach involving interventional radiology, anesthesiology, cardiac surgery, and transplant surgery, was used to diagnose, evaluate, and develop an operative plan for successful LT. In doing so, a novel approach to portosystemic bypass was utilized involving a right mini-thoracotomy with direct cannulation of the right atrium to gain central venous access and optimize venous return during LT. As a center that does not routinely use venovenous bypass, this multidisciplinary approach was crucial identifying the need for a rarely used technique for vascular access and performance of a successful LT.

Biometric analysis helps in sex differentiation, understanding development and for studies of avian biology such as foraging ecology, evolutionary ecology, and survivorship. We suggest that biometry can also be a reliable, practical and inexpensive tool to determine the age of nestlings in the field by non-invasive methods. As an example we studied the biometry of wing, culmen, talon, tarsus and body mass of nestling southern Indian Spotted Owlets (Athene brama brama). Based on the growth pattern analysis using logistic growth model, discriminant analysis and CHAID (Chi-squared Automatic Interaction Detection) based decision tree, we show that biometry of nestling Spotted Owlets is an easy, reliable and inexpensive method to determine nestling age and to assess growth rate and relative nutritional status. These biometric parameters also allow us to predict their ability to initiate first flight from the nest site. This method is described here for the first time and we postulate that such charts can be devised for other avian species as well, so as to assist conservation biologists and bird rescuers.

OBJETIVO: O propósito deste estudo é demonstrar que o reposicionamento do músculo papilar é uma técnica confiável para o reparo do prolapso da cúspide anterior, portanto, nós descrevemos esta técnica e seus resultados propondo-a como padrão. MÉTODO: Entre 1989 e 2005, 120 plastias da valva mitral foram consecutivamente realizadas por meio do reposicionamento do músculo papilar no prolapso da cúspide anterior. Oitenta e sete pacientes eram do sexo masculino e 33 do feminino, sendo, a média de idade de 59 ± 11,5 anos. Cinqüenta e nove por cento dos pacientes estavam em classe funcional (NYHA) III ou IV, a média da fração de ejeção foi 65,7 ± 8,9%. A etiologia predominante na regurgitação da valva mitral (RM) foi doença degenerativa: Barlow (n=43) e distrofia (n=62). As outras etiologias eram: endocardite cicatrizada (n=5), reumática (n=5), isquêmica (n=4), congênita (n=1). O reposicionamento do músculo papilar posterior foi realizado em 111 (92,5%) casos e do anterior em 38 (31,7%). Procedimentos associados foram realizados em 76 (63,3%) pacientes. RESULTADOS: Não houve óbito hospitalar. Durante o acompanhamento, 14 (11,7%) pacientes foram a óbito, incluindo sete (5,8%) por causas cardíacas. As taxas da curva de sobrevida acumulada em 1, 5, 10 e 15 anos foram 98,3%, 97,2%, 94,1% e 81,4%, respectivamente. Dois (1,7%) pacientes foram reoperados por regurgitação recorrente, eles foram submetidos à troca da valva 1 e 5 anos depois do reparo e morreram 3 e 6 anos após esta troca valvar. Não houve movimento anterior sistólico. As taxas de sobrevida acumulada livre de reoperação envolvendo a valva mitral em 1, 5, 10, e 15 anos foram 97,4%, 97,4%, 92,8% e 86,7%, respectivamente. Nós não achamos nenhum fator de risco de mortalidade e de reoperação. O acompanhamento completo foi realizado em todos os pacientes. Após um tempo de acompanhamento mediano de 5,9 anos (de 0,1 a 15,6 anos), 87 (72,5%) pacientes estavam na classe I - NYHA, o controle ecocardiográfico mostrou nenhuma ou mínima regurgitação em 89 (74,2 %) pacientes, leve regurgitação em oito (6,7%) e moderada regurgitação em nove (7,5%). CONCLUSÃO: O reposicionamento do músculo papilar é uma técnica confiável e segura, com excelentes resultados clínicos e ecocardiográficos a longo prazo. Desta maneira, estamos propondo-a como padrão para o reparo da cúspide anterior prolapsada.OBJECTIVE: The aim of this study was to demonstrate that papillary muscle repositioning is a reliable technique to repair anterior leaflet prolapse. Therefore we describe this technique and its long term results to propose it as a gold standard. METHOD: Between 1989 and 2005, 120 mitral valve repairs were consecutively performed using papillary muscle repositioning in cases of anterior leaflet prolapse. There were 87 males and 33 females, the mean age was 59 ± 11.5 years. 59% of patients were in NYHA III or IV. Mean ejection fraction was 65.7 ± 8.9%. Predominant aetiology of mitral regurgitation (MR) was degenerative: Barlow (n=43) and dystrophic (n=62). The other aetiologies were: healed endocarditis (n=5), rheumatic (n=5), ischemic (n=4), congenital (n=1). A posterior papillary muscle repositioning was performed in 111 (92.5%) cases and an anterior in 38 (31.7%). Associated procedures were carried out in 76 (63.3%) patients. RESULTS: There were no in-hospital deaths. During the follow-up, 14 patients (11.7%) died, including seven (5.8%) due to cardiac causes. The cumulated survival rates at 1, 5, 10 and 15 years were 98.3%, 97.2%, 94.1% and 81.4% respectively. Two patients (1.7%) were reoperated for recurrency of the regurgitation, they underwent a replacement of the valve 1 and 5 years after the repair and died 3 and 6 years, respectively after this replacement. There was no systolic anterior motion. The cumulated survival rates free from reoperation involving the mitral valve at 1, 5, 10 and 15 years were 97.4%, 97.4%, 92.8 % and 86.7% respectively. We did not find any risk factor of mortality or of reoperation. The follow-up was completed for all the patients. After a median follow-up time of 5.9 years (range from 0.1 to 15.6 years) 87 patients were in NYHA class I (72.5%), the echographic control showed no or minimal insufficiency in 89 patients (74.2%), mild insufficiency in eight patients (6.7%) and moderate insufficiency in nine patients (7.5%). CONCLUSIONS: Papillary muscle repositioning is a reliable and safe technique, with excellent clinical and echocardiographic long term results. Therefore we propose it as a gold standard to repair anterior leaflet prolapse.