Abstract Background In patients with non-communicating hydrocephalus impairment of cerebral compliance can occur pre- but also intraoperatively. Methodology In such patients (n = 6) undergoing endoscopic third ventriculostomy (ETV), the present study aimed to investigate the effect of ETCO2 (e.g 40 mmHg and 60 mmHg) and positive end-expiratory pressure (PEEP) (e.g. 6 cm and 12 cm H2O) on intraventricular pressure (IVP). Findings Before but not after ETV, hypercapnia in contrast to PEEP increased IVP (before ETV (PEEP-6/ ETCO2-40: 2.6 ± 2.4 mmHg) vs. (PEEP-6/ ETCO2-60: 12 ± 6.4 mmHg*); (PEEP-12/ ETCO2-40: 4.2 ± 4.1 mmHg) vs. (PEEP-12/ ETCO2-60: 13.7 ± 7.6 mmHg*), * significant, P ≤ 0.05; after ETV (PEEP-6/ ETCO2-40: 2.0 ± 1.2 mmHg) vs. (PEEP-6/ ETCO2-60: 4.4 ± 3.1 mmHg); (PEEP-12/ ETCO2-40: 1.6 ± 1.3 mmHg) vs. (PEEP-12/ ETCO2-60: 6.6 ± 2.6 mmHg), * significant, P ≤ 0.05). Conclusion Patients with non-communicating hydrocephalus showed that hypercapnia but not PEEP increases significantly IVP before but not after ETV.

Abstract Background Bispectral index (BIS) monitoring of depth of anesthesia has pioneered the field for more recent monitoring devices like the A-line ARX Index (AAI) or the state (SE) and response entropy (RE) monitoring devices. Following an observational design the present study aimed to simultaneously compare in the same patient recorded BIS, AAI and entropy values. Methods Data from patients (n = 32) undergoing minor gynecological operations were analyzed. For all patients, standardized anesthesia was used. Before induction of anesthesia AEP electrodes, BIS and entropy sensors were simultaneously placed on the forehead and recordings were started at 3 minutes before induction and continued until patient transfer to the postanesthesia care unit. Markers were set at defined landmarks. Results Anesthesia reduced mean BIS, AAI and entropy values. During uneventful, and even more pronounced, during eventful anesthesia BIS/ entropy and BIS/ AAI values showed better correlation than did AAI and entropy values. The prediction probability (Pk) of AAI (0.824 ± 0.036) and RE (0.786 ± 0.040) or SE (0.781 ± 0.040) for preanesthesia awake, postanesthesia awake or anesthesia was comparable and significantly greater than that of BIS (0.705 ± 0.047). However, only 20% of BIS, AAI and entropy values simultaneously categorized the state of the patient as awake, inadequate anesthesia, optimal anesthesia or deep anesthesia. Conclusion The prediction probability (Pk) of entropy and AAI was comparable and better than that of BIS. However, agreement between BIS, AAI and entropy measurements on patient state was poor.

Lignin foams are innovative materials obtained by the copolymerization of furanics with the spent liquor from the magnefite wood pulping process. In this study, the influence of the component amount in the formulation, as well as the effect of temperature on the final product, were elucidated. Several formulations, with various lignin/furanic ratios, blowing agents, and catalyst concentrations, exhibited good homogeneity and densities between 185 and 407 kg m(-3). The mechanical properties, as well as the thermal conductivities, confirmed the strong dependence on density, and the results obtained were comparable to that of tannin foams. The leaching tests revealed that the lignin foams released a certain amount of catalyst within the first minutes of water dipping. However the pH of this leachate stabilized quickly, which suggests that the catalyst can be easily recovered.

In the last years many studies were led to characterise and optimise the tannin-furanic foams. In the present work the up-scaling of the production from laboratory to industrial scale is discussed. The tannin foams produced in an industrial pilot plant have shown comparable properties with the laboratory-produced foams. In particular the panels manufactured in the continuous press presented slightly higher bulk densities of around 176 kg/m3 (+20%) which led to higher mechanical properties and thermal conductivities. The up-scaled tannin foams of around 150 kg/m3 presented 20–25% enhanced compression resistances (28 MPa) and thermal conductivities (55 mW/m × K). Lightweight sandwich panels with various side layers were produced directly in the press, without the need of external adhesives. From the marketing viewing angle, the up-scaled tannin foams show higher densities than the other commercial synthetic insulation materials but the mechanical and insulating performances observed are promising and suggests interesting industrial developments for this innovative bio-based product.

Tannin foams are innovative materials obtained exploiting the capacity of tannin for undergoing poly-addition reactions and that of furfuryl alcohol to polymerize under acid catalysis. These materials are known for many years, but only recently they have been systematically studied and many of its properties have been evaluated. The first generation of the tannin foams have shown good insulation properties and very significant resistance against fire but unfortunately they were produced with around 5% of formaldehyde needed for keeping the network stable and variable amounts of diethyl ether for allowing the blowing at room temperature. These two drawbacks have hindered the development of the foam for industrialization because formaldehyde is almost completely forbidden for inner application while diethyl ether is an easy-burning VOC. In this study an important upgrading of the original formulation is presented. The synthesis of 100% natural formulation only catalyzed by heat is described. Due to this innovative approach, the toxic chemicals have been replaced with other bio-based resources so that the interest of the insulation industry is arisen again. In particular, these second generation of foams have confirmed many of the properties of the first generation one with the significant advantages of being easily exploited as core material for many a wide range lightweight sandwich panels. The versatility of the new tannin-furanic formulations allows to produce composite materials with a broad set of decking materials according to performance required for the specific final application.

Formaldehyde-free tannin-based furanic foams were prepared by applying infrared radiation (IR) as an alternative energy source. Up to now, tannin-based rigid foams have been produced via heat conduction or microwave radiation energy. The present innovative heating system allows for the production of extra-light products with low density (≤ 50 kg/m³). The IR-produced lightweight tannin foams (IR-TF) exhibited similar properties to those made by hot pressing (HP-TF), but IR-TF can be synthesized with much shorter production time. Although microwave-produced foams (MW-TF) can be obtained with even shorter production times, the IR-TFs are much more homogeneous. Therefore, the IR radiation-based process resulted in the most suitable compromise between foam properties and production time. Overall, IR-TF showed very competitive structural characteristics, such as high homogeneity, high porosity, and limited orthotropicity, which was similar to that shown by the hot press-produced foams. The mechanical properties and material costs are rather similar, but the production time for IR-TF is considerably shorter.

A new method to produce formaldehyde-free tannin-based furanic foams has been developed. The use of microwaves as energy source allows homogeneous tannin foams to be produced in a very short time. In this paper the main characteristics of these foams are investigated and compared to the state of the art. It has been seen that the microwave production allows a high degree of repeatability in terms of bulk density. The microwave-produced foams have shown similar features to the previous tannin-furanic foams produced in the hot-press or in the oven. The high water affinity of these materials has allowed the study of partial recovering of the catalystwhile the increased fire resistance of the tannin-furanic foams leads to the assumption that there is an important effect onthe degree of polymerization in the fire resistance of these innovative, natural materials.

In cancer therapy novel concepts focus on phosphoinositide-3-kinase/protein kinase B/mammalian target of rapamycin (mTOR) inhibitors. In this context, phosphorylated S6 protein of the 40S ribosomal subunit (pS6) overexpression was previously shown to be associated with sensitivity to inhibitors of mTOR. The present study therefore evaluated pS6 expression in normal renal parenchyma (NRP), primary renal cell carcinomas (PRCC) and their metastases. pS6 and pmTOR expression was immunohistochemically analyzed in a tissue microarray (TMA) from localized primary renal cell carcinoma (lPRCC) (n=35), metastasized primary renal cell carcinoma (mPRCC) (n=45), their metastases (n=45), and NRP (n=45). pS6 expression was stronger in mPRCCs and metastases than in NRP and lPRCCs (p<0.05). In mPRCCs high-grade and high-stage tumors showed higher pS6 levels. pS6 overexpression was more frequently found in metastases (40/45; 88.9%) than in mPRCC (24/45; 53.3%) (p<0.05). Overexpression of pS6 in metastases without concomitant overexpression in their primary tumors was found in 16/45 (35.56%) cases. Patients with pS6 overexpression in mPRCCs but also in metastases showed a tendency to shorter overall survival. pS6 score and pmTOR score correlated positively in NRP and in tumorous tissue (mPRCC and metastases). In conclusion, the present study showed stronger pS6 expression and more frequent overexpression in metastases than in corresponding PRCCs. In approximately one-third of the cases pS6 overexpression was found exclusively in metastases, which is interesting with regard to the association between high pS6 expression and sensitivity to mTOR inhibitor therapy.

100% natural tannin-based rigid foams were synthesized. Tannin-furfuryl alcohol networks were polymerized in an acid environment applying a temperature between 120° and 160°C. The process was developed in two ways: in a ventilated oven and in between the heated plates of a press. The foams produced showed a high homogeneity in both cases. By modifying the formulation in terms of type and amount of components it was possible to produce two kinds of foams: (1) light with density of approximately 50 Kg/m³, and (2) resistant having a density of approximately 180 Kg/m³. The compression resistance and the water absorption of these materials were evaluated. The results of these tests, in comparison with those of formaldehyde-reinforced tannin foams, indicated that these lightweight foams have lower mechanical strength but higher water affinity. The latter was also demonstrated with moisture uptake measurements. Particular attention was dedicated to the press-produced foams for their possible application as core-layer for lightweight composite panels.

The present study evaluated pAKT, pmTOR, and PTEN expression in a tissue microarray of primary renal cell carcinomas (PRCCs), their metastases, and normal renal parenchyma (NRP) (N = 45) by means of immunohistochemistry. Metastases in most subcellular compartments showed comparable and stronger expression for pAKT, pmTOR, and PTEN than PRCC and NRP, which was even more pronounced in patients with high-risk Memorial Sloan-Kettering Cancer Center (MSKCC) score. Furthermore, most subcellular compartments showed no differences between lymphogenous, haematogenous, synchronous, and metachronous metastases, which is interesting with regard to sensitivity to mTOR inhibitor therapy in metastasized RCCs with alterations in the PI3K/AKT pathway.

背景 本研究分别采用全血阻抗法与传统透光聚集度(LTA)测定血小板聚集率,以探讨抗血小板治疗药物是否会降低心脏手术或体外循环(CPB)后的血小板聚集功能.方法 选择70例拟行择期冠状动脉旁路移植术的患者,分别于麻醉诱导前、诱导中和肝素化后15分钟及3小时采取动脉血,应用Multiplate(R)(M)测定随时间变化的电阻值作为聚集单位,同时使用以胶原(COL)、二磷酸腺苷(ADP)或花生四烯酸(AA)为激活剂的LTA(%聚集率)法进行检测.A组(n=48)为对照组,手术前停用抗血小板药物至少7天,B组(n=11)和C组(n=11)患者分别服用阿司匹林100 mg/d或阿司匹林100mg/d与氯吡格雷75mg/d(双重抗血小板治疗)至手术前一天.结果 未行抗血小板治疗的患者,给予鱼精蛋白15分钟及3小时后,应用3种激活剂及两种聚集方法 均可观察到血小板聚集率明显降低.单纯使用阿司匹林的患者,LTA-COL、LTA-ADP及M-ADP随时间发生显著改变;接受双重抗血小板治疗的患者,两种方法 的ADP检测均提示给予鱼精蛋白15分钟后血小板聚集显著减弱.通过计算受试者工作特征曲线(receiver-operating characteristic curves,ROC曲线)下面积来区分抗血小板药物,LTA-COL可以在CPB后15分钟和3小时区分出对照组与阿司匹林组或双重抗血小板治疗组,M-ADP则可在鱼精蛋白拮抗后3小时区分对照组和双重抗血小板治疗组.结论 对于未经抗血小板治疗的患者,全血电阻抗法及使用了常用激活剂的传统LTA法均可检测出CPB所致的血小板聚集功能改变.而对于接受了抗血小板治疗的患者,ADP激活的抗血小板检测方法 能更好地检测出CPB所致的血小板聚集功能减退.

Objective: Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. These operations can be performed on either the beating or arrested heart. One challenge of the latter version is a potentially increased need for blood transfusions. We investigated factors associated with transfusion requirements in totally endoscopic coronary artery bypass on the arrested heart (AH-TECAB). Patients and methods: A total of 161 patients, 124 males and 37 females, aged 59 (31-77 years) years, with European System for Cardiac Operative Risk Evaluation (EuroSCORE) 1 (0-7) underwent AH-TECAB using the daVinci telemanipulation system. The Heartport/Cardiovations (TM) or ESTECH-RAP (TM) systems were applied for remote access perfusion and aortic endoocclusion. In all cases, the operation was carried out in moderate hypothermia and cardiac arrest using cold crystalloid cardioplegia mixed with blood. Results: After 20 cases, the blood-transfusion rate dropped from 69% to 44%. The overall median number of transfusions was 1 (0-21). The following pre- and intra-operative factors showed a strong association with the application of packed red blood cells (PRBCs): preoperative haemoglobin level (p <0.001), female gender (p <0.001), shorter height (p < 0.001), lower weight (p < 0.001), long operative time (p < 0.001) and long cardiopulmonary bypass time (p = 0.001), intra-operative surgical problem (p < 0.001) and conversion to a larger thoracic incision (p < 0.001). Postoperatively, patients with longer ventilation time (p < 0.001) and those needing revision for bleeding (p < 0.001) also received significantly more PRBCs. Conclusion: We conclude that multiple factors are associated with increased blood transfusion requirements in AH-TECAB. However, the transfusion rate can be reduced with experience. Identification of these factors may help in avoiding the application of blood products in the next generation of AH-TECAB procedures. (c) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

a A b a n t i c r e b T s t r a A b c w THE EUSTACHIAN VALVE plays an important role during fetal life by directing oxygen-rich blood from the inferior vena cava (IVC) through the foramen ovale into the left atrium (LA) and the systemic circulation. After birth, the eustachian valve disappears or is reduced to a thin, nonfunctional ridge. Occasionally, it remains as an elongated and prominent structure within the right atrium (RA). If the eustachian valve is very prominent with undulating motion, it is called a giant eustachian valve.1 Otherwise, if t is very thin and small, it is called a Chiari network.2 Occasionally, it can be elongated and appears prominent with an undulating motion in echocardiography.1 It is best visualized by transesophageal echocardiography (TEE) in the midesophageal bicaval view, where it can be seen to originate from the junction of the RA and the IVC.2 A patent eustachian valve is not only a possible pitfall in echocardiography but also for the cardiac surgeon closing an atrial septum defect (ASD). There are several reports of the eustachian valve being mistaken for the lower rim of the ASD, thus causing inadvertent diversion of the IVC blood flow into the left atrium.3 Moreover, inflow obstruction of the IVC is reported to cause Budd-Chiari–like symptoms.4 TEE is superior to transthoracic echocardiography for the identification and characterization of ASDs in adults.5 Consequently, the authors resent 2 patients showing intraoperative TEE evidence of nintentional sewing of the eustachian valve into a surgical SD/PFO closure.

In cardiosurgery patients atherosclerotic debris displaced from the cannulation site but also from the opposite aortic wall by the sandblast-like effect of the high-pressure jet emanating from the cannula is a potential source of intraoperative arterial embolization and consequently postoperative neurologic dysfunction. The present study examined the extent to which shear stress exerted on the intact aortic intima by an aortic cannula jet stream can cause endothelial lesions that promote thrombogenesis and consequently thrombembolism. A single-stream, straight-tip aortic cannula was used in a porcine cardiopulmonary bypass (CPB) model. Following a 120-minute CPB pump run, a 60-minute stabilization period was allowed before sacrificing the pigs (N.=40) for histological evaluation of the ascending aorta and the brain. Opposite the cannulation site endothelial lesions (diameter: 3.81±1.3 mm; depth: 0.017±0.003 mm) were present in 22.5% (9/40) of aortic specimens. Cerebral thrombembolic lesions were not found. The present study showed that single-stream, straight-tip aortic cannulas caused jet lesions of the formerly intact aortic endothelium opposite the cannulation site in 22.5% of cases in a porcine CPB model.

In cancer therapy novel concepts focus on phosphoinositide 3-kinase (PI3K)/activated protein kinase B (p-AKT)/mammalian target of rapamycin (mTOR) inhibitors. In this context, p-AKT overexpression was previously shown to be associated with sensitivity to inhibitors of mTOR. The present study evaluated p-AKT expression in a tissue microarray of primary renal cell carcinomas (PRCCs) (n = 45), their metastases (primary onset n = 45, secondary onset n = 5), and normal renal parenchyma (n = 45) by means of immunohistochemistry. Total p-AKT overexpression was found in 24/45 (53.3%) PRCCs, in 32/45 (71.1%) primary and in 3/5 (60%) secondary onset metastases. Membranous p-AKT overexpression was seen more frequently in PRCCs, namely 11/45 (24.4%), than in primary onset metastases 1/45 (2.2%). Overexpression of total p-AKT solely in metastases without overexpression in PRCC was exclusively demonstrated in primary onset metastases, namely in 28.9%. Patients with total p-AKT overexpression in primary carcinomas showed a trend to longer, and those with total p-AKT overexpression in metastases a tendency to shorter survival. In conclusion, the present study shows total p-AKT overexpression to be more frequent in metastases than in PRCCs. Total p-AKT overexpression in metastases without concomitant overexpression in their primary tumors was found in approximately one-third of primary onset metastases, which is interesting with regard to the association between high p-AKT expression and sensitivity to mTOR inhibitor therapy.

Caffeine has been consumed since ancient times due to its beneficial effects on attention, psychomotor function, and memory. Caffeine exerts its action mainly through an antagonism of cerebral adenosine receptors, although there are important secondary effects on other neurotransmitter systems. Recently, functional MRI (fMRI) entered the field of neuropharmacology to explore the intracerebral sites and mechanisms of action of pharmacological agents. However, as caffeine possesses vasoconstrictive properties it may interfere with the mechanisms underlying the functional contrast in fMRI. Yet, only a limited number of studies dealt with the effect of caffeine on measures in fMRI. Even fewer neuroimaging studies examined the effects that caffeine exerts on cognition: Portas and colleagues used fMRI in an attentional task under different levels of arousal (sleep deprivation or caffeine administration), concluding that the thalamus is involved in mediating the interaction of attention and arousal. Bendlin and colleagues found caffeine to stabilize the extent of neuronal activation in repetitive word stem completion, counteracting the general task practice effect. Recently, Koppelstaetter and colleagues assessed the effect of caffeine on verbal working memory demonstrating a modulatory effect of caffeine on brain regions (medial frontopolar and anterior cingulate cortex) that have been associated with attentional and executive functions. This review surveys and discusses neuroimaging findings on 1) how caffeine affects the contrast underlying fMRI techniques, particularly the blood oxygen level dependent contrast (BOLD fMRI), and 2) how caffeine operates on neuronal activity underlying cognition, to understand the effect of caffeine on behavior and its neurobiological underpinnings.

Introduction: Over the last decade, totally endoscopic procedures on the beating heart and on the arrested heart have made their way into cardiac surgery. Single-lung ventilation (SLV) is a prerequisite for performing totally endoscopic coronary artery bypass surgery (TECAB). The aim of the present study was to evaluate the influence of SLV on perioperative respiratory parameters and to determine additional predictors of respiratory problems in these patients.Patients and Methods: We investigated 16 female and 69 male patients (median age, 59 years; range, 38-90 years) who underwent either arrested heart TECAB (n = 76) or beating heart TECAB (n = 9). We analyzed the correlations of the SLV, cardiopulmonary bypass (CPB), aortic cross-clamping, and overall procedure times with perioperative respiratory parameters and length of intensive care unit (ICU) stay.Results: Preoperative values for forced vital capacity and the forced expiratory volume in 1 second were negatively correlated with postoperative pulmonary dysfunction. Longer total operative times were correlated with prolonged mechanical ventilation, tube continuous positive airway pressure ventilation (tube CPAP) time, and ICU and hospital stays. Increased CPB times were associated with longer tube CPAP times, higher grades of pulmonary dysfunction, and a prolonged hospital stay. A prolonged aortic-occlusion time increased the postoperative time to extubation and the hospital stay. Postoperative pulmonary dysfunction was associated with a history of smoking, a poor preoperative respiratory status, and a prolonged CPB time. SLV, however, did not correlate with postoperative time to extubation or with length of ICU stay. Only in patients who underwent conversion to sternotomy (n = 13) was SLV associated with prolonged mechanical ventilation.Conclusions: Preoperative respiratory status showed no major influence on postoperative respiratory outcome in selected patients. Longer operative, CPB, and aortic cross-clamping times led to reversible lung injury after TECAB. Prolonged SLV times, however, did not increase the postoperative time to extubation or the length of ICU stay in TECAB patients.

BACKGROUND: In this study, we explored whether antiplatelet medications impair whole blood impedance aggregometry after cardiac surgery and cardiopulmonary bypass (CPB) compared with classical light transmission aggregometry (LTA). METHODS: Multiplate® (M) assays measuring changes in electrical resistance as aggregation units over time, and LTA assays (% aggregation) induced by collagen (COL), adenosine diphosphate (ADP), or arachidonic acid were performed simultaneously using arterial blood samples obtained before induction of anesthesia, 15 min and 3 h after neutralization of heparin in 70 consecutive patients scheduled for elective coronary artery bypass grafting. Patients in Group A (n = 48) discontinued intake of antiplatelet drugs for at least 7 days and served as controls, patients in Group B (n = 11) received aspirin 100 mg/d and those in Group C (n = 11) aspirin 100 mg/d and clopidogrel 75 mg/d (dual antiplatelet therapy) until the day before surgery. RESULTS: In patients without antiplatelet therapy, 15 min and 3 h after protamine a significant decrease in platelet aggregation was observed with all three agonists and both aggregation methods. In patients receiving aspirin alone, LTA-COL, LTA-ADP and M-ADP changed significantly over time, and ADP assays of both aggregation methods showed a significant decrease in platelet aggregation 15 min after protamine in patients receiving dual antiplatelet therapy. When calculating the areas under the receiver-operating characteristic curves for discrimination of antiplatelet agents, LTA-COL was able to discriminate between controls and patients receiving aspirin or dual antiplatelet therapy 15 min and 3 h after CPB and the M-ADP assay was able to discriminate between controls and patients receiving dual antiplatelet therapy 3 h after protamine. CONCLUSION: Whole blood and classical LTA performed with all commonly used agonists enable detection of CPB-induced changes in platelet aggregation in patients not taking antiplatelet medication, whereas in patients receiving antiplatelet therapy, ADP-induced antiplatelet assays are preferable for detecting CPB-induced impairment of platelet aggregation.

Background: The introduction of minimally invasive and totally endoscopic cardiac surgery is associated with increased use of femoral artery perfusion. Selective antegrade perfusion of the cannulated artery may be a helpful strategy to avoid ischemia of the lower extremities. The aim of the study was to evaluate the efficacy of selective distal vessel perfusion under continuous monitoring of oxygen saturation using near-infrared spectroscopy (NIRS).Methods: All patients (n = 236) who underwent peripheral cannulation for remote access perfusion and endoaortic balloon occlusion for minimally invasive or totally endoscopic cardiac surgery were prospectively analyzed. Perioperative complications, creatine kinase levels, and major complications at the long-term follow-up were recorded.Results: Minor or major complications of leg perfusion occurred in only 4 patients (1.7%); the complications in 2 of the patients were associated with an additional arterial cannula placed at the contralateral side. NIRS monitoring revealed diminished perfusion in 5 cases. Even patients with complications associated with remote-access perfusion had a rapid recovery, and no residual peripheral vascular complication was detected during follow-up.Conclusions: The use of antegrade selective perfusion of the lower extremity at the side of peripheral cannulation for port-access perfusion and endoaortic occlusion is of utmost importance in patients undergoing minimally invasive or endoscopic cardiac surgery. NIRS monitoring has proved to be very helpful for the diagnosis of impaired leg perfusion.