Towards no-scar cardiac surgery - minimally invasive access through umbilicus for aortic valve replacement.

There is an ever-growing trend towards less-invasive procedures in all fields of medicine. We designed an animal study to prove the concept that trans-apical aortic valve replacement from an incision within the umbilicus through a single channel for instruments is feasible, which would be a major leap towards no-scar cardiac surgery. In three adult pigs, after creating a single 3-cm incision at a place where the human umbilicus would be, we introduced a 30F sheath through a tunnel created by an endoscopic vein-harvesting device up to the cardiac apex, through it and up to the left ventricle simulating the approach for trans-apical aortic valve replacement. We used a standard Amplatz nitinol occluder to seal the defect in ventricle wall later. The animals were followed up for 1h. Blood loss was minimal, and no tamponade occurred in any of the animals. In addition, we performed a test with water column static pressure to evaluate the impact of preclotting on the sealing properties of the occluders: 1 min flow-through was 2860+/-176 ml for the standard occluders and 348+/-56 ml for preclotted occluders (p<0.001).

Open minded and open access: introducing NeoBiota, a new peer-reviewed journal of biological invasions

The Editorial presents the focus, scope, policies, and the inaugural issue of NeoBiota, a new open access peer-reviewed journal of biological invasions. The new journal NeoBiota is a continuation of the former NEOBIOTA publication series. The journal will deal with all aspects of invasion biology and impose no restrictions on manuscript size neither on use of color. NeoBiota implies an XML-based editorial workflow and several cutting-edge innovations in publishing and dissemination, such as semantic markup of and enhancements to published texts, data publication, and extensive cross-linking within the journal and to external sources

Assessing High-Speed Internet Access in the State of Iowa, October 2000

Report for the Iowa Utilities Board and the Iowa Department of Economic Development

Assessing High-Speed Internet Access in the State of Iowa: Second Assessment, February 2002

Report for Iowa Utilities Board

Assessing High-Speed Internet Access in the State of Iowa: Third Assessment, May 2003

Report for the Iowa Utilities Board.

Suboptimal access to primary healthcare among street-based sex workers in southwest Switzerland.

OBJECTIVES: Street-based sex workers (SSWs) in Lausanne, Switzerland, are poorly characterised. We set out to quantify potential vulnerability factors in this population and to examine SSW healthcare use and unmet healthcare requirements. METHODS: We conducted a cross-sectional questionnaire-based survey among SSWs working in Lausanne's red light district between 1 February and 31 July 2010, examining SSW socio-demographic characteristics and factors related to their healthcare. RESULTS: We interviewed 50 SSWs (76% of those approached). A fifth conducted their interviews in French, the official language in Lausanne. 48 participants (96%) were migrants, of whom 33/48 (69%) held no residence permit. 22/50 (44%) had been educated beyond obligatory schooling. 28/50 (56%) had no health insurance. 18/50 (36%) had been victims of physical violence. While 36/50 (72%) had seen a doctor during the preceding 12 months, only 15/50 (30%) were aware of a free clinic for individuals without health insurance. Those unaware of free services consulted emergency departments or doctors outside Switzerland. Gynaecology, primary healthcare and dental services were most often listed as needed. Two individuals (of 50, 4%) disclosed positive HIV status; of the others, 24/48 (50%) had never had an HIV test. CONCLUSIONS: This vulnerable population comprises SSWs who, whether through mobility, insufficient education or language barriers, are unaware of services they are entitled to. With half the participants reporting no HIV testing, there is a need to enhance awareness of available facilities as well as to increase provision and uptake of HIV testing.

Intraoperative assessment of vascular access.

PURPOSE: The intraoperative quality assessment of the arteriovenous fistula for hemodialysis is an essential process to limit early failure due to technical problems or inadequate vascular quality. This step is not clearly defined in the literature with no recommendations. METHODS: We selected published articles related to the topic of intraoperative quality control of the vascular access for hemodialysis. RESULTS: The intraoperative blood flow measurement greater than 120 ml/min in autologous fistula and less than 320 ml/min in arteriovenous graft was described as predictive factors for early failure. CONCLUSIONS: The blood flow measurement should be performed after the confection of the anastomosis. When blood flow is limited, fistulography is an essential step to assess patency.

The Smartcanula: a new tool for remote access perfusion in limited access cardiac surgery.

Devices for venous cannulation have seen significant progress over time: the original, rigid steel cannulas have evolved toward flexible plastic cannulas with wire support that prevents kinking, very thin walled wire wound cannulas allowing for percutaneous application, and all sorts of combinations. In contrast to all these rectilinear venous cannula designs, which present the same cross-sectional area over their entire intravascular path, the smartcanula concept of "collapsed insertion and expansion in situ" is the logical next step for venous access. Automatically adjusting cross-sectional area up to a pre-determined diameter or the vessel lumen provides optimal flow and ease of use for both, insertion and removal. Smartcanula performance was assessed in a small series of patients (76 +/- 17 kg) undergoing redo procedures. The calculated target pump flow (2.4 L/min/m2) was 4.42 +/- 61 L/ min. Mean pump flow achieved during cardiopulmonary bypass was 4.84 +/- 87 L/min or 110% of the target. Reduced atrial chatter, kink resistance in situ, and improved blood drainage despite smaller access orifice size, are the most striking advantages of this new device. The benefits of smart cannulation are obvious in remote cannulation for limited access cardiac surgery, but there are many other cannula applications where space is an issue, and that is where smart cannulation is most effective.

The equity core and the Lorenz-maximal allocations in the equal division core

In this paper, we characterize the non-emptiness of the equity core (Selten, 1978) and provide a method, easy to implement, for computing the Lorenz-maximal allocations in the equal division core (Dutta-Ray, 1991). Both results are based on a geometrical decomposition of the equity core as a finite union of polyhedrons. Keywords: Cooperative game, equity core, equal division core, Lorenz domination. JEL classification: C71

Assessing High-Speed Internet Access in the State of Iowa: Fourth Assessment, December 2004

The primary objective of the Fourth Assessment is to evaluate the level of progress in the deployment of high-speed Internet technologies in the State of Iowa.

Dialogic learning and interactive groups: an IMS LD template integrated in runtime systems

Dialogic learning and interactive groups have proved to be a useful methodological approach appliedin educational situations for lifelong adult learners. The principles of this approach stress theimportance of dialogue and equal participation also when designing the training activities. This paperadopts these principles as the basis for a configurable template that can be integrated in runtimesystems. The template is formulated as a meta-UoL which can be interpreted by IMS Learning Designplayers. This template serves as a guide to flexibly select and edit the activities at runtime (on the fly).The meta-UoL has been used successfully by a practitioner so as to create a real-life example, withpositive and encouraging results

The transventricular-transseptal access to the aortic root : a new route for extrapleural trans-catheter aortic stent-valve implantation

Rapport de synthèseObjectif: le remplacement valvulaire aortique par voie transcathétère est, actuellement, une méthode fiable indiquée pour des patients à haut risque porteurs d'une sténose valvulaire aortique. La voie transfémorale est utilisable seulement en cas d'absence de maladie vasculaire et la voie transapicale est contrindiquée en cas de dysfonction pulmonaire chronique sévère. Une alternative pour ne pas passer a travers l'espace pleural serait par voie sous- xiphoïdienne et trans-septale à travers le ventricule droit.Méthode: une expérience animale a été amené au laboratoire de recherche du CHUV. Cinq cochons (poids : 52.3±10.9 kg) ont été endormi et, sous anesthésie générale, le ventricule droit a été préparé a travers un accès sous- xiphoïdien. Ensuite, sous guide fluoroscopique et avec l'utilisation d'une échocardiographie intracardiaque, un accès trans-septal a été crée entre le ventricule droit et le ventricule gauche en utilisant des dilatateur de diamètre croissant (de 8F à 26F). Par la suite, une valve stentée crée dans le laboratoire en utilisant un stent en nitinol et du péricarde a été chargé dans une cartouche et introduite dans le ventricule gauche à travers un introducteur trans-septal. Enfin, la valve a été amené dans la chambre de chasse du ventricule gauche et ensuite dans la racine aortique et puis déployé au bon endroit. Quand le système a été retiré, le septum ventriculaire a pu être réparé par mise en place d'un système d'occlusion septal Amplazer. Trente minutes après la procédure, les animaux ont été sacrifié et le coeur a été analysé pour étudier le positionnement da la valve stentée, l'efficacité de la fermeture du septum inter-ventriculaire et la fermeture de la paroi du ventricule droit.Résultat : les cinq cochon ont tous eu un parfait positionnement et pose de la prothèse en position aortique au premier essai (efficacité 100%). Les procédures ont duré, moyennement, 49±4 minutes et la progressive dilatation de l'accès trans-septale à donné lieu à une communication inter-ventriculaire mesurable après dilatation avec du 18F et plus. Toutes les valves stentées ont été déployées au bon endroit avec un bon résultat du fonctionnement des valves prothétiques et absence d'insuffisance para prothétique. Pendant les procédures, des battement prématurés ainsi que des épisodes isolées de tachycardie supra ventriculaire ont été détectés. Par contre, il n'y a pas eu de bloc atrio-ventriculaire. Les pertes sanguines pendant les procédures étaient de 280±10mL, et les systèmes d'occlusion Amplatzer étaient tous bien déployés sans shunts inter-ventriculaires résiduels.Conclusion: la technique d'introduction de valve stentées par voie extrapleural (trans-ventriculaire et trans-septale) est techniquement possible et elle jette les bases pour le remplacement valvulaire aortique trans-ventriculaire sous anesthésie locale.

Bloodstream infections related to totally implantable venous access port: What is the situation in our hospital?

Port-a-Cath© (PAC) are totally implantable devices that offer an easy and long term access to venous circulation. They have been extensively used for intravenous therapy administration and are particularly well suited for chemotherapy in oncologic patients. Previous comparative studies have shown that these devices have the lowest catheter-related bloodstream infection rates among all intravascular access systems. However, bloodstream infection (BSI) still remains a major issue of port use and epidemiology data for PAC-associated BSI (PABSI) rates differ strongly depending on studies. Also, current literature about PABSI risk factors is scarce and sometimes controversial. Such heterogeneity may depend on type of studied population and local factors. Therefore, the aim of this study was to describe local epidemiology and risk factors for PABSI in adult patients in our tertiary- care university hospital. We conducted a retrospective cohort study in order to describe local epidemiology. We also performed a nested case-control study to identify local risk factors of PABSI. We analyzed medical files of adult patients who had a PAC implanted between January 1st, 2008 and December 31st, 2009 and looked for PABSI occurrence before May 1st, 2011 to define cases. Thirty nine PABSI occurred in this population with an attack rate of 5.8%. We estimated an incidence rate of 0.08/1000 PAC-days using the case-control study. PABSI causative agents were mainly Gram positive cocci (62%). We identified three predictive factors of PABSI by multivariate statistical analysis: neutropenia on outcome date (Odds Ratio [OR]: 4.05; 95% confidence interval [CI]:1.05- 15.66; p=0.042), diabetes (OR: 11.53; 95% CI: 1.07-124.70; p=0.044) and having another infection than PABSI on outcome date (OR: 6.35; 95% CI: 1.50-26.86; p=0.012). Patients suffering from acute or renal failure (OR: 4.26; 95% CI: 0.94-19.21; p=0.059) or wearing another invasive device (OR: 2.99; 95%CI:0.96-9.31; p=0.059) did not have a statistically increased risk for developing a PABSI according to classical threshold (p<0.05) but nevertheless remained close to significance. Our study demonstrated that local epidemiology and microbiology of PABSI in our institution was similar to previous reports. A larger prospective study is required to confirm our results or to test preventive measures.