bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergent Bedside Resternotomy: An Innovative Simulation Model for Training Pediatric Cardiac Intensive Care Teams
Authors: Akinpelu Toluwani , Shah Nikhil R. , Alhendy Mohammed , Thangavelu Malarvizhi , Weaver Karen , Muller Nicole , McElroy James , Bhalala Utpal S.
Published: November 2022

Cardiac tamponade after cardiac surgery is a life-threatening event that requires simultaneous resuscitation and emergent resternotomy by the intensive care team. A simulated scenario using an innovative mannequin with sternotomy wound has the capability of reproducing cardiac arrest associated with postoperative tamponade. We evaluated the validity of this mannequin to investigate the confidence level and crisis resource management skills of the team during bedside resternotomy to manage postoperative cardiac tamponade. The simulation scenario was developed using the sternotomy mannequin for a pediatric cardiac intensive care unit (CICU) team. The case involved a 3-year-old male, intubated, and mechanically ventilated after surgical repair of congenital heart disease, progressing to cardiac arrest due to cardiac tamponade. We conducted a formative learner assessment before and after each scenario as well as a structured, video debriefing following each encounter. The simulation was repeated in a 6-month interval to assess knowledge retention and improvement in clinical workflow. The data were analyzed using student t-test and chi-square test, when appropriate. Of the 72 CICU providers, a significant proportion of providers (p < 0.0001) showed improved confidence in assessing and managing cardiac arrest associated with postoperative cardiac tamponade. All providers scored ≥3 for the impact of the scenario on practice, teamwork, communication, assessment skills, improvement in cardiopulmonary resuscitation, and opening the chest and their confidence in attending similar clinical situations in future. Most (96–100%) scored ≥3 for the perception on the realism of mannequin, the scenario, reopening the sternotomy, and level of stress. Time to diagnosis of cardiac tamponade (p = 0.004), time to the first dose of epinephrine (p = 0.045), and median number of interruptions to chest compressions (p = 0.006) all significantly decreased between the two sessions. Time to completion of resternotomy improved by 81.4 seconds; however, this decrease was not statistically significant. Implementation of a high-fidelity mannequin for postoperative cardiac tamponade simulation can achieve a realistic and reproducible training model with positive impacts on multidisciplinary team education.
A Clinical Mathematical Model Estimating Postoperative Urine Output in Children Underwent Cardiopulmonary Bypass for Congenital Heart Surgery
Authors: Baloglu Orkun , Ryan Shawn D. , Onder Ali M. , Rosen David , Mullett Charles J. , Munther Daniel S.
Published: November 2022

Objectives Our objective was to build a proof of concept of the clinical mathematical model estimating postoperative urine output (UOP) utilizing preoperative, intraoperative, and immediate postoperative variables in children who underwent cardiopulmonary bypass (CPB) for congenital heart surgery.

Methods This was a single-center, retrospective cohort study in a university-affiliated children's hospital. Patients younger than 21 years old who underwent CPB for congenital heart surgery and were postoperatively admitted to West Virginia University Children's Hospital's pediatric intensive care unit (PICU) between September 1, 2007 and June 31, 2013 were included in the study. Body surface area, CPB duration, first measured hematocrit, serum pH, central venous pressure, and vasoactive-inotropic score in the PICU were used to build the mathematical model. A randomly selected 50% of the dataset was used to calculate model parameters. A cross-validation was used to assess model performance.

Results A total of 256 patients met the inclusion criteria. The model was able to achieve mean absolute error of 1.065 mL/kg/h (95% confidence interval (CI): 1.062–1.067 mL/kg/h), root mean squared error of 1.80 mL/kg/h (95% CI: 1.799–1.804 mL/kg/h), and R2 of 0.648 (95% CI: 0.646–0.650) in estimating UOP in the first 32 hours of postoperative period.

Conclusions The mathematical model utilizing preoperative, intraoperative, and immediate postoperative variables may be a potentially useful clinical tool in estimating UOP in the first 32 hours postoperative period.
Bow Echo: surrounding memories of loss
Authors: Carlisle Maxine
Published: November 2022

This art review responds to Aziz Hazara's audio-visual work Bow Echo, exhibited in the Biennale of Sydney, 2020 at the Museum of Contemporary Art, Australia. Considering anechoic chambers and stifled sound, this review explores the individual experience of warfare in Afghanistan. By metaphorically associating natural storms with military devastation, this review pays close attention to the mechanics of tone and the choreography of movement within the video work. Overall, Hazara artfully merges digital technology and installation design to create an affecting environment in memoriam of lives lost.
Studies on a sinusoidally driven gas–liquid two-phase plasma discharge and its application to sterilization
Authors: Zhang Xinying , Fan Runze , Qi Miao , Zhao Xinyi , Zhang Jin , Xu Dehui , Yang Yanjie
Published: November 2022

Atmospheric pressure cold plasmas are widely used in the biomedical field as evidenced by developments in recent years. In this study, a quartz tube-guided gas–liquid two-phase discharge has been configured with a hollow needle-water structure. The power source for the device was sinusoidal, and switching between a gas–liquid miscible discharge and a pure gaseous discharge was simple. It was discovered that the gas–liquid discharge was beneficial in terms of reactant species generation and reaction efficiency in terms of processing water. The types of particles, the physicochemical properties, and the concentrations of reactive oxygen and nitrogen species in the discharge were studied spectroscopically. The discharge was discovered to have high levels of H2O2 and NO2−, and the activated water was proven to be effective at sterilizing samples that were contaminated with micro-organisms. Key experimental parameters including the driving voltage and the air flow rate were optimized to achieve the best sterilization conditions. The membrane potential changes in the treated bacteria were also studied to explore the causes of bacterial inactivation. The results showed that the device exhibited a strong bactericidal effect for the gas–liquid mixed phase discharge operating at 17 kV for 5 min with a gas flow rate of 0.3 SLM. In addition, the present device offers enhanced sterilization efficiency relative to the efficiency of conventional plasma sterilization equipment and, therefore, has a wide range of applications.
Characterization of electrode charges and forces in an electrohydrodynamic thruster
Authors: Kim Chul , Lee Seongwon , Lee Hyeon Gi
Published: November 2022

Corona discharge generates an electrohydrodynamic (EHD) flow and a reactive thrust between electrodes in the air. Although the theory for this thrust between two electrodes has been thoroughly developed, the mechanism responsible for the reactive forces acting on the electrode surfaces is not well understood. Here, we numerically and experimentally investigate these forces and the charges that generate them. The results show that the emitter and collector surface charges deviate from the equality of capacitive charges as the discharge initiates. As the applied voltage increases, the emitter surface charge maintains its initial onset value, while the collector surface charge and the volume charge between the electrodes linearly increase. In the same manner, the emitter and collector surface forces deviate from the equilibrium of action and reaction as the discharge initiates. As the circuit current increases, the emitter surface force maintains its initial onset value, while the collector surface force and the thrust linearly increase. In particular, we demonstrate an unconventional thrust-measuring method by installing a windshield in the rear of the thruster. The force exerted on the windshield is equal to a good approximation of the pure EHD thrust. Also, the difference between this force and the thrust measured without the windshield can be taken as the approximate drag force acting on the electrodes.
Reacting and non-reacting, three-dimensional shear layers with spanwise stretching
Authors: Palafoutas Jonathan L. , Sirignano William A.
Published: November 2022

A three-dimensional, steady, laminar shear-layer flow spatially developing under a boundary-layer approximation with mixing, chemical reaction, and imposed normal strain is analyzed. The purpose of this study is to determine conditions by which certain stretched vortex layers appearing in turbulent combustion are the asymptotic result of a spatially developing shear flow with imposed compressive strain. The imposed strain creates a counterflow that stretches the vorticity in the spanwise direction. Equations are reduced to a two-dimensional form for three velocity components. The non-reactive and reactive cases of the two-dimensional form of the governing equations are solved numerically, with consideration of several parameter inputs, such as the Damköhler number, the Prandtl number, chemical composition, and free-stream velocity ratios. The analysis of the non-reactive case focuses on the mixing between hotter gaseous oxygen and cooler gaseous propane. The free-stream strain rate κ* is predicted by ordinary differential equations based on the imposed spanwise pressure variation. One-step chemical kinetics are used to describe diffusion flames and multi-flame structures. The imposed normal strain rate has a significant effect on the width of downstream mixing layers as well as the burning rate. Asymptotically in the downstream direction, a constant width of the shear layer is obtained if the imposed normal strain rate is constant. The one-dimensional asymptotic result is an exact solution to the multicomponent Navier–Stokes equation for both reacting and non-reacting flows, although it was obtained using the boundary-layer approximation. A similar solution with the layer width growing with the square root of downstream distance is found when the imposed strain rate decreases as the reciprocal of downstream distance. The reduced-order asymptotic solutions can provide useful guidance in developing flamelet models for simulations of turbulent combustion.
Bulge formation of liquid film at the trailing edge: Scaling laws and particle removal assessment
Authors: Chiu Te-Yao , Fang Ho-Yo , Fu Hsueh-Hung , Niu Yang-Yao , Chou Yi-Ju
Published: November 2022

We present numerical simulations and laboratory experiments to study bulge formation at the trailing edge of an inclined surface and its inhibitory effect on particle removal during surface cleaning. We investigate the spatial variations in liquid films near the trailing edge and find that the Weber number can be used as a dominant parameter to determine bulge occurrence over the trailing edge. We divide the film region near the trailing edge at which the bulge occurs into two: the region where the surface linearly grows and the surface tension is negligible, and the region where the surface tension force becomes dominant and the film surface is curved. In the investigated cases in which the Reynolds number is O(10) or greater, the viscous forces are negligible, which allows for the derivation of the scaling laws for the length of the two regions according to the condition that the bulge height scales with the capillary length. In the resulting scaling law, the length scales depend on the Froude number and the inclination angle. The proposed scaling law allows for the prediction of the bulge shape and the prediction agrees with the simulation results, particularly at low Weber numbers (i.e., We < 0.5). Moreover, we construct a particle removability map to assess the removal of particles of different sizes at specific locations on the substrate. The map reveals a reduction of the removability for small-size particles or particles located in the bulge.
Addressing rheumatic fever inequities in Aotearoa New Zealand: a scoping review of prevention interventions
Authors: Tu’akoi Siobhan , Ofanoa Malakai , Ofanoa Samuela , Lutui Hinamaha , Heather Maryann , Jansen Rawiri McKree , Goodyear-Smith Felicity
Published: November 2022

Introduction Rheumatic fever is a preventable illness caused by untreated Group A Streptococcus (GAS) infection. Despite reductions in most high-income countries, rheumatic fever rates remain a concern in Aotearoa New Zealand. Pacific and Māori people are inequitably affected, with risk of initial hospitalisation due to rheumatic fever 12- and 24-fold more likely, respectively, compared to non-Māori and non-Pacific people. Aim This scoping review aims to explore the range of interventions and initiatives in New Zealand seeking to prevent GAS and rheumatic fever, with a particular focus on Pacific and Māori. Methods Databases Scopus, Medline, EMBASE and CINAHL, along with grey literature sources, were searched to broadly identify interventions in New Zealand. Data were screened for eligibility and the final articles were charted into a stocktake table. Results Fifty-eight studies were included, reporting 57 interventions. These targeted school-based throat swabbing, awareness and education, housing, secondary prophylaxis, improving primary care guidelines and diagnosis of sore throats and skin infections. Some interventions reported short-term outcomes of improvements in awareness, a reduction in rheumatic fever risk and fewer hospitalisations. Evaluation outcomes were, however, lacking for many initiatives. Pacific and Māori people primarily served only in an advisory or delivery capacity, rather than as partners in co-design or leadership from the beginning. Discussion Although positive outcomes were reported for some interventions identified in this review, rheumatic fever rates have not shown any long-term reduction over time. Co-designing interventions with affected communities could ensure that strategies are better targeted and do not contribute to further stigma.
Vocabulary size estimates for Lithuanian native speakers
Authors: Vilkaitė-Lozdienė Laura , Vilkienė Loreta
Published: November 2022

The vocabulary size estimates suggested for native speakers used to vary considerably. More recently, researchers using Yes/No tests reported numbers that are much closer together. This article seeks to answer the question of whether we can give an estimate of an adult native speaker’s vocabulary size without specifying a language. First, it presents the estimate for a native speaker’s vocabulary size in Lithuanian and explores its variation depending on the person’s age (ranging from 16 to 71 years old), place of residence, their reading for pleasure habits, and gender. Then it compares this estimate to the ones suggested for German, English, and Dutch native speakers. The analysis suggests that the estimates for different languages, at least the ones based on empirical data rather than statistical predictions, do not differ considerably.
Testing the impact of remote interpreting settings on interpreter experience and performance
Authors: Chmiel Agnieszka , Spinolo Nicoletta
Published: November 2022

This paper presents methodological challenges in a study focusing on the impact of remote interpreting settings on
interpreter experience and performance. In recent years, the practice of simultaneous interpreting has undergone a robust
development with the quick uptake of remote interpreting technologies due to the global pandemic. In order to investigate remote
interpreting, we created the Inside the Virtual Booth project encompassing a survey and an experimental study. We report on
selected results of the survey that directly inform the experimental study design. We focus on challenges related to the
compromise between experimental control and ecological validity, creation of materials and selection of dependent variables,
including eyetracking measures that cannot be directly applied from reading studies to a study involving multimodal content
typical for remote interpreting assignments. The paper may serve as a source of methodological guidance to scholars entering the
field of experimental translation and interpreting studies.
Fast absolute 3D CGO-based electrical impedance tomography on experimental tank data
Authors: Hamilton S J , Muller P A , Isaacson D , Kolehmainen V , Newell J , Rajabi Shishvan O , Saulnier G , Toivanen J
Published: November 2022

Objective. To present the first 3D CGO-based absolute EIT reconstructions from experimental tank data. Approach. CGO-based methods for absolute EIT imaging are compared to traditional TV regularized non-linear least squares reconstruction methods. Additional robustness testing is performed by considering incorrect modeling of domain shape. Main Results. The CGO-based methods are fast, and show strong robustness to incorrect domain modeling comparable to classic difference EIT imaging and fewer boundary artefacts than the TV regularized non-linear least squares reference reconstructions. Significance. This work is the first to demonstrate fully 3D CGO-based absolute EIT reconstruction on experimental data and also compares to TV-regularized absolute reconstruction. The speed (1–5 s) and quality of the reconstructions is encouraging for future work in absolute EIT.
Distinguishing reionization models using the largest cluster statistics of the 21-cm maps
Authors: Pathak Aadarsh , Bag Satadru , Dasgupta Saswata , Majumdar Suman , Mondal Rajesh , Kamran Mohd , Sarkar Prakash
Published: November 2022

The evolution of topology and morphology of ionized or neutral hydrogen during different
stages of the Epoch of Reionization (EoR) have the potential to provide us a great amount of
information about the properties of the ionizing sources during this era. We compare a variety of
reionization source models in terms of the geometrical properties of the ionized regions. We show
that the percolation transition in the ionized hydrogen, as studied by tracing the evolution
of the Largest Cluster Statistics (LCS), is a robust statistic that can distinguish the
fundamentally different scenarios — inside-out and outside-in reionization. Particularly, the
global neutral fraction at the onset of percolation is significantly higher for the inside-out
scenario as compared to that for the outside-in reionization. In complementary to percolation
analysis, we explore the shape and morphology of the ionized regions as they evolve in different
reionization models in terms of the Shapefinders (SFs) that are ratios of the Minkowski
functionals (MFs). The shape distribution can readily discern the reionization scenario with
extreme non-uniform recombination in the IGM, such as the clumping model. In the rest of the
reionization models, the largest ionized region abruptly grows only in terms of its third SF —
'length' — during percolation while the first two SFs — 'thickness' and 'breadth' — almost
remain stable. Thus the ionized hydrogen in these scenarios becomes highly filamentary near
percolation and exhibit a 'characteristic cross-section' that varies among the source
models. Therefore, the geometrical studies based on SFs, together with the percolation analysis
can shed light on the reionization sources.
Optimization of tracker configuration for the CEPC
Authors: Liang Hao , Zhu Yongfeng , Lai Pei-Zhu , Ruan Manqi
Published: November 2022

We investigate the tracker configuration optimization for the Circular Electron Position
Collider (CEPC), a proposed Higgs and Z factory. Fixing the construction cost comparable to that
of the baseline detector design and considering the benchmark channels (Z ⟶ ff̅, 
WW fusion with H ⟶ ff̅, ZH ⟶ ννff̅, and 
tt̅ ⟶ bb̅μνμud) of various operating modes of the CEPC, we obtain the
optimal tracker radius that provides the best average resolution of the track momentum or jet
energy. The optimal tracker radii for track momentum resolution range from 1.59 m to 1.73 m and
for jet energy resolution from 1.82 m to 1.97 m, depending on the benchmark channels. Compared
to the jets, the tracks prefer a smaller radius and a longer length because the track momentum
resolution degrades more significantly than jet energy resolution in the forward region. The
benchmark channel for Z-pole prefers a smaller radius and longer length compared to other
benchmark channels because the final state particles at the Z-pole have a more forward
distribution. We also analyze the scaling behavior of the optimal tracker configuration at
floating construction cost and observe a weak dependence.
Cryogenic front-end amplifier design for large SiPM arrays in the DUNE FD1-HD photon detection system
Authors: Brizzolari C. , Carniti P. , Cattadori C. , Cristaldo E. , de la Torre Rojo A. , Delgado M. , Falcone A. , Francis K. , Gallice N. , Gotti C. , Guarise M. , Montagna E. , Montanari A. , Pessina G. , Pozzato M. , Smolik J. , Terranova F. , Tomassetti L. , Verdugo de Osa A. , Warner D. , Zalesak J. , Zani A. , Zuklin J. , Zutshi V.
Published: November 2022

The photon detection system of the first far detector (FD1-HD) of the DUNE experiment will
detect scintillation photons produced by particle interactions in a kiloton-scale liquid Argon
time projection chamber. The photon detectors of choice are silicon photomultipliers (SiPM),
6×6 mm2 each, arranged in groups of 48, which present a significantly low
impedance to the front-end electronics. This paper details the design of a cryogenic amplifier
with exceptionally low white voltage noise of 0.37 nV√(Hz), based on a silicon-germanium
input transistor and a BiCMOS fully differential operational amplifier. It yields excellent
single photoelectron resolution even at low overvoltage values. The signal rise time is below 100 ns, and the dynamic range is about 2000 photoelectrons at the typical operating overvoltage. It
draws 0.7 mA from a single 3.3 V supply, for a power consumption of 2.4 mW
per channel. Simplified models were developed to predict the single photolectron signal shape and
the signal to noise ratio, with a good match to measured performance.
Propofol-induced interference with activated partial thromboplastin time–based monitoring of therapeutic heparin anticoagulation
Authors: Negaard Briana J , Hobbs Ryan , Frye Jared R , Merrill Anna E
Published: November 2022

Purpose

The activated partial thromboplastin time (aPTT) is a coagulation assay commonly utilized for monitoring therapeutic heparin anticoagulation. aPTT methods based on optical detection are vulnerable to spectral interference from hemolysis, icterus, lipemia, and other substances. Intravenous lipid emulsions of primarily 20% have been shown to interfere with multiple clinical laboratory assays, including those measuring aPTT by optical methods, but there is limited data on propofol’s effect. The primary objective of this study was to determine the rate of interference of propofol with aPTT measurements in patients receiving both propofol and intravenous heparin.

Methods

A retrospective observational cohort study of intensive care unit patients who received concomitant propofol and heparin infusions (N = 38 patients) and whose heparin therapy was monitored by aPTT (N = 531 aPTTs) was conducted. Review of the electronic medical record was completed to obtain relevant clinical and laboratory data, while the laboratory information system was queried for analytical interference with the aPTT assay.

Results

A total of 109 aPTTs (21%) spanning 21 patients (55%) had documented aPTT interference. All 21 patients had at least one aPTT requiring ultracentrifugation prior to reporting, and 12 aPTTs from 4 patients were unreportable due to interference. Patients with and without aPTT interference received similar doses of propofol. None of the cases of aPTT interference were caused by hemolysis or hyperbilirubinemia.

Conclusion

A potential medication-assay interaction was observed in approximately half of patients who received concomitant propofol and heparin infusions and had aPTT measured for anticoagulation management. Sample ultracentrifugation removes the optical interference in most cases but significantly prolongs aPTT reporting and delays appropriate adjustments to heparin dosing.
An Institutional Perspective to Understand Latin America’s High Levels of Homicide
Authors: Croci Gonzalo , Chainey Spencer
Published: November 2022

Numerous studies have suggested that socio-economic structural factors offer the main reasons for international variations in homicide levels—where socio-economic conditions are better, lower levels of homicide are observed. In countries in Latin America, social and economic conditions have improved, yet high levels of homicide have remained. In this article, we examine a new line of reasoning, hypothesizing that the effectiveness of institutions (such as government justice agencies and the police) and poor controls for corruption are key factors for explaining the high levels of homicide in Latin America. We apply a random effects panel regression using a sample of 54 countries from Latin America and other parts of the world, and data for a 13-year period (2005–2017). We examine the relationships between homicide, government effectiveness, corruption and several structural variables to determine if the relationships between these variables are more apparent for countries in the Latin American region. We find that structural factors play less of a role in explaining the international variation in homicide levels, and that government effectiveness and corruption are significantly related to the high levels of homicide experienced in the Latin America region.
The Floating Signifier of ‘Safety’: Correctional Officer Perspectives on COVID-19 Restrictions, Legitimacy and Prison Order
Authors: Schultz William J , Ricciardelli Rosemary
Published: November 2022

The COVID-19 pandemic continues to affect prisons internationally. Existing research focuses on infection data, meaning we do not fully understand how COVID-19 shapes frontline prison dynamics. We draw on qualitative interviews with 21 Canadian federal correctional officers, exploring how the pandemic impacted prison management. Officers suggested inconsistent messaging around COVID-19 protocols reduced institutional and officers’ self-legitimacy, fracturing trust relationships with incarcerated people. Furthermore, officers suggest that personal protective equipment such as gowns and face shields took on multiple meanings. We use Lévi-Strauss’ floating signifier concept to analyse how individual definitions of ‘safety’ informed day-to-day prison routines. We conclude by arguing that legitimacy deficits and contested definitions of ‘safety’ will continue to create uncertainty, impacting prison operations going forward.
Exosome-transmitted S100A4 induces immunosuppression and non-small cell lung cancer development by activating STAT3
Authors: Wu Xu , Zhang Hui , Jiang Gang , Peng Minlian , Li Cheng , Lu Jiaxin , Jiang Shiyin , Yang Xiaoping , Jiang Yongliang
Published: November 2022

Non-small cell lung cancer (NSCLC) is the primary reason of tumor morbidity and mortality worldwide. We aimed to study the transfer process of S100A4 between cells and whether it affected NSCLC development by affecting STAT3 expression. First, S100A4 expression in NSCLC cells was measured. The exosomes in MRC-5, A549, and H1299 cells were isolated and identified. We constructed si-S100A4 and si-PD-L1 to transfect A549 cells and oe-S100A4 to transfect H1299 cells, and tested the transfection efficiency. Cell function experiments were performed to assess cell proliferation, clone number, apoptosis, cell cycle, migration, and invasion abilities. In addition, ChIP was applied to determine the targeting relationship between S100A4 and STAT3. Next, we explored NSCLC cell-derived exosomes role in NSCLC progress by transmitting S100A4. Finally, we verified the function of exosome-transmitted S100A4 in NSCLC in vivo. High expression of S100A4 was secreted by exosomes. After knocking down S100A4, cell proliferation ability was decreased, clones number was decreased, apoptosis was increased, G1 phase was increased, S phase was repressed, and migration and invasion abilities were also decreased. ChIP validated STAT3 and PD-L1 interaction. After knocking down S100A4, PD-L1 expression was decreased, while ov-STAT3 reversed the effect of S100A4 on PD-L1 expression. Meanwhile, S100A4 inhibited T-cell immune activity by activating STAT3. In addition, knockdown of PD-L1 inhibited cell proliferation, migration, and invasion. NSCLC cell-derived exosomes promoted cancer progression by transmitting S100A4 to activate STAT3 pathway. Finally, in vivo experiments further verified that exosome-transmitted S100A4 promoted NSCLC progression. Exosome-transmitted S100A4 induces immunosuppression and the development of NSCLC by activating STAT3.
An aggressive solution for patients with heart failure and atrial fibrillation: nodal ablation and cardiac resynchronization therapy
Authors: Bianchi Stefano , Corradetti Sara
Published: November 2022

Heart failure and atrial fibrillation are two diseases that often coexist and contribute to worsening the prognosis and quality of life of patients. Managing this situation is still a challenge today. The ablation of the atrioventricular node associated with cardiac resynchronization therapy (CRT) fits into this context as a definitive but effective solution. Indeed, long-term positive results have been demonstrated in patients with atrial fibrillation ineligible for ablation and refractory to medical therapy in terms of symptom reduction and, more recently, also mortality. Furthermore, the role of this strategy in obtaining adequate biventricular pacing in patients who may benefit from CRT but are ineligible due to the presence of atrial fibrillation is being highlighted.
Echocardiography strain: why is it used more and more?
Authors: Cameli Matteo
Published: November 2022

In the last decade, speckle tracking echocardiography (STE) has acquired a fundamental role in the evaluation of the systolic function of the left ventricle, with several advantages over the Doppler method, including angle independence, greater reproducibility, and rapidity of image acquisition. Speckle tracking finds application in various pathologies, ranging from ischaemic heart disease, to cardiomyopathies, to heart failure, both with reduced and preserved ejection fraction (EF), in which the EF is not a reliable prognostic marker and the estimate of left ventricular function by means of ‘strain’ is of crucial utility. In addition, the strain of the left atrium finds application in many clinical contexts as an early index of diastolic dysfunction and left ventricular filling pressures. Finally, the strain of the right ventricle is of particular prognostic importance in the evaluation of heart failure, particularly in its advanced form, becoming an indispensable index in the evaluation of patients who are candidates for advanced therapeutic strategies. This document aims to describe the various fields of clinical application of STE, with particular emphasis on its diagnostic and prognostic role, so much that it is now integrated into the algorithms for managing multiple pathologies in daily clinical practice.
Therapeutic uncertainties: first finding of atrial fibrillation in acute coronary syndrome
Authors: Greco Antonio , Capodanno Davide
Published: November 2022

Atrial fibrillation (AF) and coronary artery disease share several risk factors and their simultaneous presentation in the same patient, sometimes in the course of acute coronary syndrome (ACS), is not a rare occurrence. Patients with AF and ACS represent an important clinical challenge in terms of diagnosis, prognosis and therapy. From a diagnostic point of view, AF may be new onset as a complication of ACS, or a pre-existing asymptomatic AF that is occasionally diagnosed during ACS. Regarding the prognosis, AF, whether new onset or already known, has been shown to exert a negative prognostic impact during ACS. Finally, the main therapeutic dilemma concerns the selection of the optimal antithrombotic therapy, which, at least in the first period following ACS, would require the combination of anticoagulant and antiplatelet drugs, with a consequent increase in the risk of bleeding complications. Several randomized studies have evaluated the therapeutic options in patients with AF and coronary artery disease, overall showing the advantage of a dual therapy with an antiplatelet and an anticoagulant compared with a long-term triple therapy with dual antiplatelet and anticoagulant therapy; the analyses of the ACS subgroups of these randomized studies confirmed such results also in the acute setting.
The many NOs to the use of Class IC antiarrhythmics: weren’t the guidelines too strict?
Authors: Turturiello Dario , Cappato Riccardo
Published: November 2022

Class IC antiarrhythmic drugs (AADs) currently represent a cornerstone in the therapy of atrial fibrillation, both for the restoration of sinus rhythm and for the prophylaxis of long-term relapses. They also play an important role in the treatment of idiopathic ventricular arrhythmias. Following the results of the Cardiac Arrhythmia Suppression Trial study, flecainide and by extension the other Class IC AADs were contraindicated in patients with ischaemic and structural heart disease, due to their pro-arrhythmic effect and the consequent increase in mortality observed in the study. Recent studies carried out on patients with chronic coronary heart disease without previous heart attacks and/or residual ischaemia have shown a good safety profile for this class of drugs. In addition, other studies have shown excellent efficacy in the absence of pro-arrhythmic effects of Class IC AADs in patients with structural heart disease such as arrhythmogenic right ventricular cardiomyopathy (ARVC) and tachy-cardiomyopathy. The purpose of this review is to evaluate the appropriate use of Class IC AADs in the different patient subgroups, in the light of the evidence and new diagnostic and therapeutic tools available.
Clinical implications of cardiac magnetic resonance imaging fibrosis
Authors: Guglielmo Marco , Pontone Gianluca
Published: November 2022

Cardiac magnetic resonance (CMR) is a non-invasive imaging method that allows to characterize myocardial tissue. In particular, using the late gadolinium enhancement technique, it is possible to identify areas of focal fibrosis. Specific distribution patterns of this fibrosis allow us to distinguish ischaemic cardiomyopathy (iCMP) from non-ischaemic cardiomyopathy (nCMP) and sometimes to identify the aetiology of the latter. Diffuse fibrosis can also be identified using the parametric T1 mapping sequences. For this purpose, the native T1 of the tissue is measured before the administration of the contrast agent (c.a.) or the extracellular volume is calculated after c.a. Both focal and diffuse fibrosis evaluated with CMR appear to be strong prognostic predictors for the identification of threatening ventricular arrhythmias and sudden cardiac death. These evidence open the doors to a possible role of CMR in the selection of the patient to be sent to a defibrillator implant in primary prevention. In this review, we will briefly review the techniques used in CMR for the evaluation of fibrosis. We will then focus on the clinical role of myocardial tissue fibrosis detection in iCMP and nCMP.
When to set anticoagulant therapy in asymptomatic AF? looking for a cut-off duration
Authors: Rossini Roberta , Peirone Andrea
Published: November 2022

The incidence of atrial fibrillation (AF) is progressively increasing, in line with the aging of the population and with the increase in chronic diseases. The care burden of the disease and above all to its consequences (i.e. ischaemic stroke and heart failure) significantly impacts the various health systems with forecasts of exponential increase in the near future. Clinical forms of AF, i.e. those diagnosed with electrocardiogram, have a clear correlation with systemic embolic events and also with a reduction in survival. Thromboembolic prophylaxis in these patients, with anticoagulant drugs, has in fact been shown to greatly reduce the incidence of ischaemic stroke and improve survival. In recent decades, the widespread use of therapeutic intra-cardiac devices, which allow constant and continuous monitoring of myocardial electrical activity, is bringing to light a large number of atrial high rate episodes (AHREs), which are not associated with clinical manifestation. The incidence of these findings grows linearly with the duration of the observation. More independent studies have shown that AHREs are associated with a risk of stroke that is higher (about double) than controls but significantly lower than in patients with manifest AF. However, taking into consideration patients with ischaemic stroke and wearers of implantable devices, no temporal correlation emerged between the incidence of the ischaemic episode and arrhythmia. The presence of AHRE is associated with an approximately six-fold increase in the incidence of clinical AF but only a minority of these patients meet the criteria for prescribing anticoagulation. Pending the publication of the studies still in progress, the European Society of Cardiology guidelines for the treatment of AF recommend considering the initiation of anticoagulant therapy in patients with long-lasting AHRE (> 24 h) associated with a high embolic risk. In patients with episodes of shorter duration (1–24 h), especially if with high burden, anticoagulant therapy can be considered in case of very high embolic risk (e.g. secondary prevention, CHADVASc ≥ 3).
Selection of patients eligible for implantable cardioverter defibrillator: beyond left ventricular ejection fraction
Authors: Rizzello Vittoria
Published: November 2022

The selection of patients eligible for implantable cardioverter defibrillator (ICD), in primary prevention, is a critical moment in the management of the patients with cardiomyopathies as it needs a right balance of the patients’ arrhythmic risk and the risks related to the implantation, as well as the device costs. Several data indicate that left ventricular ejection fraction alone is not a sufficient criterion for a proper identification of patients who could benefit most from ICD. Numerous findings show that genetic analysis and characterization of myocardial fibrosis with magnetic resonance imaging allow an important improvement of this process.
The enigma of resistant hypertension: from lifestyle changes and pharmacological treatment to renal denervation
Authors: Volpe Massimo , Gallo Giovanna
Published: November 2022

Resistant hypertension consists in the failure to achieve effective control of blood pressure despite the use of at least three drugs, including a diuretic, at the maximum tolerated dosage. Despite the progress made in terms of improving awareness and effectiveness of the available therapeutic strategies, the percentage of patients with resistant hypertension represents up to 18% of the entire hypertensive population. The management of resistant hypertension includes the combination of different strategies from lifestyle changes to complex interventional procedures. Lifestyle interventions include reducing salt intake, weight loss, quitting smoking and alcohol consumption, and performing aerobic physical activity. With regard to drug therapy, international guidelines recommend the introduction of a mineralocorticoid receptor antagonist or, if not tolerated, of a loop diuretic, or of the beta-blocker bisoprolol, or of the alpha-blocker doxazosin. In the last few years, promising results have been obtained from studies that have evaluated the efficacy and safety of the denervation of the renal arteries by ablation. This procedure may constitute an increasingly widespread option for those patients suffering from resistant hypertension despite the use of different drug classes, or who are intolerant or poorly adherent to medical therapy.
Surgical approach to combined mitral and tricuspid valve disease: good neighbourhood rules
Authors: Ascione Guido , Carino Davide , Alfieri Ottavio
Published: November 2022

Tricuspid regurgitation afflicts more than one-third of patients with mitral valve disease during their clinical history, and negatively affects their outcomes, increasing mortality and hospitalizations for heart failure and reducing the quality of life. A renewed interest in the ‘neglected valve’ has increased the frequency of the combined treatment of these two diseases. Undoubtedly necessary in patients with degenerative mitral valve disease in the presence of two severe valve defects, tricuspid annuloplasty has proven to be safe and effective even if performed prophylactically, when tricuspid annular dilation coexists with primary mitral dysfunction. In the absence of survival benefits, however, this additional surgical procedure increases the risk of high-grade atrio-ventricular blocks and the need for a definitive pacemaker. On the other hand, the role of surgery has been scaled down in patients with functional mitral and tricuspid regurgitation. In this context, a multidisciplinary approach is needed and transcatheter alternatives are increasingly the chosen treatment option. A new therapeutic algorithm is therefore looming on the horizon. In the future, the treatment of tricuspid and mitral valve disease may be considered two potentially distinct and successive phases of an integrated heart failure patients care process.
Transcatheter mitral valve replacement: there is still work to be done
Authors: Bartorelli Antonio L , Monizzi Giovanni , Mastrangelo Angelo , Grancini Luca , Fabbiocchi Franco , Conte Edoardo , Moltrasio Marco , Andreini Daniele
Published: November 2022

Transcatheter mitral valve replacement (TMVR) is a novel therapeutic option for patients with severe mitral regurgitation (MR) at high or prohibitive surgical risk. Most TMVR technologies under investigation use either a trans-apical or a trans-septal approach via dedicated multistep anchoring systems. Transcatheter mitral valve replacement offers several potential advantages over transcatheter repair, notably a greater and more sustained MR reduction. At the same time, significant engineering challenges and potential disadvantages must be acknowledged. Preclinical and clinical studies have shown promising results, demonstrating TMVR feasibility. Nevertheless, further development, testing, and trials are needed before considering TMVR as a definitive therapeutic option for MR in a wide range of anatomical scenarios.
Why can primary angioplastics be ineffective despite the precocity of the intervention?
Authors: Patti Giuseppe , Ghiglieno Chiara
Published: November 2022

Early coronary revascularization is a first choice therapeutic strategy in the case of acute myocardial infarction (MI). Despite an early coronary angioplasty, however, in some cases, there is a lower efficacy of revascularization, with less favourable clinical outcome in the short and long terms. Various elements participate in the distant prognosis after primary coronary angioplasty (PCI). Among the clinical risk factors that predispose to a recurrence of ischaemic cardiovascular events are advanced age, diabetes mellitus, chronic renal failure, peripheral vascular disease, atrial fibrillation and the multiplicity of cardiovascular risk factors, which identify a higher baseline risk profile. The risk factors associated with the percutaneous interventional procedure include the presence of diffuse or complex coronary lesions, the use of small diameter stents or a suboptimal post procedural thrombolysis in MI flow. The occurrence of procedural complications, such as no-reflow, is in fact associated with an increase in the infarct area and a worse prognosis, as it favours negative ventricular remodelling. The presence of concomitant right ventricular dysfunction, the high ventricular arrhythmic burden in the acute phase, the presence of risk factors for thrombosis or intra-stent restenosis also affect the outcome after primary PCI.
The point on the electronic cigarette more than 10 years after its introduction
Authors: Spoladore Roberto , Daus Francesca , Pezzini Sara , Milani Martina , Limonta Antonella , Savonitto Stefano
Published: November 2022

Electronic cigarettes (e-cigarettes) are battery-powered devices containing a liquid based on propylene glycol or vegetable glycerin, compounds which, when vaporized, act as a vehicle for nicotine, flavours, and other chemical components. These devices have been marketed without clear evidence of risks, long-term safety, and efficacy as a means of traditional smoking cessation. Recent clinical studies have shown how the use of the e-cigarette, combined with adequate psychological support, can be effective in reducing traditional smoking but not nicotine addiction. However, meta-analyses of observational studies have not confirmed this efficacy. Several studies have also highlighted an increase in sympathetic tone, vascular stiffness, and endothelial dysfunction, all factors associated with an increased cardiovascular risk. Clinicians, therefore, should carefully monitor the possible risks to public health deriving from the use of e-cigarettes and should discourage non-smokers and adolescents from using such devices. Finally, particular attention should be paid to smokers so that the combined use of electronic and traditional cigarettes can be limited as much as possible.
Cardiology of the future: xenotransplantation with porcine heart
Authors: Sinagra Gianfranco , Pagura Linda , Radesich Cinzia , Gagno Giulia , Cannata’ Antonio , Barbisan Davide , Cittar Marco , Paldino Alessia , Perotto Maria , Mase’ Marco , Dal Ferro Matteo , Mazzaro Enzo , Merlo Marco
Published: November 2022

The reduced availability of human donor hearts compared with the needs of patients with advanced heart failure refractory to medical therapy has promoted the search for therapeutic alternatives to cardiac allografts. Porcine heart xenotransplantation represents one of the most promising frontiers in this field today. From the first researches in the 1960s to today, the numerous advances achieved in the field of surgical techniques, genetic engineering and immunosuppression have made it possible at the beginning of 2022 to carry out the first swine-to-human heart transplant, attaining a survival of 2 months after surgery. The main intellectual and experimental stages that have marked the history of xenotransplantation, the latest acquisitions in terms of genetic editing, as well as the improvement of immunosuppressive therapy are discussed analytically in this article in order to illustrate the underlying complexity of this therapeutic model.