Valoración subjetiva de la onda de pletismografia como predictor en la administración de líquidos endovenosos.

Introducción: Determinar el balance de líquidos en pacientes quirúrgicos es un factor de suma importancia, la variabilidad de la onda de pletismografía puede ser un soporte para ayudar a superar este objetivo. La interpretación subjetiva por parte del anestesiólogo de la variabilidad de la onda de pletismografía, puede inferirse como una herramienta confiable para predecir y guiar la administración de líquidos en pacientes que no requieran monitoria invasiva. Metodología: Estudio exploratorio desarrollado por método de observación con la colaboración de 90 médicos anestesiólogos, mediante observación de la variabilidad de la onda de pletismografía en 5 videos aleatorizados. El porcentaje de decisiones correctas se analizó mediante IC del 95% para proporciones. Para evaluar la homogeneidad en la fracción de respuestas correctas se realizan pruebas chi-cuadrado de homogeneidad con un nivel de significancia de 0.05. Resultados: El 75% de la población encuestada con (IC) 95% de la proporción acertó en la estimación del IVP. La conducta de administrar o no líquidos y/o vasopresores fue correcta en el 80% de la población para 4 videos, con una tasa de error de 8,2% por video. El video 4 obtuvo un 32% de acierto y una tasa de error de 10,6%. Conclusiones: El estudio permitió de manera subjetiva, determinar que el uso de la variabilidad de la onda de pletismografía es una herramienta de fácil lectura que ayuda a la administración de líquidos durante el intraoperatorio en el paciente sometido a ventilación mecánica en procedimientos quirúrgicos de baja a intermedia complejidad.

African easterly wave variability and its relationship to Atlantic tropical cyclone activity

Automatic tracking of vorticity centers in European Centre for Medium-Range Weather Forecasts analyses has been used to develop a 20-yr climatology of African easterly wave activity. The tracking statistics at 600 and 850 mb confirm the complicated easterly wave structures present over the African continent. The rainy zone equatorward of 15 degreesN is dominated by 600-mb activity, and the much drier Saharan region poleward of 15 degreesN is more dominated by 850-mb activity. Over the Atlantic Ocean there is just one storm track with the 600- and 850-mb wave activity collocated. Based on growth/decay and genesis statistics, it appears that the 850-mb waves poleward of 15 degreesN over land generally do not get involved with the equatorward storm track over the ocean. Instead, there appears to be significant development of 850-mb activity at the West African coast in the rainy zone around (10 degreesN, 10 degreesW), which, it is proposed, is associated with latent heat release. Based on the tracking statistics, it has been shown that there is marked interannual variability in African easterly wave (AEW) activity. It is especially marked at the 850-mb level at the West African coast between about 10 degrees and 15 degreesN, where the coefficient of variation is 0.29. For the period between 1985 and 1998, a notable positive correlation is seen between this AEW activity and Atlantic tropical cyclone activity. This correlation is particularly strong for the postreanalysis period between 1994 and 1998. This result suggests that Atlantic tropical cyclone activity may be influenced by the number of AEWs leaving the West African coast, which have significant low-level amplitudes, and not simply by the total number of AEWs.

La onda de pletismografía y su correlación con la reposición de líquidos intraoperatorios en pacientes sometidos a anestesia general

Introducción: Se ha conocido la necesidad de la monitoria del estado hemodinámico de los pacientes quirúrgicos de forma dinámica, que permita realizar una valoración rápida, menos invasiva y confiable para un diagnóstico acertado y evaluar la respuesta a las conductas tomadas. El delta de pletismografía es una herramienta confiable, no invasiva y dinámica que logra cumplir con las características antes mencionadas y que además puede llegar a tener un papel preponderante en la terapia hídrica dirigida. Metodología: Estudio de correlación, se realizaron evaluaciones sistemáticas de la onda de pletismografía y las variables del paciente desde la inducción anestésica hasta el inicio del procedimiento quirúrgico, se determinó la correlación entre la variabilidad de la onda de pletismografía, el delta de pletismografía y el requerimiento de líquidos intraoperatorios. Se incluyeron pacientes adultos en el rango de 18 a 80 años, que cumplían los criterios de inclusión, programados para cirugía bajo anestesia general en la Fundación Cardioinfantil Instituto de Cardiología, hasta lograr la muestra calculada de 31 pacientes. Siguiendo los principios éticos de la declaración de Helsinki y la normatividad colombiana, este estudio no consideró la realización de ningún tipo de intervención en los pacientes lo que lo cataloga de bajo riesgo. Resultados: El 80.6% presentó variabilidad aumentada, con correlación entre la variabilidad de la onda del pulso, el delta POP y la cantidad de líquidos intraoperatorios (0.245 IC 95%). Disminución del delta POP en T3, sugiriendo respuesta a líquidos, correlación entre uso de vasopresores, analgesia y náuseas y vómito postoperatorio. Conclusión: Existe correlación entre la variabilidad de la onda de pletismografía, el delta de pletismografía y la reposición de líquidos endovenosos en los pacientes ventilados mecánicamente durante anestesia general. Además se encuentra asociación entre uso de vasopresores, analgesia y náuseas y vómito postoperatorio.

Flow structure and variability in the subtropical Indian Ocean: Instability of the South Indian Ocean Countercurrent

The origin of the eddy variability around the 25°S band in the Indian Ocean is investigated. We have found that the surface circulation east of Madagascar shows an anticyclonic subgyre bounded to the south by eastward flow from southwest Madagascar, and to the north by the westward flowing South Equatorial Current (SEC) between 15° and 20°S. The shallow, eastward flowing South Indian Ocean Countercurrent (SICC) extends above the deep reaching, westward flowing SEC to 95°E around the latitude of the high variability band. Applying a two-layer model reveals that regions of large vertical shear along the SICC-SEC system are baroclinically unstable. Estimates of the frequencies (3.5–6 times/year) and wavelengths (290–470 km) of the unstable modes are close to observations of the mesoscale variability derived from altimetry data. It is likely then that Rossby wave variability locally generated in the subtropical South Indian Ocean by baroclinic instability is the origin of the eddy variability around 25°S as seen, for example, in satellite altimetry.

Laparoscopic versus open splenectomy in the management of hematologic diseases

Splenectomy is the best available treatment for severe forms of hereditary spherocytosis, idiopathic thrombocytopenic purpura, and other hematologic conditions when these prove refractory to conservative management. It has been employed for many decades with low mortality and favorable remission rates. The use of laparoscopic splenectomy in recent years has been rapidly and even enthusiastically adopted in this field. However, the exact role of laparoscopic versus open surgery for hematologic diseases is still debated. In this study of 58 adult patients, laparoscopic procedures were compared with conventional splenectomies for similar indications. METHODS: All patients were operated on within an 8-year period. Subjects underwent similar procedures under the supervision of the same surgical school and were compared regarding age, gender, body mass index, and diagnosis. Laparoscopically managed cases (Group I, n = 30) were prospectively followed according to a written protocol, whereas the same investigation was retrospectively done with regard to traditional laparotomy (Group II, n = 28). Methods included general and demographic findings, duration and technical steps of operation, blood loss, weight of spleen, need for conversion (in minimally invasive subjects), intraoperative and postoperative complications, time until realimentation, postoperative hospitalization, mortality, and late follow-up including recurrence rate. RESULTS: Idiopathic thrombocytopenic purpura was the surgical indication in over 50% of the patients in both groups, but familial spherocytosis, thalassemia, myelodysplasia, and lymphomas were also represented in this series. Laparoscopic procedures took more time to perform (P = 0.004), and postoperative hospitalization was 2 days shorter, but this difference was not statistically significant. Postoperative hematocrit and volume of blood transfusions was equivalent, although the laparoscopic cases had a somewhat lower preoperative hematocrit (NS) and displayed better recovery for this measurement (P = 0.03). More patients in Group I were able to accept oral food on the first day than subjects undergoing conventional operations (P < 0.05). Relatively few conversions were necessary during the minimally invasive surgeries (13.3%), and postoperative early and late complications as well as recurrences occurred in similar proportions. Also, the mean weight of the spleen was not statistically different between the groups, although there was a marked numerical tendency toward larger masses in conventional procedures. No spleen in Group I exceeded 2.0 kg, whereas in Group II values up to 4.0 kg occurred, and the mean weight was 50% higher in the latter group. CONCLUSIONS: 1) Minimally invasive splenectomy was essentially comparable to open surgery with regard to safety, efficacy, and late results; 2) Advantages concerning shorter postoperative hospitalization could not be shown, despite earlier food intake and a non-significant tendency toward earlier discharge; 3) This new modality should be considered an option in cases of hematologic conditions whenever the spleen is not hugely enlarged.

Ensaios não-destrutivos de propagação de ondas em toras e madeira serrada de Pinus. taeda L.

In this paper it was evaluated the influence of the relative position of logs on the trees, the type of wood (juvenile and mature wood and pith) and the dimension of sawed wood elements on the velocity of propagation of stress waves into the material on condition. P. taeda L wood (43 years old trees) from Horto Florestal of Manduri (latitude 230 00’ south, longitude 400 19’ west and altitude de 700 m) São Paulo State, Brazil were used, considering its easy growth rings visualization and the better ju regions definition. Six trees were randomly chosen in the plantation. Trees were sawed into 4 logs (2,5 m long each. In each log it was delimited the central board (80mm tick) region and the lateral boards (25mm tick) regions, cons right hand. It were evaluated relation between velocity of stress waves on logs and the correspondent lumber (central and lateral boards), on green condition, on the three main region of the elements (mature wood results obtained revealed the concordance between velocities of stress waves in the material before and after the its mechanical processing. It was also revealed statistical differences between the velocity of stress waves at juvenile wood, mature wood and pith regions. Keywords: stress wave method, velocity 17 destrutivos de propagação da propagação de ondas de tensão em toras e madeira serrada de taeda L. Hernando Alfonso Lara Palma - Universidade Estadual Paulista Faculdade de Ciências Agronômicas – FCA/UNESP – Botucatu - SP, e-mail: awballarin@fca.unesp.br Luiz Antonio Vasques Hellmeister - Universidade Estadual Paulista - Faculdade de Arquitetura, FAAC/UNESP – Bauru - SP, e-mail: hellmeister@faac.unesp.br Este trabalho teve como objetivo analisar a influência do tipo de lenho, da posição da tora ao longo do fuste e das dimensões das peças desdobradas, na velocidade de as de tensão (Stress wave method), na condição de madeira verde. P. taeda L., originária de árvores de plantio do Horto Florestal de SP., com idade aproximada de 43 anos, pela facilidade de identificação dos anéis imento e demarcação das regiões de madeira adulta e madeira juvenil. Foram amostradas 6 árvores distintas, escolhidas ao acaso do talhão selecionado. De cada árvore foram retiradas 4 toras com comprimento de 2,5 m cada. Foram demarcadas nas toras a ha central (8 cm de espessura) e 4 tábuas laterais (espessura comercial de 2,5 cm), sendo duas à esquerda e duas à direita da prancha central. Foram avaliadas as relações existentes entre as velocidades de propagação das ondas de tensão na madeira íntegra (toras) e desdobrada (pranchas e tábuas), na condição de madeira verde, nas três regiões distintas do lenho: medula, madeira adulta e madeira juvenil. A análise comparativa dos resultados revelou a concordância entre as velocidades antes e após o desdobr madeira. Houve diferenciação estatisticamente significativa entre as velocidades de propagação das ondas de tensão nos lenhos adulto, juvenil e na medula. -destrutivos, método das ondas de tensão, Pinus taeda stress wave tests on green logs and lumber of Pinus taeda In this paper it was evaluated the influence of the relative position of logs on the trees, the type of wood (juvenile and mature wood and pith) and the dimension of sawed wood elements on the velocity of propagation of stress waves into the material on L wood (43 years old trees) from Horto Florestal of Manduri (latitude 19’ west and altitude de 700 m) São Paulo State, Brazil were used, considering its easy growth rings visualization and the better juvenile and mature wood regions definition. Six trees were randomly chosen in the plantation. Trees were sawed into 4 logs (2,5 m long each. In each log it was delimited the central board (80mm tick) region and the lateral boards (25mm tick) regions, considering 2 boards on the left and 2 at the right hand. It were evaluated relation between velocity of stress waves on logs and the correspondent lumber (central and lateral boards), on green condition, on the three main region of the elements (mature wood, juvenile wood and pith). Comparative analyses of results obtained revealed the concordance between velocities of stress waves in the material before and after the its mechanical processing. It was also revealed statistical differences ty of stress waves at juvenile wood, mature wood and pith regions

Stimulation induced variability of pulse plethysmography does not discriminate responsiveness to intubation

BACKGROUND: Hypnotic depth but not haemodynamic response to painful stimulation can be measured with various EEG-based anaesthesia monitors. We evaluated the variation of pulse plethysmography amplitude induced by an electrical tetanic stimulus (PPG variation) as a potential measure for analgesia and predictor of haemodynamic responsiveness during general anaesthesia. METHODS: Ninety-five patients, ASA I or II, were randomly assigned to five groups [Group 1: bispectral index (BIS) (range) 40-50, effect site remifentanil concentration 1 ng ml(-1);Group 2: BIS 40-50, remifentanil 2 ng ml(-1); Group 3: BIS 40-50, remifentanil 4 ng ml(-1); Group 4: BIS 25-35, remifentanil 2 ng ml(-1); Group 5: BIS 55-65, remifentanil 2 ng ml(-1)]. A 60 mA tetanic stimulus was applied for 5 s on the ulnar nerve. From the digitized pulse oximeter wave recorded on a laptop computer, linear and non-linear parameters of PPG variation during the 60 s period after stimulation were computed. The haemodynamic response to subsequent orotracheal intubation was recorded. The PPG variation was compared between groups and between responders and non-responders to intubation (anova). Variables independently predicting the response were determined by logistic regression. RESULTS: The probability of a response to tracheal intubation was 0.77, 0.47, 0.05, 0.18 and 0.52 in Groups 1-5, respectively (P<0.03). The PPG variability was significantly higher in responders than in non-responders but it did not improve the prediction of the response to tracheal intubation based on BIS level and effect site remifentanil concentration. CONCLUSION: Tetanic stimulation induced PPG variation does not reflect the analgesic state in a wide clinical range of surgical anaesthesia.

The effect of workplace smoking bans on heart rate variability and pulse wave velocity of non-smoking hospitality workers

OBJECTIVES: To investigate the effect of a change in second-hand smoke (SHS) exposure on heart rate variability (HRV) and pulse wave velocity (PWV), this study utilized a quasi-experimental setting when a smoking ban was introduced. METHODS: HRV, a quantitative marker of autonomic activity of the nervous system, and PWV, a marker of arterial stiffness, were measured in 55 non-smoking hospitality workers before and 3-12 months after a smoking ban and compared to a control group that did not experience an exposure change. SHS exposure was determined with a nicotine-specific badge and expressed as inhaled cigarette equivalents per day (CE/d). RESULTS: PWV and HRV parameters significantly changed in a dose-dependent manner in the intervention group as compared to the control group. A one CE/d decrease was associated with a 2.3 % (95 % CI 0.2-4.4; p = 0.031) higher root mean square of successive differences (RMSSD), a 5.7 % (95 % CI 0.9-10.2; p = 0.02) higher high-frequency component and a 0.72 % (95 % CI 0.40-1.05; p < 0.001) lower PWV. CONCLUSIONS: PWV and HRV significantly improved after introducing smoke-free workplaces indicating a decreased cardiovascular risk.

Variability of voriconazole plasma levels measured by new high-performance liquid chromatography and bioassay methods, [and] Voriconazole therapeutic drug monitoring in patients with invasive mycoses improves efficacy and safety outcomes

Rapport de synthèse1. Partie de laboratoireCette première étude décrit le développement et la validation, selon les standards internationaux, de deux techniques de mesure des concentrations sanguines de voriconazole, un nouvel agent antifongique à large spectre: 1) la chromatographic en phase liquide à haute pression et 2) le bio-essai utilisant une souche mutante de Candida hypersensible au voriconazole. Ce travail a aussi permis de mettre en évidence une importante et imprévisible variabilité inter- et intra-individuelle des concentrations sanguines de voriconazole malgré l'utilisation des doses recommandées par le fabriquant. Ce travail a été publié dans un journal avec "peer-review": "Variability of voriconazole plasma levels measured by new high- performance liquid chromatography and bioassay methods" by A. Pascual, V. Nieth, T. Calandra, J. Bille, S. Bolay, L.A. Decosterd, T. Buclin, P.A. Majcherczyk, D. Sanglard, 0. Marchetti. Antimicrobial Agents Chemotherapy, 2007; 51:137-432. Partie CliniqueCette deuxième étude a évalué de façon prospective l'impact clinique des concentrations sanguines de voriconazole sur l'efficacité et sécurité thérapeutique chez des patients atteints d'infections fongiques. Des concentrations sanguines élevées étaient significativement associés à la survenue d'une toxicité neurologique (encéphalopathie avec confusion, hallucinations et myoclonies) et des concentrations sanguines basses à une réponse insuffisante au traitement antifongique (persistance ou progression des signes cliniques et radiologiques de l'infection). Dans la majorité des cas, un ajustement de la dose de voriconazole, sur la base des concentrations mesurées, a abouti à une récupération neurologique complète ou à une résolution de l'infection, respectivement. Ce travail a été publié dans un journal avec "peer-review": " Voriconazole Therapeutic Drug Monitoring in Patients with Invasive Mycoses Improves Efficacy and Safety Outcomes" by A. Pascual, T. Calandra, S. Bolay, T. Buclin, J. Bille, and O. Marchetti. Clinical Infectious Diseases, 2008 January 15; 46(2): 201-11.Ces deux études, financées de façon conjointe par un "grant" international de la Société suisse d'infectiologie et la Société internationale de maladies infectieuses et par la Fondation pour le progrès en microbiologie médicale et maladies infectieuses (FAMMID, Lausanne), ont été réalisées au sein du Service des Maladies Infectieuses, Département de Médecine, au CHUV, en étroite collaboration avec la Division de Pharmacologie Clinique, Département de Médecine, au CHUV et l'Institut de Microbiologie du CHUV et de l'Université de Lausanne.

Successful minimally invasive surgery for primary hyperparathyroidism: influence of preoperative imaging and intraoperative parathyroid hormone levels.

PURPOSE: Adenoma is the main parathyroid disorder leading to primary hyperparathyroidism (PHP). Minimally invasive parathyroidectomy (MIP) is recognized as a valid procedure for adenoma-related PHP. It requires precise preoperative localization combining Tc-99m-MIBI (methoxy-isobutyl-isonitrile) scintigraphy and single-photon emission computed tomography (SPECT) with x-ray computed tomography (CT) and intraoperative confirmation of successful excision by change in intact parathormone (iPTH) levels. The study aim was to assess the surgery success in relation to these two parameters. METHODS: All patients operated on for PHP from 2005 to mid-2014 at our institution were retrospectively reviewed. MIP was performed in case of precise preoperative adenoma localization on scintigraphy, absence of past cervical surgery, and absence of concomitant thyroid resection necessity. In these patients, iPTH levels were monitored intraoperatively. Confirmation criteria for iPTH values were a return to normal level or a decrease >50 % of basal iPTH level. RESULTS: There were 197 PHP operations during the study period: 118 MIP and 79 bilateral neck explorations (BNEs). The MIP success rate was 95 % (112/118) with a preoperative MIBI scan ± CT accurate in 94 % (111/118) of the patients and with correct iPTH in 90 % (106/118) of the cases. Among the 12 iPTH levels that did not meet the confirmation criteria, 10 returned to normal range by postoperative day 2. Treatment failure appeared in three patients (one BNE, two MIPs). CONCLUSIONS: Tc-99m-MIBI dual-phase scintigraphy with SPECT/CT is the key examination for functional and morphological parathyroid adenoma localization. If preoperative scintigraphy is obvious and intraoperative assessment is clear, one could possibly safely omit iPTH, as it may lead to unnecessary BNE in primary PHP.

Sensitivity of GCM tropical middle atmosphere variability and climate to ozone and parametrized gravity wave changes

This paper describes the impact of changing the current imposed ozone climatology upon the tropical Quasi-Biennial Oscillation (QBO) in a high top climate configuration of the Met Office U.K. general circulation model. The aim is to help distinguish between QBO changes in chemistry climate models that result from temperature-ozone feedbacks and those that might be forced by differences in climatology between previously fixed and newly interactive ozone distributions. Different representations of zonal mean ozone climatology under present-day conditions are taken to represent the level of change expected between acceptable model realizations of the global ozone distribution and thus indicate whether more detailed investigation of such climatology issues might be required when assessing ozone feedbacks. Tropical stratospheric ozone concentrations are enhanced relative to the control climatology between 20–30 km, reduced from 30–40 km and enhanced above, impacting the model profile of clear-sky radiative heating, in particular warming the tropical stratosphere between 15–35 km. The outcome is consistent with a localized equilibrium response in the tropical stratosphere that generates increased upwelling between 100 and 4 hPa, sufficient to account for a 12 month increase of modeled mean QBO period. This response has implications for analysis of the tropical circulation in models with interactive ozone chemistry because it highlights the possibility that plausible changes in the ozone climatology could have a sizable impact upon the tropical upwelling and QBO period that ought to be distinguished from other dynamical responses such as ozone-temperature feedbacks.

Response of the North Atlantic wave climate to atmospheric modes of variability

This study investigates the relationship between the wind wave climate and the main climate modes of atmospheric variability in the North Atlantic Ocean. The modes considered are the North Atlantic Oscillation (NAO), the East Atlantic (EA) pattern, the East Atlantic Western Russian (EA/WR) pattern and the Scandinavian (SCAN) pattern. The wave dataset consists of buoys records, remote sensing altimetry observations and a numerical hindcast providing significant wave height (SWH), mean wave period (MWP) and mean wave direction (MWD) for the period 1989–2009. After evaluating the reliability of the hindcast, we focus on the impact of each mode on seasonal wave parameters and on the relative importance of wind-sea and swell components. Results demonstrate that the NAO and EA patterns are the most relevant, whereas EA/WR and SCAN patterns have a weaker impact on the North Atlantic wave climate variability. During their positive phases, both NAO and EA patterns are related to winter SWH at a rate that reaches 1 m per unit index along the Scottish coast (NAO) and Iberian coast (EA) patterns. In terms of winter MWD, the two modes induce a counterclockwise shift of up to 65° per negative NAO (positive EA) unit over west European coasts. They also increase the winter MWP in the North Sea and in the Bay of Biscay (up to 1 s per unit NAO) and along the western coasts of Europe and North Africa (1 s per unit EA). The impact of winter EA pattern on all wave parameters is mostly caused through the swell wave component.

On the ability of statistical wind-wave models to capture the variability and long-term trends of the North Atlantic winter wave climate

A dynamical wind-wave climate simulation covering the North Atlantic Ocean and spanning the whole 21st century under the A1B scenario has been compared with a set of statistical projections using atmospheric variables or large scale climate indices as predictors. As a first step, the performance of all statistical models has been evaluated for the present-day climate; namely they have been compared with a dynamical wind-wave hindcast in terms of winter Significant Wave Height (SWH) trends and variance as well as with altimetry data. For the projections, it has been found that statistical models that use wind speed as independent variable predictor are able to capture a larger fraction of the winter SWH inter-annual variability (68% on average) and of the long term changes projected by the dynamical simulation. Conversely, regression models using climate indices, sea level pressure and/or pressure gradient as predictors, account for a smaller SWH variance (from 2.8% to 33%) and do not reproduce the dynamically projected long term trends over the North Atlantic. Investigating the wind-sea and swell components separately, we have found that the combination of two regression models, one for wind-sea waves and another one for the swell component, can improve significantly the wave field projections obtained from single regression models over the North Atlantic.