Cristina Barbero

Catheter-Related Complications in Cancer Patients on Home Parenteral Nutrition A Prospective Study of Over 51,000 Catheter Days

BACKGROUND Although home parenteral nutrition (HPN) is often indicated in cancer patients, many physicians are concerned about the risks potentially associated with the use of central venous access devices (VADs) in these patients. The aim of this prospective study was to investigate the actual incidence of VAD-related complications in cancer patients on HPN. METHODS All adult cancer patient candidates for VAD insertion and HPN were enrolled. The incidence of complications associated with 4 types of VADs (peripherally inserted central catheter [PICC], Hohn catheter, tunneled Groshong catheter, and port) was investigated, as well as the most significant risk factors. RESULTS Two hundred eighty-nine VADs in 254 patients were studied, for a total of 51,308 catheter-days. The incidence of catheter-related bloodstream infections (CRBSIs) was low (0.35/1000 catheter-days), particularly for PICCs (0/1000; P < .01 vs Hohn and tunneled catheters) and for ports (0.19/1000; P < .01 vs Hohn and P < .05 vs tunneled catheters). Mechanical complications were uncommon (0.8/1000), as was VAD-related venous thrombosis (0.06/1000). Ultrasound-guided venipuncture was associated with a decreased risk of CRBSI (P < .04) and thrombosis (P < .001). VAD securement using sutureless devices reduced the risk of CRBSI and dislocation (P < .001). Hohn catheters had no advantage over PICCs (higher complication rate and shorter dwell time; P < .001). CONCLUSIONS In cancer patients, HPN can be safely carried out with a low incidence of complications. Also, VADs are not equal in terms of complication rates, and strict adherence to meticulous insertion policies may effectively reduce catheter-related complications.

Occlusion of Both Caval Veins by an Endovascular Occluder

Minimally invasive surgery (MIS) for redo mitral/tricuspidal surgery is going to increase, offering good results for early and late mortality and morbidity. In a case of redo surgery through a right thoracotomy (RT), when tricuspid surgery is planned, the superior (SVC) and inferior caval veins (IVC) are usually isolated and snared in order to prevent air embolism and significant blood regurgitation. We describe our experience in eight redo patients, operated for combined mitral/tricuspid or isolated tricuspid surgery, where the endovascular occlusion of the SVC and IVC was obtained by means of an endovascular occluder (Equalizer).

64 slice-coronary computed tomography sensitivity and specificity in the evaluation of coronary artery bypass graft stenosis: A meta-analysis.

A non-invasive approach to define grafts patency and stenosis in the follow-up of coronary artery bypass graft (CABG) patients may be an interesting alternative to coronary angiography. 64-slice-coronary computed tomography is nowadays a diffused non-invasive method that permits an accurate evaluation of coronary stenosis, due to a high temporal and spatial resolution. However, its sensitivity and specificity in CABG evaluation has to be clearly defined, since published studies used different protocols and scanners. We collected all studies investigating patients with stable symptoms and previous CABG and reporting the comparison between diagnostic performances of invasive coronary angiography and 64-slice-coronary computed tomography. As a result, sensitivity and specificity of 64-slice-coronary computed tomography for CABG occlusion were 0.99 (95% CI 0.97-1.00) and 0.99 (95% CI: 0.99-1.00) with an area under the curve (AUC) of 0.99. 64-slice-coronary computed tomography sensitivity and specificity for the presence of any CABG stenosis >50% were 0.98 (95% CI: 0.97-0.99) and 0.98 (95% CI: 0.96-0.98), while AUC was 0.99. At meta-regression, neither the age nor the time from graft implantation had effect on sensitivity and specificity of 64-slice-coronary computed tomography detection of significant CABG stenosis or occlusion. In conclusion 64-slice-coronary computed tomography confirmed its high sensitivity and specificity in CABG stenosis or occlusion evaluation.

Intraoperative Vancomycin Pharmacokinetics in Cardiac Surgery With or Without Cardiopulmonary Bypass

BACKGROUND Vancomycin is administered as antimicrobial prophylaxis to patients undergoing cardiac surgery, an intervention that usually requires cardiopulmonary bypass (CPB). Previous studies reported that CPB modifies vancomycin pharmacokinetic parameters. OBJECTIVE To investigate intraoperative vancomycin pharmacokinetic changes in a large population of patients undergoing cardiac surgery with CPB (on-pump) and without CPB (off-pump). METHODS In this prospective study, patients undergoing cardiac surgery received a single dose of vancomycin 1000 mg in a 60-minute intravenous infusion, with skin incision performed between 16 and 120 minutes after the end of the infusion. For the on-pump group, arterial samples were drawn before CPB (end of infusion, skin incision), during CPB (5, 30, and 60 minutes, and then every 60 minutes until CPB end), and after CPB (wound closure). For the off-pump group, arterial samples were drawn time-matched to the CPB period of the on-pump group. RESULTS Two hundred thirty-six consecutive patients were enrolled: 215 in the on-pump group and 21 in the off-pump group. A total of 1682 serum vancomycin concentrations (median 7/patient) were measured. Vancomycin maximum concentration ([Cmax] on-pump, 45.6 mg/L; off-pump, 47.3 mg/L); area under the concentration-time curve, zero to 8 hours ([AUC0–8] on-pump, 104.6 mg*h/L; off-pump, 96.1 mg*h/L); volume of distribution ([Vd] on-pump, 31 L; off-pump, 28.2 L); and total body clearance ([Cl] on-pump, 6.23 L/h; off-pump, 7.05 L/h) were similar. Moreover, Cmax and AUC0-∞ (AUC, zero to infinity) showed values comparable to those found in previous studies performed on noncardiac surgery patients. CONCLUSIONS In our study there were no significant differences in vancomycin Cmax, AUC0–8, Vd, and Cl between the on-pump and off-pump groups. CPB does not seem to significantly modify intraoperative vancomycin pharmaco ki netics in patients undergoing cardiac surgery. The results of this study may contribute to increased knowledge of vancomycin pharmacokinetics.

Temporary Neurological Dysfunction After Minimal Invasive Mitral Valve Surgery: Influence of Type of Perfusion and Aortic Clamping Technique

important outcome measure. However, the superior outcomes with pulmonary complications such as atelectasis and pneumonia in this study indicate that this was indeed the case. We agree with the authors that any retrospective study (even using propensity scores and matching) is not likely to give reliable answers. Clearly, we need a multicenter randomized trial. The endpoints of this trial should be restricted to postoperative pulmonary complications, where the evidence is strongest. Equivalence in oncological outcomes should be expected, but superior outcomes in other (nonpulmonary) postoperative complications, mortality and survival should only be considered a bonus and not a necessary result to show superiority of VATS lobectomy. The challenges of conducting such trials notwithstanding, this is the only way we can conclusively answer this important question.

Some Improvements on the IRST Mixed Initiative Dialogue Technology

The paper describes the ITC-irst approach for handling spoken dialogue interactions over the telephone network. Barge-in and utterance verification capabilities are going to be introduced into the developed software architecture. Some research activities that should enable accessing information in a new large applicative domain (i.e. the tourism domain) have been started. Objectives of the research are: language model adaptation and efficient information presentation, using a mixed representation approach.

Dependency Graphs in Natural Language Processing

The paper illustrates the suitability of the dependency approach in practical applications of NLP. We introduce a compact representation called dependency graph, produced by an all-path left-to-right parser for a dependency grammar. The dependency graph keeps all the syntactic trees of a sentence in a single structure, thus allowing an economy of representation and an easier comparison between the alternative paths for the semantic processor.

Minimal access surgery for mitral valve endocarditis

OBJECTIVES Minimal access mitral valve surgery (MVS) has already proved to be feasible and effective with low perioperative mortality and excellent long-term outcomes. However, experience in more complex valve diseases such as infective endocarditis (IE) still remains limited. The aim of this retrospective study was to evaluate early and long-term results of minimal access MVS for IE. METHODS Data were entered into a dedicated database. Analysis was performed retrospectively for the 8-year period between January 2007 and April 2015. RESULTS During the study period, 35 consecutive patients underwent minimal access MVS for IE at our department. Twenty-four had diagnosis of native MV endocarditis (68.6%) and 11 of mitral prosthesis endocarditis (31.4%).Thirty patients underwent early MVS (85.7%), and 5 patients were operated after the completion of antibiotic treatment (14.3%). Seven patients underwent MV repair (20%), 17 patients underwent MV replacement (48.6%), and 11 patients underwent mitral prosthesis replacement (31.4%). Thirty-day mortality was 11.4% (4 patients). No neurological or vascular complications were reported. One patient underwent reoperation for prosthesis IE relapse after 37 days. Overall actuarial survival rate at 1 and 5 years was 83%; freedom from MV reoperation and/or recurrence of IE at 1 and 5 years was 97%. CONCLUSIONS Minimally invasive MVS for IE is feasible and associated with good early and long-term results. Preoperative accurate patient selection and transoesophageal echocardiography evaluation is mandatory for surgical planning.

Violation of prophylactic vancomycin administration timing is a potential risk factor for rate of surgical site infections in cardiac surgery patients: a prospective cohort study

BackgroundIntensivists and cardiothoracic surgeons are commonly worried about surgical site infections (SSIs) due to increasing length of stay (LOS), costs and mortality. The antimicrobial prophylaxis is one of the most important tools in the prevention of SSIs. The objective of this study was to investigate the relationship between the timing of antimicrobial prophylaxis administration and the rate of SSIs.MethodsA prospective cohort study was carried out over 1-year period in all consecutive adult patients undergoing elective cardiac surgery. The population was stratified in patients whose antimicrobial prophylaxis administration violated or not the vancomycin timing protocol (i.e., when the first skin incision was performed before the end of vancomycin infusion). To compare SSI rates, the cohort was further stratified in patients at low and high risk of developing SSIs.ResultsOver the study period, 1020 consecutive adult patients underwent cardiac surgery and according to study inclusion criteria, 741 patients were prospectively enrolled. A total of 60 SSIs were identified for an overall infection rate of 8.1%. Vancomycin prophylaxis timing protocol was violated in 305 (41%) out of 741 enrolled patients. SSIs were observed in 3% of patients without violation of the antimicrobial prophylaxis protocol (13/436) compared with 15.4% of patients with a violation of the timing protocol (47/305) (P < 0.0001). Patients at low risk with protocol violation had a higher occurrence of SSIs (P = 0.004) and mortality (P = 0.03) versus patients at low risk without protocol violation. Similarly, patients at high risk with protocol violation had a higher occurrence of SSIs (P < 0.001) and mortality (P < 0.001) versus patients at high risk without protocol violation. The logistic regression analysis showed that internal mammary artery use (P = 0.025), surgical time (P < 0.001), intensive care unit (ICU) LOS (P = 0.002), high risk of developing SSIs (P < 0.001) and protocol violation (P < 0.001) were risk factors for SSI occurrence as well as age (P = 0.003), logistic EuroSCORE (P < 0.001), ICU LOS (P < 0.001), mechanical ventilation time (P < 0.001) and protocol violation (P < 0.001) were risk factors for mortality.ConclusionsThis study showed that violation of the timing of prophylactic vancomycin administration significantly increased the probability of SSIs and mortality from infectious cause in cardiac surgery patients.

Port-access redo mitral valve surgery in a 13-year-old child

is reported. The patient had undergone 3 previouscardiac surgeries.At the age of 8 months, the patient underwent correctionof an anomalous left coronary artery originating from thepulmonary artery trunk with the Takeuchi procedure, and amitral valve repair with the Kay technique. At 2 years ofage, he underwent reoperation for a posterior leaflet exten-sionwithapericardialpatchasaresultofseveremitralregur-gitation. A few months later the mitral valve was replacedwith a mechanical prosthesis (17 mm; St Jude Medical, StPaul, Minn) for severe residual insufficiency. All previousprocedures were performed through a longitudinal mediansternotomy. At 13 years of age, the patient came to ourattention for onset and worsening of dyspnea (New YorkHeart Association class II-III). Upon physical examination,adiastolicprecordialmurmurwasfound.Ameangradientof12mmHgwasmeasuredbytransthoracicechocardiographywith normal movement of both prosthesis disks.Given these echocardiographic findings and symptoms,the indication for mitral prosthesis replacement wasconfirmed. Feasibility, safety, and efficacy of redo cardiacsurgeries in adults using a mini-invasive port-access plat-formhasbeenreportedpreviouslybymanyinvestigators,