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This article discusses a pulmonary artery pseudoaneurysm (PAP) formation following pulmonary artery catheter (PAC) placement for cardiac surgery. The patient, an 82-year-old female with a history of hypertension and chronic heart failure, underwent elective mitral and tricuspid valve surgery. After surgery, bleeding was observed in the endotracheal tube, indicating a potential complication. Fiberoptic bronchoscopy revealed bleeding mainly in the right bronchus. Subsequent computed tomography pulmonary angiogram (CTPA) confirmed the presence of a small pseudoaneurysm in a branch of the pulmonary artery. Prompt collaboration between anesthesiologists, cardiac surgeons, and interventional radiologists led to the successful embolization of the pseudoaneurysm with a minimally invasive approach by using the PAC as a guide catheter to reach the PAP. The article outlines the potential causes of PAP formation, clinical presentation, and management strategies. While conservative, surgical, and interventional approaches are discussed, the preferred treatment is coil embolization due to its effectiveness and minimal invasiveness. The authors emphasize the importance of rapid diagnosis, multidisciplinary collaboration, and the feasibility of using the pulmonary artery route for embolization to rapidly reach the lesion to stabilize. Overall, the case demonstrates the successful resolution of a life-threatening complication through timely intervention and coordinated teamwork. [ABSTRACT FROM AUTHOR]

Protection of ecosystem services is increasingly emphasized as a risk-assessment goal, but there are wide gaps between current ecological risk-assessment endpoints and potential effects on services provided by ecosystems. The authors present a framework that links common ecotoxicological endpoints to chemical impacts on populations and communities and the ecosystem services that they provide. This framework builds on considerable advances in mechanistic effects models designed to span multiple levels of biological organization and account for various types of biological interactions and feedbacks. For illustration, the authors introduce 2 case studies that employ well-developed and validated mechanistic effects models: the inSTREAM individual-based model for fish populations and the AQUATOX ecosystem model. They also show how dynamic energy budget theory can provide a common currency for interpreting organism-level toxicity. They suggest that a framework based on mechanistic models that predict impacts on ecosystem services resulting from chemical exposure, combined with economic valuation, can provide a useful approach for informing environmental management. The authors highlight the potential benefits of using this framework as well as the challenges that will need to be addressed in future work. Environ Toxicol Chem 2017;36:845-859. © 2017 SETAC.

Ecological risk assessment (ERA) is the process used to evaluate the safety of manufactured chemicals to the environment. Here we review the pros and cons of ERA across levels of biological organization, including suborganismal (e.g., biomarkers), individual, population, community, ecosystem and landscapes levels. Our review revealed that level of biological organization is often related negatively with ease at assessing cause-effect relationships, ease of high-throughput screening of large numbers of chemicals (it is especially easier for suborganismal endpoints), and uncertainty of the ERA because low levels of biological organization tend to have a large distance between their measurement (what is quantified) and assessment endpoints (what is to be protected). In contrast, level of biological organization is often related positively with sensitivity to important negative and positive feedbacks and context dependencies within biological systems, and ease at capturing recovery from adverse contaminant effects. Some endpoints did not show obvious trends across levels of biological organization, such as the use of vertebrate animals in chemical testing and ease at screening large numbers of species, and other factors lacked sufficient data across levels of biological organization, such as repeatability, variability, cost per study and cost per species of effects assessment, the latter of which might be a more defensible way to compare costs of ERAs than cost per study. To compensate for weaknesses of ERA at any particular level of biological organization, we also review mathematical modeling approaches commonly used to extrapolate effects across levels of organization. Finally, we provide recommendations for next generation ERA, submitting that if there is an ideal level of biological organization to conduct ERA, it will only emerge if ERA is approached simultaneously from the bottom of biological organization up as well as from the top down, all while employing mathematical modeling approaches where possible to enhance ERA. Because top-down ERA is unconventional, we also offer some suggestions for how it might be implemented efficaciously. We hope this review helps researchers in the field of ERA fill key information gaps and helps risk assessors identify the best levels of biological organization to conduct ERAs with differing goals.

perioperative hyperglycemia is common in patients undergoing cardiac surgery and it is associated with increased risks of mortality and morbidity1. The pathogenesis of perioperative dysglycemia is a complex interaction between underlying patient's condition (diabetes, metabolic syndrome) and surgical stress. This study evaluates an intraoperative glucose control protocol designed according to the European Association for Cardio-Thoracic Surgery (EACTS) guidelines2 to manage blood glucose levels during surgery. we developed an intraoperative blood glucose (BG) control protocol (figure 1) with a target of BG <180 mg/dL. Patients were divided into three risk categories: very high (HH) for type 1 diabetes, high (H) for insulin-dependent or non-insulin- dependent diabetes, metabolic syndrome, or chronic steroid therapy, and low (L) for patients without these conditions. BG was measured first after general anesthesia induction, subsequently every 30-40 minutes, the last measurement was at ICU admission. Insulin therapy was started at BG>180 mg/dL for H and L groups, and BG>110 mg/dL for HH group. Patients with urgent or emergent surgeries were treated as H group regardless their comorbidities. 1-year retrospective analysis (March, 2023 – March, 2024). Data were analyzed by Sigmastat 11 (SPSS inc. Chicago, IL) and presented as mean ± SD or median [interquartile range], t-test was used for comparisons. 495 patients were treated with this protocol. Data from 442 patients (HH=1; H=266; L=175) were analyzed, while 53 patients (10%) were excluded due to incorrect protocol application. Overall 180 (41%) patients underwent glycemic control protocol as described above (HH n=1, 100%, H n=125, 46% and L n=54, 31%).344 patients underwent elective surgery and 35% of these (n=120; group L n= 53, 44%; group H n= 67, 56%) needed insulin protocol. Urgent surgeries showed a higher prevalence of hyperglycemia, affecting 60 of 97 patients (62%). Figure 2 describes intraoperative BG (off-pump surgery n=16, 3%; on-pump surgery n=426, 96% with CPB time = 107 [88-128] minutes). At the end of surgery, BG was on average under 180 mg/dl in all groups and urgent surgery. In the elective group BG at ICU admission was 145±40 mg/dL in patients with intraoperative insulin protocol, versus 136±25 mg/dL in patients who did not require insulin (p=0.010). A higher difference (<0.01) was observed in BG at ICU admission between patients that required insulin protocol and who did not (165±59 versus 129±24 mg/dL). Mild hypoglycemia was observed in 3 cases, all during elective surgery. Two patients in group H (BG 69 and 66 mg/dL) and one patient in group L (BG 57 mg/dL), treated without any complication. The protocol showed to be effective in managing intraoperative hyperglycemia, as reflected by a good glycemic control at ICU admission. The stratification of patients by risk allowed a more tailored approach which optimal BG control and minimal hypoglycemia risk. Furthermore, urgent surgery remains a significant trigger for hyperglycemia, resulting in more patients requiring the protocol application with less efficacy than the elective group. [ABSTRACT FROM AUTHOR]

Ustekinumab (UST) and vedolizumab (VDZ) are biologic therapies for moderate-to-severe Crohn's disease (CD) in patients who failed or had contraindication to anti-TNF treatment. To evaluate ustekinumab efficacy as third-line treatment after swapping from VDZ for failure. We conducted a monocentric, retrospective, observational study where CD patients were followed for 12 months from the beginning of UST therapy. We assessed clinical activity (HBI) and laboratory markers (CRP) at the initiation of UST therapy (T0) and after 2(T2), 6(T6) and 12(T12) months. Endoscopic activity was recorded at T0 and T12. We registered data regarding their clinical history and previous biologic treatments. Steroid-free clinical remission was defined as HBI ≤ 4 without need for steroids. Clinical response was defined as HBI reduction of at least three points or the suspension of steroids. 27 CD patients treated with UST after VDZ failure had a minimum follow up of 12 months and were included. All patients had previously been treated with anti-TNF agents. After 12 months, steroid-free clinical remission was evident in 15 (55.5%) patients, 5 (18.5%) had clinical response, while 7 (26%) had suspended for failure or persisted on treatment after optimization. Ustekinumab should be considered as third-line biologic treatment in multi-refractory CD patients. [ABSTRACT FROM AUTHOR]