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Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence. To determine whether early HVHF decreases all-cause mortality 30 days after randomization. This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury. On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia. For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).

An experimental investigation was conducted to analyze the effect of cutting parameters (cutting speed, feed rate and depth of cut) and workpiece hardness on surface roughness and cutting force components. The finish hard turning of AISI 52100 steel with coated Al 2 O 3 + TiC mixed ceramic cutting tools was studied. The planning of experiment were based on Taguchi’s L 27 orthogonal array. The response table and analysis of variance (ANOVA) have allowed to check the validity of linear regression model and to determine the significant parameters affecting the surface roughness and cutting forces. The statistical analysis reveals that the feed rate, workpiece hardness and cutting speed have significant effects in reducing the surface roughness; whereas the depth of cut, workpiece hardness and feed rate are observed to have a statistically significant impact on the cutting force components than the cutting speed. Consequently, empirical models were developed to correlate the cutting parameters and workpiece hardness with surface roughness and cutting forces. The optimum machining conditions to produce the lowest surface roughness with minimal cutting force components under these experimental conditions were searched using desirability function approach for multiple response factors optimization. Finally, confirmation experiments were performed to verify the pertinence of the developed empirical models.

Background Fibrinogen concentrate may reduce allogeneic blood product transfusion in cardiac surgery patients with bleeding associated with acquired hypofibrinogenemia. The European Society of Anaesthesiology and Intensive Care (ESAIC) has issued guidelines, but compliance to these guidelines has not been studied yet. Methods This multicentre observational cohort study was aimed at evaluating the compliance of fibrinogen prescription with ESAIC. Adult patients undergoing cardiac surgery with cardiopulmonary bypass in 13 French cardiac surgery centres were recruited from March 2017 to April 2018. Compliance with ESAIC guidelines was considered whenever patients received fibrinogen in case of hypofibrinogenemia and clinically relevant bleeding, or when patients did not receive fibrinogen concentrate if there was no hypofibrinogenemia and/or no clinically relevant bleeding. The primary endpoint was the percentage of patients who complied those guidelines. Secondary endpoints were to assess the consequences of non-compliance on in-hospital deaths and hospital length-of-stay. Results Among 2,649 adult patients undergoing cardiac surgery with cardiopulmonary bypass, 374 (14.1%) received fibrinogen concentrate. Rates of prescription among centres varied from < 1.0% to 31.2% ( p  < 0.001). Compliance with guidelines was observed in 2,291 (86.5%) patients, driven by a high number of patients without prescription ( N  = 2,158; 94.5%). In non-compliance patients ( N  = 358; 13.5%), fibrinogen over-prescription ( N  = 241) exceeded under-prescription ( N  = 117). In multivariate analyses, non-compliance with the guidelines was not significantly associated with in-hospital deaths or hospital stay. Conclusions Fibrinogen concentrate prescription varied significantly among centres but compliance with the ESAIC guidelines was high (86.5%). Non-compliance (13.5%)—mostly due to over-prescription—was not associated with adverse outcomes. Trial registration Clinicaltrials.gov identifier: (NCT03075774).

IntroductionDuring cardiac surgery-associated bleeding, the early detection of coagulopathy is crucial. However, owing to time constraints or lack of suitable laboratory tests, transfusion of haemostatic products is often inappropriately triggered, either too late (exposing to prolonged bleeding and thus to avoidable administration of blood products) or blindly to the coagulation status (exposing to unnecessary haemostatic products administration in patients with no coagulopathy). Undue exposition to transfusion risks and additional healthcare costs may arise. With the perspective of secondary care-related costs, the IMOTEC study (Intérêt MédicO-économique de la Thrombo-Elastographie, dans le management transfusionnel des hémorragies péri-opératoires de chirurgies Cardiaques sous circulation extracorporelle) aims at assessing the cost-effectiveness of a point-of-care viscoelastic haemostatic assay (VHA: RoTem or TEG)-guided management of bleeding. Among several outcome measures, particular emphasis will be put on quality of life with a 1-year follow-up.Methods and analysisThis is a multicentre, prospective, pragmatic study with stepped-wedge cluster randomised controlled design. Over a 36-month period (24 months of enrolment and 12 months of follow-up), 1000 adult patients undergoing cardiac surgery with cardiopulmonary bypass will be included if a periprocedural significant bleeding occurs. The primary outcome is the cost-effectiveness of a VHA-guided algorithm over a 1-year follow-up, including patients’ quality of life. Secondary outcomes are the cost-effectiveness of the VHA-guided algorithm with regard to the rate of surgical reexploration and 1-year mortality, its cost per-patient, its effectiveness with regard to haemorrhagic, infectious, renal, neurological, cardiac, circulatory, thrombotic, embolic complications, transfusion requirements, mechanical ventilation free-days, duration of intensive care unit and in-hospital stay and mortality.Ethics and disseminationThe study was registered at Clinicaltrials.gov and was approved by the Committee for the Protection of Persons of Nantes University Hospital, The French Advisory Board on Medical Research Data Processing and the French Personal Data Protection Authority. A publication of the results in a peer-reviewed journal is planned.Trial registration numberNCT02972684; Pre-results.

PURPOSE: To evaluate the visualization and depth of the demarcation line with anterior segment optical coherence tomography (AS-OCT) after iontophoresis-assisted transepithelial corneal collagen cross-linking (CXL). METHODS: This prospective, consecutive, single center, non-randomized clinical study involved 15 eyes of 12 patients with keratoconus who underwent an AS-OCT scan (Spectralis; Heidelberg Engineering, Inc., Carlsbad, CA) to search for a demarcation line and its depth at 1 month after iontophoresis-assisted transepithelial CXL. AS-OCT scan measurements were performed by two independent examiners. RESULTS: No intraoperative or postoperative complications were observed. Kappa coefficient estimation for operator agreement in demarcation line visualization (whether it was visualized) was 70.6%. The corneal stromal demarcation line was identified in 9 eyes (60%) by both examiners. Mean depth of the corneal stromal demarcation line was 246.67 ± 50.72 No intraoperative or postoperative complications were observed. Kappa coefficient estimation for operator agreement in demarcation line visualization (whether it was visualized) was 70.6%. The corneal stromal demarcation line was identified in 9 eyes (60%) by both examiners. Mean depth of the corneal stromal demarcation line was 246.67 ± 50.72 µ m (range: 183 to 339 µ m) for the first examiner and 241.89 ± 62.52 µ m (range: 163 to 358 µ m) for the second examiner. There were no statistically significant differences for the measurements of the paired comparisons between the two examiners ( P = .61). The Pearson correlation coefficient between the measurements was 0.910. CONCLUSIONS: Iontophoresis-assisted transepithelial CXL creates a demarcation line that can be visualized with AS-OCT, which seems less easily distinguishable and shallower than in conventional CXL. However, its depth and visualization seems to be more similar to conventional CXL than transepithelial CXL. [[ J Refract Surg . 2015;31(1):36–40.]

Background Malaria endemic countries need to assess efficacy of anti-malarial treatments on a regular basis. Moreover, resistance to artemisinin that is established across mainland South-East Asia represents today a major threat to global health. Monitoring the efficacy of artemisinin-based combination therapies is of paramount importance to detect as early as possible the emergence of resistance in African countries that toll the highest burden of malaria morbidity and mortality. Methods A WHO standard protocol was used to assess efficacy of the combinations artesunate–amodiaquine (AS–AQ Winthrop ® ), dihydroartemisinin–piperaquine (DHA–PPQ, Eurartesim ® ) and artemether–lumefantrine (AM–LM, Coartem ® ) taken under supervision and respecting pharmaceutical recommendations. The study enrolled for each treatment arm 212 children aged 6–59 months living in Maradi (Niger) and suffering with uncomplicated falciparum malaria. The Kaplan–Meier 42-day PCR-adjusted cure rate was the primary outcome. A standardized parasite clearance estimator was used to assess delayed parasite clearance as surrogate maker of suspected artemisinin resistance. Results No early treatment failures were found in any of the study treatment arms. The day-42 PCR-adjusted cure rate estimates were 99.5, 98.4 and 99.0% in the AS–AQ, DHA–PPQ and AM–LM arms, respectively. The reinfection rate (expressed also as Kaplan–Meier estimates) was higher in the AM–LM arm (32.4%) than in the AS–AQ (13.8%) and the DHA–PPQ arm (24.9%). The parasite clearance rate constant was 0.27, 0.26 and 0.25 per hour for AS–AQ, DHA–PPQ and AM–LM, respectively. Conclusions All the three treatments evaluated largely meet WHO criteria (at least 95% efficacy). AS–AQ and AL–LM may continue to be used and DHA–PPQ may be also recommended as first-line treatment for uncomplicated falciparum malaria in Maradi. The parasite clearance rate were consistent with reference values indicating no suspected artemisinin resistance. Nevertheless, the monitoring of anti-malarial drug efficacy should continue. Trial registration details Registry number at ClinicalTrial.gov: NCT01755559

PURPOSE: To analyze the refractive outcomes and satisfaction of presbyopic hyperopes treated with central presbyopicLASIK (presbyLASIK) with induced micro-monovision. METHODS: This retrospective study included 74 eyes of 37 patients treated with central presbyLASIK with micro-monovision using the Technolas 217P excimer laser (Technolas Perfect Vision GmbH, Munich, Germany) between June 2011 and March 2014. Study parameters included uncorrected distance visual acuity (UDVA) and uncorrected near visual acuity (UNVA), aberrometry, the central steep zone, and patient satisfaction. RESULTS: Median age was 54.3 ± 4 years (range: 46 to 63 years). Mean postoperative spherical equivalent refraction was 0.00 ± 0.58 diopters (D) for dominant eyes and −0.51 ± 0.54 D for non-dominant eyes. Mean binocular UDVA was 0.01 ± 0.10 logMAR (Snellen 20/20) at 6 months and −0.01 ± 0.05 logMAR (Snellen 20/19) at 1 year postoperatively. Mean binocular UNVA was 0.18 ± 0.14 logMAR (Parinaud 2) (Jaeger 1) at 6 months and 0.18 ± 0.12 logMAR (Parinaud 2) (Jaeger 1) at 1 year postoperatively. At 6 months, 79.31% of patients achieved 20/25 and could read Parinaud 2 (Jaeger 1) binocularly. At 1 year, 84.21% of patients achieved 20/25 and could read Parinaud 2 (Jaeger 1) binocularly. The mean central steep zone was 2.35 ± 1.00 D. There were significantly more negative spherical aberration and vertical coma in the central 5 mm postoperatively (Median age was 54.3 ± 4 years (range: 46 to 63 years). Mean postoperative spherical equivalent refraction was 0.00 ± 0.58 diopters (D) for dominant eyes and −0.51 ± 0.54 D for non-dominant eyes. Mean binocular UDVA was 0.01 ± 0.10 logMAR (Snellen 20/20) at 6 months and −0.01 ± 0.05 logMAR (Snellen 20/19) at 1 year postoperatively. Mean binocular UNVA was 0.18 ± 0.14 logMAR (Parinaud 2) (Jaeger 1) at 6 months and 0.18 ± 0.12 logMAR (Parinaud 2) (Jaeger 1) at 1 year postoperatively. At 6 months, 79.31% of patients achieved 20/25 and could read Parinaud 2 (Jaeger 1) binocularly. At 1 year, 84.21% of patients achieved 20/25 and could read Parinaud 2 (Jaeger 1) binocularly. The mean central steep zone was 2.35 ± 1.00 D. There were significantly more negative spherical aberration and vertical coma in the central 5 mm postoperatively ( P < .05). The re-treatment rate was 6.75%. Eighty-three percent of these patients did not need any glasses for distance and near vision. CONCLUSIONS: This procedure may improve functional near, intermediate, and distance vision in presbyopic patients with low and moderate hyperopia. [[ J Refract Surg. 2015;31(8):540–546.]

To compare the shape of the capsulotomy, its change, and its impact on visual quality over 1 year using the femtosecond laser system from the manual technique. In this two-center cross-sectional study from May 2012 to June 2013, each patient had femtosecond laser-assisted cataract surgery in one eye (FLACS group) and conventional phacoemulsification cataract surgery in the other eye (CPCS group). An evaluation of the capsulotomy was performed using retroillumination slit-lamp photographs at 7 days, 6 months, and 1 year after surgery. Effective lens position (ELP), refractive error, and corrected distance visual acuity (CDVA) were analyzed. Thirty-three patients were included in the study. Diameters of capsulorhexis were more precise and deviation surfaces were lower in the FLACS group than in the CPCS group at each evaluation (P < .05). Femtosecond laser capsulotomies were less modified over time than manual continuous curvilinear capsulorhexis. No significant differences were observed for CDVA, refractive error, and ELP between groups. More precise capsulotomy sizing can be achieved with the femtosecond laser compared to continuous curvilinear capsulorhexis. Femtosecond laser capsulotomies are less modified over time but did not improve ELP or visual quality. [J Refract Surg. 2017;33(1):44-49].

Background Propofol infusion syndrome (PRIS) is a rare but serious complication of propofol administration consisting of metabolic disorder with acidosis, often leading to fatal cardiovascular collapse. Methods A case of PRIS is described in a 17-year-old female with refractory status epilepticus (RSE) who was receiving high-dose propofol for seizure control and sedation. Results Metabolic syndrome was observed with renal failure, severe metabolic acidosis, and rhabdomyolysis after 58 h of propofol infusion at a maximum dose of 8.8 mg/kg/h. It was not initially associated with circulatory failure. Propofol was stopped immediately, and brief bradycardia was observed. The patient was started on continuous hemofiltration resulting in correction of the metabolic disorder. However, cardiocirculatory failure occurred a few hours later. Her clinical evolution and biological assessments were typical of PRIS. Extracorporeal membrane oxygenation (ECMO) was initiated despite the presence of cardiocirculatory arrest. Cardiocirculatory function improved rapidly, and the patient was weaned off ECMO after 5 days. No severe neurologic effects were observed, and she left the intensive care unit after 36 days, returning home after 2 months. Conclusions Careful consideration should be given before prescribing propofol as first-line therapy for RSE, and this drug should be avoided altogether if high doses are required. Close biochemical monitoring is needed if propofol is used for more than a few hours, so that PRIS can be recognized promptly. Immediate discontinuation of propofol is essential, and early hemofiltration should be initiated. ECMO should be considered in cases of cardiocirculatory failure.

Improvement in machining efficiency requires better comprehension of multiphysical cutting process phenomenon under real dynamic cutting conditions. Present work suggests a multi-scale interaction of mesoscopic level cutting with macroscopic level machine tool dynamics to optimize cutting process parameters and potentially improve interactive design process. For that, the case of an orthogonal down-cut peripheral milling, for an aeronautic aluminium alloy A2024-T351, has been treated. A finite element based multi-scale dynamic cutting model has been conceived with a commercial finite element based code ABAQUS ® /EXPLICIT to predict the chip morphology under dynamic cutting conditions. Later, combines the elasticity of a classical high speed milling spindle system (tool, tool-holder and rotor) with the mesoscopic level chip formation process. A qualitative parametric study with various stiffness and damping coefficient values for high speed milling spindle system shows that, a less rigid un-damped milling system generates higher amplitude tool vibrations during cutting. In this situation, the temperature rises at tool-workpiece interface, enhancing material softening. Present study deals with the consequences of this softening on affecting the chip morphology (evolution of segmented chip morphology), and machined surface integrity. Further, numerical simulation results depict that the higher values of cutting speed and uncut chip thickness are associated with higher values of milling cutter vibration amplitudes.