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The PASS intelligence theory (Planning, Attention-Arousal, Simultaneous and Successive) was used together with Feuerstein's mediation model to develop a system of categories for mediation in educational games. This system was used to analyze and improve the design of interactive games that can enhance mediation in learning, particularly in children with attention deficit hyperactivity disorder (ADHD). To this end, interactive games designed for a tabletop device were evaluated within an educational context. 27 children (3-14 years old), who had been diagnosed with ADHD, took part. The tabletop has an intuitive system that allows children to interact directly with objects with which they are familiar, providing opportunities for play and communication. These games were evaluated by the participant observation of individual and group playing experiences, interviews, and two focus groups. The results show that mediation recommendations can be useful in the design of the games. They also confirm the need to improve the adaptability of the games to enable children with ADHD to mediate, plan, and focus their attention. With the aid of a facilitator, the mediating function of learning-games can therefore be applied in the development of the executive functions that are key to learning.

Importance: Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. Comprehensive analyses of deployment of the intervention in real-life scenarios are required. Objective: To assess health outcomes and cost of prehabilitation. Design: Prospective cohort study with a control group built using propensity score–matching techniques. Setting: Prehabilitation Unit in a tertiary-care university hospital. Participants: Candidates for major digestive, cardiac, thoracic, gynecologic, or urologic surgeries. Intervention: Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization, and psychological support. Main Outcomes and Measures: The comprehensive complication index, hospital and intensive care unit length of stay, and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis. Results: The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay [9.9 (7.2) vs 12.8 (12.4) days; P =0.035]. Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay [2.3 (2.7) vs 3.8 (4.2) days; P =0.021] and generated mean cost savings per patient of €3092 (32% cost reduction) (P =0.007). Five priority areas for action to enhance service efficiencies were identified. Conclusions and Relevance: The study indicates a low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance the effectiveness of prehabilitation. [ABSTRACT FROM AUTHOR]

Due to the increase of population admitted to waiting list for heart transplant, new techniques have arisen and donation after circulatory death (DCD) is helping to expand the donor pool. Nevertheless, DCD hearts are more susceptible to myocardial edema and inflammation than donation after brain death (DBD) hearts. The presence of systolic anterior movement (SAM) of the mitral valve can occur after warm ischemia period. That can create a dilemma on the medical team regarding the suitability of the donor heart. A 66-year-old gentleman with ischemic cardiomyopathy and advanced heart failure was admitted for heart transplantation. His transthoracic echocardiography (TTE) showed severe dilatation of the left ventricle with severe global hypokinesia with a left ventricular ejection fraction (LVEF) of 15% and moderate tricuspid regurgitation with an estimated systolic pulmonary artery pressure of 76 mmHg. The donor was a 59-year-old man without relevant past medical history, who was diagnosed of spontaneous subarachnoid haemorrhage with bad prognosis. TTE showed a hyperdynamic left ventricle of normal dimensions with normal left ventricle wall thickness (8 mm) and mildly abnormal movement of the interventricular septum with a basal intraventricular gradient of 24 mmHg, right ventricle was normal in size and function and no valvular abnormalities were visualized.. After family consent, patient was considered suitable for multiorgan donation after circulatory death under CPB and peripheral access. Warm ischemia time (WIT) was 28 minutes. Procurement approach was thoraco-abdominal normothermic regional perfusion followed by static cold storage. During CPB separation, severe mitral regurgitation with SAM was visualized and LVWT increased to 24 mm. This scenario created a dilemma in the Heart Team about the potential risks of accepting the organ; but after analysing receptor condition, and considering dynamic nature of SAM and likelihood of reversibility, the organ was accepted. Heart transplant was performed using biatrial technique. Transesophageal echocardiography after CPB separation showed normal biventricular function without SAM and mild mitral regurgitation. Accepting or refusing a donor heart can sometimes be challenging. Hemodynamic and echocardiographic criteria are used routinely but there is still a lack of strong evidence that supports the decision-making in particular situations. In these particular scenarios, many factors need to be analysed: not only global considerations like donor and receptor age and condition but also, perioperative variables such as hemodynamic situation, vasoactive drugs and ischemia time. Several mechanisms could have contributed to the presence of SAM in this context. First of all, hemodynamic conditions can modify its presentation. Secondly, studies have shown that the longer the WIT, the greater the edema formation. That's why current limit for WIT is set at 30 minutes. And last but not least, anatomical changes like aortic-mitral angle could also play a role. This case illustrates the complex assessment of the donor heart, the dynamic changes during the donation process and its potential reversibility. The authors found useful to analyze a case with a good outcome that could help accepting more organs in a situation of shortage. [ABSTRACT FROM AUTHOR]

Robotic cardiac surgery (RCS) has been demonstrated to be feasible and safe by many groups. Several studies reported better outcomes of RCS (lower complication rate, reduced length of stay, improved quality of life) compared to non-robotic technique In minimally invasive cardiac surgery locoregional aneasthesia (LRA) has been demonstrated to improve postoperative pain control. Specific to RCS, the optimal LRA technique has yet to be determined. Erector spinae plane (ESP) block is an easy-to-perform technique that can provide an adequate pain control in chest surgery, reducing the postoperative dose of opioids. The aim of the present study is to assess the beneficial effects of continuous unilateral ESP block in the management of the postoperative pain after RCS. Design A randomized controlled trial. Setting Single-center, university tertiary-care institution. Participants Patients undergoing non-coronary robotic-assisted cardiac surgery. Interventions Patients were randomized to the "ESP" group, receiving an ESP block (intraoperative loading dose of 20 ml followed by continuous infusion of ropivacaine 0.2% for 24 hours) versus "control" group, receiving conventional perioperative pain management (continuous infusion of intravenous morphine). In addition, all patients received multimodal analgesia including acetaminophen, dexamethasone and patient-controlled analgesia with intravenous morphine. Measurements The primary outcomes were morphine consumption at 12 and 24 hours, as well as the total postoperative dose. The secondary outcomes were pain scores on a Numeric Rating Scale (NRS) at 6, 12, 24, and 48 hours after surgery. Main Results Fifty-four patients were randomized. However, 24 patients were withdrawn from the trial for various reasons. The main reasons included inability to assess analgesia (n=5), seizures (n=3), and other issues (n=16), such as catheter dysfunction or removal, reconversion to sternotomy, and postoperative bleeding. The data from the remaining 30 patients were analysed appropriately. ESP block was successfully performed in all patients in the intervention group without observing any perioperative adverse effects. In comparison with the control group, a trend of lower opioid consumption was observed in the ESP group, with a significant difference in morphine use 12 hours after surgery (p = 0.049, Table 1 and Figure 1). No difference was observed in postoperative pain scores measured by the NRS (Table 2 and Figure 2). Table 1: Comparison of the postoperative opioid consumption between ESP group and control group. Data expressed as median (interquartile range). Figure 1: Box-plot representing the data of Table 1. Table 2: Comparison of the postoperative pain between ESP group and control group. Data expressed as median (interquartile range). Figure 2: Box-plot representing the data of Table 2. In RCS continuous ESP block is a safe and feasible, providing an adequate pain relief. Compared to conventional multimodal analgesia, this technique can improve perioperative pain management decreasing opioid consumption, especially during the first postoperative period. If validated by the analysis of the complete study sample, these preliminary findings suggest that continuous ESP block could be considered an affordable opioid-sparing strategy in patients undergoing RCS. [ABSTRACT FROM AUTHOR]

Limited aerobic capacity, low exercise tolerance, and frailty are highly prevalent in patients awaiting heart transplantation (HT) and tightly related to negatively impacting postoperative outcomes and healthcare resource consumption. Prehabilitation (prehab) has shown efficacy in improving functional status and preventing postoperative complications in selected high-risk surgical populations. However, the implementation of these programs feasibility and efficacy has not been evaluated in advanced heart failure patients. Prehab could be health resource-consuming and represent an economic burden. This study aimed to investigate the impact of prehab on HT postoperative outcomes and to evaluate the cost-effectiveness of a multimodal prehab program for HT candidates. Single-centre, ambispective cohort study including forty-six candidates for elective HT from 2017 to 2021 attending a multimodal prehab program (intervention) consisting of supervised exercise training, physical activity promotion, nutritional optimization, and psychological support. The postoperative outcomes and total cost of the prehab program (n=31) were compared with a group of twelve contemporaneous patients who did not join the program and those transplanted from 2014 to 2017 before the implementation of the program (n=51). Main postoperative measured outcomes: Comprehensive Complication Index (CCI), mechanical ventilation time, total hospitalization and intensive care length-of-stay, destination at discharge (home vs. rehabilitation facility), hospital readmissions at 30 days, and mortality at 30-days, 3-months, and 1-year. A prehab program cost analysis was performed. Healthcare use included HT surgical procedures, direct hospitalization (until discharge), and prehab costs. Data were obtained through micro-costing techniques according to resource use, combined with diagnostic-related centre-specific hospital fees. A bootstrapping approach was performed to control the skewness of the distribution. Thirty-one prehab patients underwent HT. Their postoperative outcomes were compared to the previously described control group. Significant improvements were observed in functional capacity (endurance time: 293 vs. 632s, p<0.001) and quality-of-life (Minnesota score: 58 vs. 47, p=0.046) after prehab. No exercise-related events were registered. Five candidates were eventually removed from the waitlist due to significant functional capacity improvement after prehab. Prehab cohort showed a lower rate and severity of postoperative medical complications (CCI 37 vs. 31, p=0.033), lower mechanical ventilation time (37 vs. 20 hours, p=0.032), ICU stay (7 vs. 5 days, p=0.01), total hospitalization stay (23 vs. 18 days, p=0.008) and less need for transfer to nursing/rehabilitation facilities after hospital discharge (31% vs. 3%, p=0.009). The mean cost per prehab program patient was 2,195€ mainly driven by supervised exercise training (1,971€). The healthcare-related mean cost for the HT index hospitalization, including the cost of the prehab program, did not show differences between groups (prehab: 56,503€ vs. control: 66,556€; p=0.12). The difference in costs was only statistically significant when removing the outliers from the analysis. Our findings support the beneficial impact of a multimodal prehabilitation intervention in the short-term postoperative outcomes of HT recipients without increasing direct healthcare costs, which may be interpreted as evidence of higher value for money (cost-effective intervention). [ABSTRACT FROM AUTHOR]

Background: There is no international consensus on optimal follow-up schedules and which supplementary tests should be used after resection of a primary melanoma.Objective: We sought to analyze the performance of the follow-up components and identify procedures that detect melanoma metastasis earlier.Methods: This was a prospective cohort from 290 consecutive patients given a diagnosis of stage IIB, IIC, and III melanoma. Patients were followed up with an intensive protocol based on imaging studies (computed tomography of the chest, abdomen, and pelvis, and brain magnetic resonance imaging), periodic laboratory tests, regular physical examinations, and patient self-examinations.Results: A total of 2382 clinical examinations and 3069 imaging tests were performed. The patients completed 899.8 person-years of follow-up, with a median of 2.5 years. In all, 115 recurrences in 290 patients were recorded, of which computed tomography detected 48.3%; brain magnetic resonance imaging, 7.6%; laboratory test, 2.5%; physician, 23.7%; and patient, 17.8%.Limitations: Patients with stage III melanoma were not systematically classified into subgroups and overall survival was not evaluated.Conclusion: We observed that this intensive monitoring is appropriate for early detection of recurrence in stage IIB, IIC, and III melanoma. Prompt diagnosis of metastasis and the recent development of new therapeutic targets may improve overall survival. [ABSTRACT FROM AUTHOR]

Background: Natural orifice transluminal endoscopic surgery (NOTES) mediastinoscopy (MED) through the esophagus has proved to be feasible in the animal model. However, injury of the adjacent pleura and pneumothorax has been reported as a frequent adverse event when using a blind access. Objective: To assess the utility and safety of a CT-based image registration system (IRS) for navigation in the mediastinum. Design: Prospective, randomized, controlled trial in 30 Yorkshire pigs. Thirty-minute MEDs were performed: 15 MEDs were performed with IRS guidance (MED-IRS), and 15 MEDs were performed with a blind access. Setting: Animal research laboratory. Interventions: In both groups, the mediastinum was accessed through a 10-cm submucosal tunnel in the esophageal wall. Timed exploration was performed with identification of 8 mediastinal structures. Main Outcome Measurements: Technical feasibility, adverse events, and the number of mediastinal structures identified. Results: Thirty animals weighing 31.5 ± 3.5 kg were included in this study. MED was not possible in 2 animals in the “MED with blind access” group but was possible in all MEDs performed with IRS. The mean number of identified organs was slightly higher in “with IRS-MED” (6.13 ± 1.3) than with MED with blind access (4.7 ± 2.3; P = .066). Moreover, the right atrium and vena cava were identified in more cases with IRS-MED than in MED with blind access (13 vs 3 and 15 vs 11, P = .000 and P = .03, respectively). There were 3 (23%) adverse events with IRS-MED and 4 (27%) with “MED with blind access” (P = not significant), with pneumothorax being the most frequent (2 and 3, respectively). Limitations: Nonsurvival animal study. Conclusions: This study demonstrates that the IRS system appears feasible in natural orifice transluminal endoscopic surgery MED and suggests that IRS guidance might be useful for selected procedures. [Copyright &y& Elsevier]

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Three patients who presented with massive hemoptysis after the insertion of a Swan-Ganz catheter for cardiac surgery are reported. Pulmonary artery pseudoaneurysms were diagnosed and successfully treated by embolization with a vascular plug. Follow-up at 15 months showed no recurrence of hemoptysis, and computed tomography helped confirm complete occlusion of the pseudoaneurysms. [Copyright &y& Elsevier]

Background and Objectives: Damage to peripheral nerves provokes chronic neuropathic pain that lasts beyond the duration of the nerve injury. The presence of pain signs have been reported in areas other than those attributed to the injured nerve, i.e., in contralateral regions. We evaluated the presence, magnitude, and chronology of mechanical and cold allodynia in the contralateral paw of rats undergoing unilateral ligation of the L5 and L6 spinal nerves. Methods: Twenty-three male Sprague-Dawley rats underwent spinal nerve ligation of the left L5 and L6 spinal nerves (SNL group) and 7 rats received a sham surgery without nerve ligation (sham group). Signs of mechanical allodynia as assessed with von Frey filaments, and cold allodynia as assessed with the acetone drop test, were studied before surgery and throughout 21 postoperative days. Responses of ipsilateral and contralateral paws of the SNL group were compared between themselves and with those in the sham group. Results: Rats in the SNL group developed mechanical and cold allodynia responses in the ipsilateral paw, and also in the contralateral paw. Allodynia in the contralateral paw appeared later, becoming statistically significant on day 10 after surgery for mechanical allodynia and on day 21 for cold allodynia as compared with the sham group. Contralateral pain was of a lower intensity than on the ipsilateral side. Conclusions: After L5 and L6 spinal nerve ligation, rats developed mechanical and cold allodynia in the contralateral paw, suggesting extraterritorial development of neuropathic signs. This finding has implications for future study design and therapeutic approaches. [Copyright &y& Elsevier]

Transoesophageal echocardiography (TOE) use has experienced an exponential growth in cardiac surgery (CS). The latest guidelines recommend TOE for all adult patients undergoing CS, but the management of unexpected-TOE findings (ATOEF) after cardiopulmonary bypass (CPB) might be controversial. We reviewed the outcomes of those patients with ATOEF after CBP managed without immediate surgical revision. A systematic TOE use policy is applied in our institution for patients undergoing CS. Intraoperative TOE is performed by a senior anaesthesiologist. Data from intraoperative TOE cases were collected prospectively between January 2014 and December 2017. The presence of post-CPB ATOEF and its impact on the immediate surgical treatment decision-making was analysed. A total of 2421 TOE examinations were registered, with 197 post-CPB ATOEF. Among those with post-CPB ATOF, 108 (55%) led to immediate surgical treatment. The remaining 89 (45%) cases with post-CPB ATOEF did not received surgical treatment. These non-treated ATOEF were characterised into: 25 (28%) periprosthetic leak, 1 (1%) intraprosthetic regurgitation, 20 (22%) regurgitations after mitral valve (MV) repair, 11 (12%) regurgitations after aortic valve (AoV) repair, 7 (8%) and 2 (2%) regurgitations related to native MV and AoV respectively, 12 (13%) systolic anterior motion of the MV and 11 (12%) classified as other findings. The immediate postoperative follow-up showed the persistence of 36% of periprosthetic regurgitations, 100% of intraprosthetic regurgitations, 70% and 91% related to MV and AoV repair respectively, 86% and 100% related to native MV and AoV respectively. Two patients died in the immediate postoperative period and none required immediate re-do surgery due to the findings. The 6-12 month follow-up showed the persistence of 34% of periprosthetic leaks, 100% of intraprosthetic regurgitations, 70% and 91% of those related to MV and AoV repair, 71% and 100% of those related to native MV and AoV. Among all post-CPB ATOEF, 2 (2%) patients have required surgical treatment related to the finding in the long-term follow-up. Almost half of the post-CBP ATOEF did not lead to an immediate surgical treatment. Follow up echocardiography in the immediate postoperative period and at 6-12months, showed reduction of periprosthetic leaks. However, we observed stability of left-sided valve repair regurgitations. The incidence of reinterventions due to post-CBP ATOEF was low, reinforcing our current decision making. [ABSTRACT FROM AUTHOR]

Background: Data for the utility of continuous trans-esophageal echocardiography (TEE) monitoring during trans venous lead extraction remain scarce. Removal of the implanted transvenous lead system can be a significantly complex procedure, facing main complications. Our objective: the retrospective assessment of the TEE in the monitoring during trans venous lead extraction of implantable cardiac devices (pacemaker and implantable cardiac defibrillator). From November 2013 to November 2018 the transvenous lead extraction of 93 leads in 50 patients was reviewed. Lead extraction techniques combined traction and mechanical approach by the same surgeon. Extraction procedures were performed under general anesthesia either total intravenous or inhalation anesthesia. Invasive arterial line blood pressure and continuous TEE monitoring were performed. TEE images of different projections were acquired and stored before and immediately after the extraction of each lead. From the 50 patients (mean age 58.9 years, 64% male, 1.86% lead per patient) which had the following indication: lead dysfunction (24%), upgrade (8%), infection (54%), or other (14%). The lead extraction was complete for 69 out of 93 leads (74.19%), partial extraction was for 24 leads out of 93 leads (25.80%). General anesthesia by total intravenous (30%) and inhalation anesthesia (70%). New TEE findings following TEE were observed in 7 of 50 cases (14%). Two cases which had new mild tricuspid regurgitation without the need of re-intervention, new appearance or worsening of tricuspid regurgitation in three cases which needed non-emergency re-intervention and pericardial effusion in two cases. No cases needed rescue surgery. In all other cases, TEE findings did not entail immediate diagnostic or therapeutic measures. New findings necessitating immediate therapeutic measures occurred zero cases, no mortality, yet all patients with new TEE findings had strict observational control. We suggest TEE monitoring during trans venous lead extraction, as it provides useful real-time information and should be standard of care monitoring during lead extraction, to guide trans operative and postoperative management. TEE presents some non-negligible risks associated with its use and is a costly procedure, such investment, however, may have a high return in terms of increased patient safety. [ABSTRACT FROM AUTHOR]

Adult congenital heart disease (ACHD) represents a growing population in many cardiac centers and it's a challenge for all physicians involved. Multidisciplinary teams integrated by cardiologists, echocardiographers, cardiac surgeons, cardiac anesthesiologists, radiologists and others, have been created in many hospitals to manage such patients (1). The objective was to describe the adult congenital cardiac population scheduled for cardiac surgery in our reference center. We included all patients scheduled for cardiac surgery with a diagnosis of ACHD from January 2017 to May 2018. A retrospective review of medical records was performed for demographics, type of heart defect, intraoperative management, postoperative evolution, ICU length of stay and outcome at 30 days. A total of 1060 patients underwent elective cardiac surgery between the study period. Sixty-six patients (6.22%) had the diagnosis of ACHD. Mean age was 53.5±17 years [range 19 to 85 years], 63.6% were male and mean EuroSCORE II was 1.51 [range 0.5 to 5.41]. Type and number of diagnoses were: bicuspid aortic valve 45 patients, atrial septal defect 12 patients, congenital pulmonary stenosis 2 patients, congenital aortic stenosis 1 patient, sub-aortic membrane 1 patient, right coronary artery anomaly 1 patient, single ventricle 1 patient, tetralogy of Fallot 1 patient, Ebstein's anomaly 1 patient and partial atrioventricular canal defect 1 patient. Eight of the 45 patient with aortic bicuspid valve had associated aortic root aneurysm. All patients were monitored with transesophageal echocardiography (TEE). Twenty-five patients (37.8%) were extubated in the operating room. Nine patients (13.6%) required blood products. Percentage of postoperative complications were: arrhythmias (28.7%), renal dysfunction (15.1%), hemorrhage >500ml at 24h (10.6%), respiratory alterations (7.5 %), neurologic events (4.5%), intubation >24h (4.5%), re-operation (3.03 %) and gastrointestinal problems (1.51%). Mean ICU length of stay was 3.27 days [range 1 to 9 days]. There was no mortality at 30 days. The incidence of ACHD in this review was low and bicuspid aortic valve was the most common anomaly. Operative cardiac risk and age showed a wide range. In this small sample post-operative complications were lower than reported in the literature (2). As reference center for ACHD now the number of complex cases is increasing mainly by those diagnosed and treated in the childhood and coming for a second or third operation. [ABSTRACT FROM AUTHOR]