RESUMEN
Objective: Patients with profound cardiogenic shock may require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for circulatory support most commonly via the femoral vessels. The rate of cardiac recovery in this population remains low, possibly because peripheral VA-ECMO increases ventricular afterload. Whether direct ventricular unloading in peripheral VA-ECMO enhances cardiac recovery is unknown, but is being more frequently utilized. A randomized trial is warranted to evaluate the clinical effectiveness of percutaneous left ventricle venting to enhance cardiac recovery in the setting of VA-ECMO. Methods: We describe the rationale, design, and initial testing of a randomized controlled trial of VA-ECMO with and without percutaneous left ventricle venting using a percutaneous micro-axial ventricular assist device. Results: This is an ongoing prospective randomized controlled trial in adult patients with primary cardiac failure presenting in cardiogenic shock requiring peripheral VA-ECMO, designed to test the safety and effectiveness of percutaneous left ventricle venting in improving the rate of cardiac recovery. Conclusions: The results of this nonindustry-sponsored trial will provide critical information on whether left ventricle unloading in peripheral VA-ECMO is safe and effective.
RESUMEN
OBJECTIVE: Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking. DESIGN: We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%). RESULTS: Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005). CONCLUSION: In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.
Asunto(s)
Desbridamiento , Drenaje , Duodenoscopía , Páncreas/patología , Pancreatitis Aguda Necrotizante/cirugía , Adulto , Anciano , Brasil , Canadá , Desbridamiento/métodos , Drenaje/métodos , Duodenoscopía/métodos , Femenino , Alemania , Hospitales , Humanos , Hungría , India , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Necrosis , Países Bajos , Pancreatitis Aguda Necrotizante/mortalidad , Pancreatitis Aguda Necrotizante/patología , Estudios Prospectivos , Resultado del Tratamiento , Estados UnidosAsunto(s)
Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/prevención & control , Profilaxis Antibiótica/clasificación , Profilaxis Antibiótica/estadística & datos numéricos , Profilaxis Antibiótica/instrumentación , Atención Dental para Enfermos Crónicos/métodos , Atención Dental para Enfermos Crónicos , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/terapiaRESUMEN
We present a dynamical model of the processes involved in birdsong production, relating qualitatively its parameters with biological ones. In this way, we intend to unify the activity patterns of the muscles controlling the vocal organ with the resulting vocalization. With relatively simple paths in the parameter space of our model, we reproduce experimental recordings of the Chingolo sparrow (Zonotrichia capensis).