How to prevent venous cannula orifice obstruction during extracorporeal circulation.

Venous cannula orifice obstruction is an underestimated problem during augmented cardiopulmonary bypass (CPB), which can potentially be reduced with redesigned, virtually wall-less cannula designs versus traditional percutaneous control venous cannulas. A bench model, allowing for simulation of the vena cava with various affluent orifices, venous collapse and a worst case scenario with regard to cannula position, was developed. Flow (Q) was measured sequentially for right atrial + hepatic + renal + iliac drainage scenarios, using a centrifugal pump and an experimental bench set-up (afterload 60 mmHg). At 1500, 2000 and 2500 RPM and atrial position, the Q values were 3.4, 6.03 and 8.01 versus 0.77*, 0.43* and 0.58* l/min: p<0.05* for wall-less and the Biomedicus(®) cannula, respectively. The corresponding pressure values were -15.18, -31.62 and -74.53 versus -46.0*, -119.94* and -228.13* mmHg. At the hepatic position, the Q values were 3.34, 6.67 and 9.26 versus 2.3*, 0.42* and 0.18* l/min; and the pressure values were -10.32, -20.25 and -42.83 versus -23.35*, -119.09* and -239.38* mmHg. At the renal position, the Q values were 3.43, 6.56 and 8.64 versus 2.48*, 0.41* and 0.22* l/min and the pressure values were -9.64, -20.98 and -63.41 versus -20.87 -127.68* and -239* mmHg, respectively. At the iliac position, the Q values were 3.43, 6.01 and 9.25 versus 1.62*, 0.55* and 0.58* l/min; the pressure values were -9.36, -33.57 and -44.18 versus -30.6*, -120.27* and -228* mmHg, respectivly. Our experimental evaluation demonstrates that the redesigned, virtually wall-less cannulas, allowing for direct venous drainage at practically all intra-venous orifices, outperform the commercially available control cannula, with superior flow at reduced suction levels for all scenarios tested.

Strokes in the anterior circulation: comparison between bridging and intravenous thrombolysis.

BACKGROUND AND PURPOSE: To compare safety and efficacy of bridging approach with intravenous (IV) thrombolysis in patients with acute anterior strokes and proximal occlusions. PATIENTS AND METHODS: Consecutive patients with ischemic anterior strokes admitted within a 4 h 30 min window in two different centers were included. The first center performed IV therapy (alteplase 0.6 mg/kg) during 30 min and, in absence of clinical improvement, mechanical thrombectomy with flow restoration using a Solitaire stent (StS); the second carried out IV thrombolysis (alteplase 0.9 mg/kg) alone. Only T, M1 or M2 occlusions present on CT angiography were considered. Endpoints were clinical outcome and mortality at 3 months. RESULTS: There were 63 patients in the bridging and 163 in the IV group. No significant differences regarding baseline characteristics were observed. At 3 months, 46% (n = 29) of the patients treated in the combined and 23% (n = 38) of those treated in the IV group had a modified Rankin scale (mRS) of 0-1 (P < 0.001). A statistical significant difference was observed for all sites of occlusion. In a logistic regression model, National Institute of Health Stroke Scale (NIHSS) and bridging therapy were independent predictors of good outcome (respectively, P = 0.001 and P = 0.0018). Symptomatic hemorrhage was documented in 6.3% vs 3.7% in the bridging and in the IV group, respectively (P = 0.32). There was no difference in mortality. CONCLUSIONS: Our results suggest that patients treated with a bridging approach were more likely to have minimal or no deficit at all at 3 months as compared to the IV treated group.

L'interdiction de discrimination en raison de la nationalité au sens de l'Accord sur la libre circulation des personnes

Au coeur même du premier paquet de sept accords bilatéraux conclu entre la Suisse et la Communauté européenne le 21 juin 1999, l'Accord sur la libre circulation des personnes (ALCP) vise à garantir la libre circulation et à faciliter la prestation de services sur le territoire des parties contractantes. Or la réalisation de ces objectifs dépend avant tout de la mise en oeuvre effective de l'interdiction de discrimination en raison de la nationalité consacrée par l'ALCP, véritable clé de voûte de l'Accord. Le présent ouvrage s'attache, dans un premier temps, à l'analyse du principe de libre circulation et à l'examen du fonctionnement de l'ALCP - examen portant notamment sur le rôle joué par la jurisprudence de la Cour de justice des Communautés européennes dans le cadre de l'interprétation de cet Accord (Partie I). Dans un second temps, cet ouvrage se penche sur la question centrale de l'interdiction de discrimination en raison de la nationalité (Partie II). Pour ce faire, il propose tout d'abord une définition de la notion de discrimination elle-même et détermine ensuite le champ d'application matériel et personnel des principales dispositions de l'ALCP interdisant les discriminations. Dans ce cadre, une attention toute particulière est accordée à la question de la potentielle portée horizontale de ces dispositions. Ensuite, l'ouvrage procède à une analyse complète des principes et dispositions susceptibles de limiter la portée de cette interdiction,avant de conclure par un examen détaillé des conséquences administratives et civiles induites par la présence d'un cas de discrimination effectif.