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Background: Due to the substantial improvement in survival among pediatric patients undergoing congenital heart surgery, reducing early and long-term morbidity is becoming the major focus of care. Blood transfusion is associated with worse postoperative outcomes after cardiac surgery. Acute normovolemic hemodilution (ANH) is a blood conservation strategy that aims to reduce allogenic blood transfusion during cardiac surgery. However, there are scant data regarding its efficacy for pediatric cardiac surgery patients.Methods: We designed a single-center, controlled, randomized, pilot trial in patients between 6 and 36 months old undergoing pediatric heart surgery. Patients were equally assigned to undergo ANH prior to initiation of cardiopulmonary bypass or to be managed per usual care. The primary end point was the amount of blood product transfused perioperatively. Secondary end points were markers of morbidity: postoperative bleeding, hematocrit, inotropic agents use, intensive care unit, and hospital stay. The analysis was by intention-to-treat. Estimates of differences between groups are presented with 95% CIs.Results: Twelve pediatric heart surgery patients were randomized to each group, ANH and usual care. Baseline characteristics were similar between groups. Acute normovolemic hemodilution implementation did not result in a reduction in the administration of blood product transfused (difference between ANH and usual care among patients transfused = −1.4 mL [−29.4 to 26.6], P= .92). Secondary end points were not different between groups.Conclusions: In this small trial of pediatric cardiac surgery patients, ANH as a strategy to reduce blood component therapy was safe; however, the study failed to show a reduction in perioperative transfusion or other postoperative outcomes.

There is little information showing the use of microporous polypropylene hollow fiber oxygenators during extracorporeal life support (ECLS). Recent surveys have shown increasing use of these hollow fibers amongst ECLS centers in the United States. We performed a retrospective analysis comparing the Terumo BabyRx hollow fiber oxygenator to the Medtronic 800 silicone membrane oxygenator on 14 neonatal patients on extracorporeal membrane oxygenation (ECMO). The aim of this study was to investigate the similarities and differences when comparing pressure drops, prime volumes, oxygenator endurance, and gas transfer capabilities between the two groups.

We report a post-Norwood Stage I patient requiring ECMO support using Argatroban as an anticoagulant following diagnosis of heparin-induced thrombocytopenia (HIT). A 2.6 kg female was born with hypoplastic left heart syndrome and underwent a Norwood Stage I operation on day 4 of life. The patient weaned off cardiopulmonary bypass with no complications and was routinely placed on a ventricular assist device (VAD) for 3 days. Heparin was infused at a rate of 16–32 IU/kg/h to maintain an ACT of 160–180 seconds. Two days after VAD termination, the patient was placed on continuous veno– veno hemofiltration (CVVH). Shortly after CVVH, the patient was diagnosed with HIT and placed on an Argatroban infusion. Five days later, a VAD and subsequent ECMO was used because of decreasing left ventricular function, gross body edema, and poor renal function. This case report summarizes the use of Argatroban during VAD and ECMO support for a patient diagnosed with HIT.

We present high‐resolution elastic models and relocated seismicity of a very active segment of the Apennines normal faulting system, computed via transdimensional local earthquake tomography (trans‐D LET). Trans‐D LET, a fully nonlinear approach to seismic tomography, robustly constrains high‐velocity anomalies and inversions of Pwave velocity, i.e., decreases of VPwith depth, without introducing bias due to, e.g., a starting model, and giving the possibility to investigate the relation between fault structure, seismicity, and fluids. Changes in seismicity rate and recurring seismic swarms are frequent in the Apennines extensional belt. Deep fluids, upwelling from the delaminating continental lithosphere, are thought to be responsible for seismicity clustering in the upper crust and lubrication of normal faults during swarms and large earthquakes. We focus on the tectonic role played by the Alto Tiberina low‐angle normal fault (ATF), finding displacements across the fault consistent with long‐term accommodation of deformation. Our results show that recent seismic swarms affecting the area occur within a 3 km thick, high VP/VS, densely cracked, and overpressurized evaporitic layer, composed of dolostones and anhydrites. A persistent low VP, low VP/VSvolume, present on top of and along the ATF low‐angle detachment, traces the location of mantle‐derived CO2, the upward flux of which contributes to cracking within the evaporitic layer. High‐resolution local earthquake tomography of a low‐angle normal fault systemCorrelation between Triassic evaporites, natural CO2source, and swarm‐like seismicitySeismogenic processes in fault zones, deformation, and tectonics of normal faulting systems

We present a case of a 68-year-old woman undergoing 18F-choline PET/CT due to a history of hepatocellular cancer treated with multimodal therapies and with a rapid increase in α-fetoprotein. 18F-Choline PET/CT showed multiple uptakes in the skeletal muscles compatible with the recurrence of disease. The interpretation of 18F-choline PET/CT in this cancer should be careful and discussed in a multidisciplinary team.

Sample centrifugation is an essential step in the coagulation laboratory, as clotting tests are typically performed on citrated platelet (PLT) poor plasma (PPP). Nevertheless, no clear indication has been provided as to whether centrifugation of specimens should be performed with the centrifuge brake set to on or off. Fifty consecutive sodium citrate anticoagulated samples were collected and divided into two aliquots. The former was centrifuged as for Clinical Laboratory Standards Institute (CLSI) guidelines with the centrifuge brake set to on, whereas the latter was centrifuged again as for CLSI guidelines, but with the brake set to off. In the PPP of all samples, a PLT count was performed, followed by the analysis of activated partial thromboplastin time (APTT), prothrombin time (PT) and fibrinogen (FBG). The PLT count after samples centrifugation was substantially reduced, either with centrifuge brake set to on or off (5±1 versus 3±1×109l; P=0.009). The frequency of samples exceeding a PLT count less than 10×109l was nearly double in samples centrifuged with the brake on than in those with the brake off (14 versus 8; P<0.01). Although no significant difference was found for APTT values, PT was slightly prolonged using the centrifuge brake set to on (mean bias 0.2s; P<0.001). FBG values were also significantly higher using the centrifuge brake set to on (mean bias 0.29gl; P<0.001). The results of this study indicate that sample centrifugation for routine coagulation testing should be preferably performed with the centrifuge brake set to off for providing a better quality specimen.

Sentinel lymph node biopsy (SLNB) has progressively replaced complete axillary lymph node dissection in the evaluation of breast cancer patients with clinically node-negative disease. Our study investigates the rate of and risk factors involved in sentinel node identification failure.

A patient was born with transposition of the great arteries, double-outlet right ventricle, interrupted aortic arch, and a ventricular septal defect and underwent a Damus–Kaye–Stansel procedure with a modified Blalock–Taussig shunt at 14 days old. Three months later, this patient presented with hypoxia and bradycardia was found to have a thrombus present in the main pulmonary artery extending to right pulmonary artery. After initiation of thrombolytic therapy, the patient became severely hypoxic and required the institution of extracorporeal membrane oxygenation. As the result of unknown heparin resistance independent of adequate antithrombin III levels, argatroban therapy was used to achieve desired anticoagulation. The patient was taken to the operating room and converted to conventional cardiopulmonary bypass once adequate activated clotting times were achieved using argatroban. This case report summarizes the use of argatroban as an anticoagulant for a 6.0-kg pediatric patient undergoing cardiopulmonary bypass.

Patients undergoing congenital heart surgery are at risk of morbidity and mortality. The reasons underlying this risk are complex. To identify opportunities to reduce adverse sequelae, the cardiovascular perfusion community was invited to amend existing perfusion-related fields as well as add new ones to the current version of the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD). The International Consortium for Evidence-Based Perfusion (ICEBP) was invited by the STS-CHSD Task Force to identify and resolve ambiguities related to definitions among the 3 current perfusion-related fields as well as to propose new variables (and definitions) for inclusion in the 2010 update of the STS-CHSD. The ICEBP used teleconferences, wiki-based communication software, and e-mail to discuss current definitions and create new fields with definitions. The ICEBP created modified definitions to existing fields related to cardiovascular perfusion and also developed and defined new fields that focus on (1) techniques of circulatory arrest and cerebral perfusion, (2) strategies of myocardial protection, and (3) techniques to minimize hemodilution and allogeneic blood transfusions. Three fields in the STS-CHSD related to perfusion were redefined, and 23 new variables and definitions were selected for inclusion. Identifying and defining fields specific to the practice of perfusion are requisite for assessing and subsequently improving the care provided to patients undergoing congenital heart surgery. The article describes the methods and justification for adjudicating extant and new perfusion-related fields added to the 2010 update of the STS-CHSD.

AbstractObjective:To assess the efficacy of an alternative disinfection method for hospital water distribution systems contaminated with Legionella.Methods:Disinfection with peracetic acid was performed in a small hospital contaminated with L. pneumophilaserotype 1. The disinfectant was used at concentrations of 50 ppm (first three surveillance phases) and 1,000 ppm (fourth surveillance phase) for 30 minutes.Results:Environmental monitoring revealed that disinfection was maintained 1 week after treatment; however, levels of recontamination surpassing baseline values were detected after approximately 1 month. Comparison of water temperatures measured at the distal outlets showed a statistically significant association between temperature and bacterial load. The circulating water temperature was found to be lower in the two wards farthest away from the hot water production plant than in other wards. It was thought that the lower water temperature in the two wards promoted the bacterial growth even after disinfection.Conclusion:Peracetic acid may be useful in emergency situations, but does not provide definitive protection even if used monthly.

Due to many innovative techniques and technologies, the overall rate of survival for infants undergoing surgical repair of congenital cardiac malformations is excellent. Despite these excellent outcomes, neonates with hypoplasia of the left heart represent a very unique population, and pose difficult challenges for the entire team involved in care. Despite some centers reporting outstanding outcomes, overall rate of survival rate is reported at only 53 percent,1 and survivors often show neurodevelopmental deficits. Many attempts have been made to identify predictors of neurologic outcomes, with heavy concentration around the pre- and peri-operative periods. Little attention has been paid, however, to assessing how attempts at balancing the systemic and pulmonary circulation affect neurodevelopmental outcomes. In the past, we have reported excellent rates of survival with use of routine postoperative circulatory support to augment cardiac output.2,3 This strategy, nonetheless, is still widely debated. It seems plausible that, by augmenting cardiac output in the immediate postoperative period, cerebral perfusion and oxygenation can be optimized, thereby improving neurologic outcomes. In this review, we describe our experience to date in assessing neurological outcomes, and discuss whether outcomes are associated with cerebral saturation and extraction of oxygen during the period of postoperative circulatory assist.

Ettore Majorana probably belongs to the most mysterious and most fascinating personalities of the recent physics history. Majoranas work shows also nowadays more than 60 years after its appearance an amazingly fresh reference to present physics problems. A short representation of Ettore Majoranas life and scientific work will be given in this article.

AIM: To define the value of digital radiography with a clinical flat panel detector system for evaluation of wrist fractures in comparison with state of the art storage phosphor radiography. MATERIAL AND METHODS: Hard copy images of 26 fractured wrist specimens were acquired with the same exposure dose on a state of the art storage phosphor radiography system and a clinical flat panel detector. Image features like cortical bone surface, trabecular bone, soft tissues and fracture delineation were independently analysed by 4 observers using a standardised protocol. Image quality ratings were evaluated with an analysis of variance (ANOVA). RESULTS: Flat panel detector radiographs were rated superior with respect to cortical and trabecular bone representation as well as fracture evaluation, while storage phosphor radiographs produced better soft tissue detail. CONCLUSION: In some of the observed image quality aspects, the performance of caesium iodide/amorphous silicon flat panel detector exceeds state of the art storage phosphor radiography. This makes it well suited for skeletal imaging particularly in trauma as seen in the detection of wrist fractures. Peer, S. et al. (2002). Clinical Radiology57, 258–262.

Fault coverage estimation critically depends on the choice of the faults inserted in the fault list. This paper addresses the issues related to automatic fault list generation, pointing out some typical limitations of available CAD tools.

Es wurde ein Flußmodell zur Simulation der Hämodynamik menschlicher Gefäßsysteme entwickelt. Das Modell besteht aus arteriellen und venösen Gefäßbäumen und einem dazwischengeschalteten Kapillarbett, welches einen definierten Strömungswidersland darstellt. Als Modellgefäße werden Silikonschläuche mit der menschlichen Physiologie entsprechenden Elastizitätsmoduln gewählt. Das Blutsimulat ist ein mit Zellulosepartikeln zur Simulation der Erythrozyten versetztes Wasser-Glycerin-Gemisch mit ähnlicher Viskosität wie menschliches Blut. Die Simulation der Herzaktion wird so realisiert, daß sich verschiedene physiologische Geschwindigkeitsspektren reproduzierbar erzeugen lassen. Die Flußgeschwindigkeiten und Drücke entsprechen denen in menschlichen Gefäßsystemen. Flußdynamisch relevante Parameter, wie z. B. systolische Spitzen- und diastolische Minimalgeschwindigkeit, werden dopplersonographisch erfaßt und ausgewertet. Die so gewonnenen Daten werden mit bereits vorhandenen Geschwindigkeitsspektren und Dopplerparametern aus Untersuchungen an Probanden verglichen. Es ergibt sich eine gute Übereinstimmung der am Modell erzeugten Dopplerspektren mit den an Probanden abgeleiteten Signalen. In weiterer Folge sollen diese Vergleichsmessungen zu einem lieferen Verständnis der Hämodynamik in physiologischen und pathologischen Gefäßstrukturen beitragen und damit eine Diagnosehilfe für die Medizin darstellen.

A long‐lasting question in earthquake physics is why slip on faults occurs as creep or dynamic rupture. We compute passive measurements of the seismic Pwave velocity gradient across the San Andreas Fault near Parkfield, where this transition of slip mode occurs at a scale of a few kilometers. Unbiased measurements are obtained through the application of a new Bayesian local earthquake tomographic code that avoids the imposition of any user‐defined, initial velocity‐contrast across the fault, or any damping scheme that may cause biased amplitude in retrieved seismic velocities. We observe that across‐fault velocity gradients correlate with the slip behavior of the fault. The Pwave velocity contrast decays from 20% in the fault section that experience dynamic rupture to 4% in the creeping section, suggesting that rapid change of material properties and attitude to sustain supra‐hydrostatic fluid pressure are conditions for development of dynamic rupture. Low Vpand high Vp/Vssuggest that fault rheology at shallow depth is conversely controlled by low frictional strength material. Slip behavior of faults is a long‐lasting question in earthquake physics. The San Andreas Fault (SAF) near Parkfield is the perfect place for investigating this issue because of the different slip attitude of the SAF and the wide abundance of data. We applied a new fully nonlinear seismic tomography technique to get rid of all the subjective assumptions associated with classical tomography approaches, which strongly influenced past results obtained with such data. We obtained high‐resolution images of the fault, achieving structural details useful to addressing physical processes on the fault. Our main finding is that velocity gradients across the SAF (differences in Vpand Vp/Vsbetween the two sides of the fault) correlate with the slip attitude. Strong gradients are observed in the fault section where velocity weakening is the principle slip mode. This correlation indicates processes governing the unstable slip of the fault. This finding has great impact on understanding natural processes and earthquake physics and represents one good example of creating bridges over different disciplines and scales (nature to labs). A further significance is that cautious monitoring of elastic properties in time can be useful to predict eventual changes at seismogenic depths and recognize weakening mechanisms. Velocity gradients across the SAF (differences in Vpand Vp/Vsbetween the two sides of the fault) correlate with the slip attitudeThis finding has great impact for understanding earthquake physics and help creating bridges over disciplines and scales (nature to labs)The newly developed fully nonlinear tomographic technique permits to resolve high details of faults and seismogenic processes

Ischemic vascular disease of the upper extremity represents a difficult therapeutic problem wherein medical treatment often fails. Epidural spinal cord stimulation has been shown to be an effective alternative in severe peripheral arterial disease. Although this method has been used for nearly two decades only limited experience exists in Raynaud's phenomenon of the upper limbs. In addition objective parameters to prove therapeutic success are not well defined. Herein we describe a patient with severe primary Raynaud's phenomenon over several years who had significant pain relief and complete healing of ischemic digital ulcerations after spinal cord stimulation. Pain level was evaluated using a visual rating scale before and after surgery. Micro-circulatory parameters were assessed before and after spinal cord stimulation by capillary microscopy and laser Doppler anemometry. Significant improvement of red blood cell velocity, capillary density, and capillary permeability was demonstrated. At follow-up 18 months after surgery the patient had no complaints and all ulcerations of her fingertips had healed. Spinal cord stimulation appears to be an effective treatment in severe cases of Raynaud's phenomenon and we recommend its use in the case of failed medical therapy. Pain rating and capillary microscopy enable one to assess and visualize the effects of spinal cord stimulation.