Development, Validation, and Comparison of a Novel Nociception/Anti-Nociception Monitor against Two Commercial Monitors in General Anesthesia

In this paper, we present the development and the validation of a novel index of nociception/anti-nociception (N/AN) based on skin impedance measurement in time and frequency domain with our prototype AnspecPro device. The primary objective of the study was to compare the Anspec-PRO device with two other commercial devices (Medasense, Medstorm). This comparison was designed to be conducted under the same conditions for the three devices. This was carried out during total intravenous anesthesia (TIVA) by investigating its outcomes related to noxious stimulus. In a carefully designed clinical protocol during general anesthesia from induction until emergence, we extract data for estimating individualized causal dynamic models between drug infusion and their monitored effect variables. Specifically, these are Propofol hypnotic drug to Bispectral index of hypnosis level and Remifentanil opioid drug to each of the three aforementioned devices. When compared, statistical analysis of the regions before and during the standardized stimulus shows consistent difference between regions for all devices and for all indices. These results suggest that the proposed methodology for data extraction and processing for AnspecPro delivers the same information as the two commercial devices.

Deficiency of Vitamin D, a Major Risk Factor for SARS-CoV-2 Severity

BACKGROUND

The SARS-CoV-2 outbreak started in March 2020 with more than 120,552,261 cases at present and having caused over 2,667,248 deaths worldwide at the time this paper was written. The clinical signs of SARS-CoV-2 infection are especially evident in the respiratory and cardiovascular systems. Patients can be asymptomatic or present mild respiratory symptoms to severe acute lung injury leading to multiorgan failure and death. The study aims to assess the levels of serum 25-hydroxyvitamin D (25-(OH)-D) in 20 hospitalized patients infected with SARS-CoV-2 and 20 deceased people and to analyze the influence of vitamin D status on the severity of their disease.

METHODS

The present study was conducted on 40 patients who tested positive for SARS-CoV-2 infection. They were divided into two groups: 20 patients admitted to the "Victor Babes" Hospital of Infectious Diseases and 20 postmortem cases autopsied at the Institute of Legal Medicine Timisoara, Romania. During the autopsy, blood and bronchial fluid samples were collected for the laboratory. Automate Viral RNA extraction was performed on the Maxwell 48 RSC Extraction System (Promega, USA) using the Maxwell RSC Viral Total Nucleic Acid Purification kit (Promega, USA). After RNA extraction, the samples were amplified on a 7500 real-time PCR (Applied Biosystems, USA) using the genesig® Real-Time PCR Assay 2G (Primer Design, UK).

RESULTS

The living and deceased patients selected for the research presented decreased vitamin D levels, which are associated with increased levels of D-dimers, C reactive protein (CRP), and interleukin-6 (IL-6). These patients had a severe form of the SARS-CoV-2 disease, which led to death.

CONCLUSIONS

We conclude that deficiency of vitamin D in patients infected with SARS-CoV-2 presents a major risk factor related to the evolution and severity of the disease.

Event-based fractional order control

The present study provides a generalization of event-based control to the field of fractional calculus, combining the benefits brought by the two approaches into an industrial-suitable control strategy. During recent years, control applications based on fractional order differintegral operators have gained more popularity due to their proven superior performance when compared to classical, integer order, control strategies. However, the current industrial setting is not yet prepared to fully adapt to complex fractional order control implementations that require hefty computational resources; needing highly-efficient methods with minimum control effort. The solution to this particular problem lies in combining benefits of event-based control such as resource optimization and bandwidth allocation with the superior performance of fractional order control. Theoretical and implementation aspects are developed in order to provide a generalization of event-based control into the fractional calculus field. Different numerical examples validate the proposed methodology, providing a useful tool, especially for industrial applications where the event-based control is most needed. Several event-based fractional order implementation possibilities are explored, the final result being an event-based fractional order control methodology.

P1266 Infectious endocarditis- still a diagnostic dilemma

INTRODUCTION

Infectious endocarditis is still a challenge with a high mortality and complication rate despite the progress made in its management.

DESCRIPTION OF CLINICAL CASE

A 58 years old female, with a history of mitral and aortic mechanical prosthesis for rheumatic valvular disease and mitral infectious endocarditis with Aggregatibacter Actinomycetemcomita due to an apical abscess was referred to our service for persistent fever.

The clinical examination revealed irregular mechanical prosthesis beats, with no heart murmurs and no signs of heart failure, but with a tender splenomegaly.

The laboratory tests showed an inflammatory syndrome, but no positive blood cultures. An extensive panel for endocarditis was negative for Coxiella burnetii, Brucella Spp, Legionella Spp, Mycoplasma Spp and for the immunology markers (rheumatoid factor, antinuclear antibodies and anti-cardiolipin antibodies)

ECG

AF, 88 bpm, PVC bigeminy, LBBB.

Infectious endocarditis was the most likely diagnosis considering the fever, the inflammatory syndrome, the presence of the mechanical valves and the history of endocarditis.

An echocardiography was performed that showed a non-dilated left ventricle with a preserved EF, no aortic prosthesis dysfunction, nor mitral; a dilated RV with normal function, moderate tricuspid regurgitation, no intracardiac masses and no pericardial effusion.

The TEE revealed no vegetation, no abscess or pseudoaneurysms and no dehiscence of the prosthetic valves.

The Endocarditis Team was reunited and empirical antimicrobial therapies with Amoxiciline, Gentamicine and Cloxaciline for 6 weeks, as well as a PET scan were recommended.

The PET-CT revealed abnormal fixation in the posterior-inferior part of the aortic valve.

As we had only one major criterion and two minor criteria for the diagnosis of endocarditis a radiolabeled leukocytes SPECT CT that showed no pathological fixation was realised. The result was inconclusive as it was performed at the end of the antimicrobial treatment.

A computed tomography of the brain, thorax, abdomen and pelvis didn’t reveal any vascular phenomena. The tender splenomegaly was secondary to two hemangiomas.

Also a dental computed tomography revealed an apical abscess of 1.2 that was treated after discharge with antibiotic prophylaxis.

DISCUSSION

This clinical case confirms that the diagnosis on infectious endocarditis can be challenging in patients with prosthetic valves. The multimodality imaging is of major importance for the diagnosis of these patients.

Additionally the microbiological criteria was not met in this case as it was a blood culture-negative endocarditis with a history of previous antibiotic therapy.

CONCLUSION

Our knowledge of infectious endocarditis is constantly evolving. Blood culture negative endocarditis accounts for one third of cases and is still a challenge. The Endocarditis Team and multimodality imaging play a central role in the diagnosis and treatment of these patients.

Abstract P1266 Figure. PET-CT showing AV abnormal fixation

Extensive Fatty Replacement of the Pancreas (Pancreatic Lipomatosis) in a Dog

A 12-year-old neutered female mixed-breed dog was referred for occasional vomiting that had increased progressively in frequency over the past 3 months. Palpation of the abdomen revealed a firm mass of unknown aetiology, located within the cranial to mid abdomen, while abdominal surgical exploration revealed a well-defined abdominal mass of pancreatic origin. The pancreatic mass caused lateral displacement of the duodenum as well as medial displacement of the pylorus, resulting in impairment of pyloric outflow. Further examination revealed a firm, poorly vascularized and coarsely lobulated structure. The histopathological findings were consistent with severe pancreatic lipomatosis and atrophy. Immunohistochemically, the remnant pancreatic cells were positive for cytokeratins AE1/AE3 and glucagon, and negative for insulin. Routine follow-up with the referring veterinarian showed no evidence of postoperative complications, but the dog continued to deteriorate further and died despite medical management. Pancreatic lipomatosis is a rare condition in small animal practice. The aetiology or predisposing factors have not been identified in animals.

Cardiovascular profiles of scleroderma patients with arrhythmias and conduction disorders

Introduction Arrhythmias and conduction disorders are common among patients with scleroderma. Their early identification is important, since scleroderma patients with arrhythmias have a higher mortality risk compared with scleroderma patients without arrhythmias. The aim of this study was to characterize the cardiovascular profiles of scleroderma patients with different types of arrhythmias and conduction disorders. Methods One hundred and ten consecutive patients with a diagnosis of systemic sclerosis according to the ACR criteria were included in the study. Patients underwent a 12-lead ECG and a 24-hour Holter ECG monitoring for arrhythmias and conduction disorders identification. Blood sample testing, echocardiography, spirometry, chest X-ray and, when considered appropriate, high resolution chest CT were also performed. A subgroup of 21 patients underwent NT-pro BNP level measurements. Patients' clinical and para-clinical characteristics were compared according to the presence or absence of arrhythmias and conduction disorders. Results The prevalence of arrhythmia and conduction disturbances was 60.9%. Patients with such disorders were older (54.4 ± 13.3 vs. 49.7 ± 10.1 years, p=0.05), had a higher prevalence of pulmonary hypertension (p=0.008), valve disease (p < 0.001), especially mitral and tricuspid regurgitation, chamber enlargement on echocardiography (left atrial and right ventricular, p = 0.012 and 0.005, respectively) as well as higher NT-pro BNP levels: 265.5 ± 399.7 vs. 163 ± 264.3 pg/ml, p=0.04. Conclusion Arrhythmias and conduction disorders are common in patients with scleroderma. Patients with such disorders are older, have a higher prevalence of pulmonary hypertension, more severe mitral and tricuspid regurgitation, left atrial and right ventricular dilation on echocardiography.

Podocyte-specific GLUT4-deficient mice have fewer and larger podocytes and are protected from diabetic nephropathy

Podocytes are a major component of the glomerular filtration barrier, and their ability to sense insulin is essential to prevent proteinuria. Here we identify the insulin downstream effector GLUT4 as a key modulator of podocyte function in diabetic nephropathy (DN). Mice with a podocyte-specific deletion of GLUT4 (G4 KO) did not develop albuminuria despite having larger and fewer podocytes than wild-type (WT) mice. Glomeruli from G4 KO mice were protected from diabetes-induced hypertrophy, mesangial expansion, and albuminuria and failed to activate the mammalian target of rapamycin (mTOR) pathway. In order to investigate whether the protection observed in G4 KO mice was due to the failure to activate mTOR, we used three independent in vivo experiments. G4 KO mice did not develop lipopolysaccharide-induced albuminuria, which requires mTOR activation. On the contrary, G4 KO mice as well as WT mice treated with the mTOR inhibitor rapamycin developed worse adriamycin-induced nephropathy than WT mice, consistent with the fact that adriamycin toxicity is augmented by mTOR inhibition. In summary, GLUT4 deficiency in podocytes affects podocyte nutrient sensing, results in fewer and larger cells, and protects mice from the development of DN. This is the first evidence that podocyte hypertrophy concomitant with podocytopenia may be associated with protection from proteinuria.

Inferior mesentericocaval shunt--an efficient therapeutical alternative in Budd Chiari syndrome associated with portal and splenic vein thrombosis in a teenager

The authors present the case of a 17 year old girl admitted to hospital for poor general state, mild scleral jaundice, deficient nutritional state, oliguria and massive ascites. She was diagnosed with Budd-Chiari syndrome: thrombosis of the left suprahepatic vein and nonocclusive thrombosis of the inferior vena cava at the level of the 12th thoracal and the lumbar vertebrae. The specific feature of the case was the association of portal and splenic vein thrombosis. A mesentericocaval shunt with external jugular grefon was performed. The evolution at 20 months after surgery has been favorable. She has no ascites, the nutritional state has normalized and hepatic laboratory findings have returned to normal values. There still persists a high consistency splenomegaly, but without hematological hypersplenism. Even though the mesentericocaval shunt is not without complications, it represents an efficient alternative for the treatment of Budd-Chiari syndrome, when endovascular techniques are not available.