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Search Results: 1 - 10 of 223847 matches for " Nicholas C. Cavarocchi "
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Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement in Patients with Continuous-Flow Left Ventricular Assist Devices (LVAD)  [PDF]
Ryan Cobb, Nicholas C. Cavarocchi, Hitoshi Hirose
World Journal of Cardiovascular Surgery (WJCS) , 2013, DOI: 10.4236/wjcs.2013.32017
Abstract: Introduction: Inadequate nutritional support after LVAD placement is known to increase postoperative infections and to decrease survival. LVAD patients with prolonged mechanical ventilation and complicated postoperative recovery requiring prolonged mechanical ventilation may require long-term tube feedings. Placement of a PEG requires knowledge of the location of the LVAD pocket and driveline to avoid device infection and injury. Methods: Between August 2008 and December 2011, 39 patients underwent HeartMate II LVAD placement in our institution. Among them, 5 patients underwent PEG tube placement for long-term nutritional support. Procedure management consisted of cessation of anticoagulation and correction of abnormal coagulation; a cardiothoracic surgeon or intensivist in the operating room to communicate with the surgeon who performed the PEG procedure; and VAD coordinator or perfusionist in the operating room to assist in monitoring the VAD. Data were retrospectively analyzed to investigate complications related to the PEG placement. Results: The studied patients consisted of 3 males and 2 females with mean age of 58 +/﹣5.0. The interval of LVAD to PEG placement was a mean 21 +/﹣8.8 days. PEG was successfully performed in the operating room in all patients. There were no LVAD device or driveline injuries related to the PEG procedure. There were no postoperative short-term or long-term PEG related complications such as acute gastric bleeding or dislodgement of the PEG tube. Conclusions: PEG placement for HeartMate II LVAD patients can be done without increasing the risk of device or intraabdominal organ injury with carefully coordinated efforts from both the mechanical support team and surgical services.
Prone Position: Does It Help with Acute Respiratory Distress Syndrome (ARDS) Requiring Extracorporeal Membrane Oxygenation (ECMO)?  [PDF]
Nava Azimzadeh, Michael Baram, Nicholas C. Cavarocchi, Hitoshi Hirose
Open Journal of Respiratory Diseases (OJRD) , 2017, DOI: 10.4236/ojrd.2017.71003
Abstract: Introduction: Lung protective ventilation therapy with low tidal volume-high PEEP is the standard treatment for the patients with acute respiratory distress syndrome (ARDS). Oscillators are occasionally used for salvage ventilation in cases where poor compliance restricts the use of traditional ventilation with ARDS. In addition to ventilator therapy, prone positioning has been used to improve oxygenation. We presented a challenging case of ARDS, which failed medical management extracorporeal membrane oxygenation (ECMO) support and oscillatory ventilation. Prone positioning was initiated which improved oxygenation, respiratory compliance and posterior atelectasis. Case presentation: A 41-year-old morbid obese female developed ARDS due to influenza pneumonia. The patient remained hypoxic despite optimum medical and ventilator management and required veno-venous extracorporeal membrane oxygenation (VV ECMO). CT scan of the chest showed ARDS with posterior consolidation. Despite ARDSnet ventilation support, antiviral therapy and ECMO support, there was no clinical improvement. High frequency oscillatory ventilation was initiated on ECMO day #13, which resulted in no respiratory improvement over the next 5 days. On ECMO day #18, the patient was placed on a Rotaprone? bed Therapy, utilizing a proning strategy of 16 hours a day. The clinical improvements observed were resolving of the consolidation on CXR, improvements in ventilatory parameters and decreased oxygen requirements. The patient was successfully weaned off ECMO on POD#25 (8 days post prone bed). Conclusions: Prone position improved oxygen saturation and pulmonary compliance in severe ARDS requiring ECMO and it might facilitate early weaning.
Percutaneous endoscopic gastrostomy tube placement in patients with extracorporeal membrane oxygenation
Ryan Cobb,Jay S. Jenoff,Nicholas C. Cavarocchi,Hitoshi Hirose
Mechanical Circulatory Support , 2013, DOI: 10.3402/mcs.v4i0.20093
Abstract: Introduction: Inadequate nutritional support after mechanical circulatory device placement is known to increase postoperative infections and to decrease survival. The extracorporeal membrane oxygenation (ECMO) patients with complicated postoperative recovery may require long-term nutritional support using percutaneous endoscopic gastrostomy (PEG) tube feeding. In this study, the feasibility of PEG procedure on patients on ECMO was evaluated. Methods: Between November 2010 and July 2012, 43 patients were placed on venoarterial or venovenous ECMO for cardiogenic shock or severe respiratory failure. All of the long-term ECMO patients were supported with tube feeding. Four patients underwent PEG tube placement for long-term nutritional support while they were on ECMO. Procedure management consisted of cessation of anticoagulation 12 hours before and 12 hours after procedure. Anticoagulation was continued while on ECMO. Data were retrospectively analyzed to investigate complications related to the PEG placement. Results: The studied patients consisted of two males and two females with a mean age of 55.5±7.9 years. The interval of ECMO to PEG placement was a mean 16.8±4.2 days. The mean total length of ECMO support for these patients was 22.7±5.6 days. PEG was successfully performed in the operating room or bedside in all patients. There were no ECMO-device-related issues during or after the PEG procedure. There were no postoperative short-term or long-term PEG-related complications, such as, acute gastric bleeding or dislodgement of the PEG tube. Conclusions: PEG placement for ECMO patients can be done without increasing the risk of device or intra-abdominal organ injury with carefully coordinated efforts from both the intensive care team and surgical services.
End Organ Recovery and Survival with the QuadroxD Oxygenator in Adults on Extracorporeal Membran Oxygenation  [PDF]
Joshua K. Wong, Vei Shaun Siow, Hitoshi Hirose, Pawel Karbowski, Joseph Miessau, Michael Baram, Matthew DeCaro, Harrison T. Pitcher, Nicholas C. Cavarocchi
World Journal of Cardiovascular Surgery (WJCS) , 2012, DOI: 10.4236/wjcs.2012.24015
Abstract: Introduction: Extracorporeal Membrane Oxygenation (ECMO) is used in selected patient with cardiogenic and/or re- spiratory shock. We report our experience with standardized management protocols and the application of the Qua- droxD oxygenator with a centrifugal pump to maximize end-organ recovery and improve survival. Methods: This is an Internal Review Board (IRB) approved, single institution retrospective study of end-organ recovery and survival in pa- tients who required ECMO for cardiogenic and/or respiratory shock between July 2010 and June 2011. Results: Sixteen patients (median age: 46 years) were initiated on either Veno-Arterial (VA) or Veno-Venous (VV) ECMO. Cardiogenic shock, acute respiratory distress syndrome (ARDS) and a combined respiratory and cardiogenic compromise were the primary indications for ECMO in 8 (50%), 5 (31%) and 3 (19%) patients respectively. The median time on ECMO was 8 days (range: 4 - 26 days). Twelve patients (75%) were successfully weaned off ECMO, of which four (25%) were bridged to a ventricular assist device (VAD) and eight (50%) were weaned to recovery. All eight patients (100%) that were weaned to recovery and two patients (50%) that were bridged to a VAD were successfully discharged from the hospital, resulting in a discharge rate of 63%. There was an improvement in pre- vs. post-ECMO AST (449 IU/L vs. 63 IU/L, p < 0.05) in 5 patients (31%) with liver injury; serum lactate (9.1 mmol/L vs. 1.9 mmol/L, p < 0.05) in 8 patients (50%); and PaO2/FiO2 ratio (87 to 161, p = 0.01) in 10 patients (62%) with ARDS. Patients with evidence of pulmonary edema (n = 8. 50%) and ARDS (n = 8, 50%) on chest X-ray showed radiographic evidence of complete resolution. Renal function was preserved in 15 patients (94%). Conclusion: ECMO using the QuadroxD oxygenator and a centrifugal pump, coupled with standardized management protocols is beneficial in carefully selected patients. Improvement or main- tenance of end-organ function is associated with successful bridge to device therapy and/or increased survival.
Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation
Hitoshi Hirose, Kentaro Yamane, Gregary Marhefka, Nicholas Cavarocchi
Journal of Cardiothoracic Surgery , 2012, DOI: 10.1186/1749-8090-7-36
Abstract: The Avalon Elite bicaval dual lumen cannula (Avalon Laboratories, Rancho Dominguez, CA) has been used for venovenous extracorporeal oxygenation (VV-ECMO) [1,2]. The cannula consisted of 2 lumens: one lumen allows the deoxygenated blood to drain from the distal and proximal ports, from the inferior vena cava (IVC) and the superior vena cava (SVC), respectively; and a second lumen allows the oxygenated blood to return from the external pump to the right atrium directed toward the tricuspid valve (Figure 1). We have used the Avalon cannula for adult VV-ECMO in salvageable patients with severe refractory adult respiratory distress syndrome (ARDS) since 2009. We have performed VV-ECMO in 4 patients specifically using the Avalon cannula system since then, with successful weaning in all 4 patients. We describe one patient who developed right ventricular rupture and acute cardiac tamponade at the time of cannula insertion.A 53 year old female without significant past medical history developed severe viral pneumonia, with rapid, progressive deterioration in her respiratory status. She developed ARDS and mechanical ventilatory management using ARDS protocol were unable to maintain adequate oxygenation. As a result, bedside VV-ECMO was planned. Transesophageal echocardiography (TEE) was performed to visualize proper positioning of the guidewire and cannula. Using the Seldinger technique, the right internal jugular vein was accessed and a guide wire was placed. Placement of the guidewire into the IVC proved difficult due to repeated migration of the guidewire into the right ventricle. After multiple attempts, the guidewire was visualized to course properly from the SVC to the IVC. After a bolus dose of 5000 units of intravenous heparin was given, the right internal jugular venous access site was dilated. Just as the final dilatation was completed and upon dilator exchange with simultaneous advancement of the 23 French Avalon cannula, TEE lost visualization of the guidewire. Mul
Role of Serum Cytokine Levels in Acute Respiratory Distress Syndrome Patients on Extracorporeal Membrane Oxygenation Support  [PDF]
Ena Gupta, Kyle Carey, Lydia McDermott, Nicholas Cavarocchi, Hitoshi Hirose, Michael Baram
World Journal of Cardiovascular Surgery (WJCS) , 2020, DOI: 10.4236/wjcs.2020.101001
Abstract: Background: Even with the use of extracorporeal membrane oxygenation (ECMO) in acute respiratory distress syndrome (ARDS), mortality remains high. Also, prognostication of patients with ARDS and ECMO is difficult. Cytokines are thought to be markers of inflammation in both ARDS and in ECMO, however, understanding is limited. We aimed to study the association of three serum cytokine levels with mortality in these patients with ARDS on ECMO. Methods: We performed a retrospective chart review of ARDS patients on ECMO between 2011 and 2017. Patients with serum TNF-α, IL-6 and IL-2 measured while on ECMO were included, with measurements recorded weekly up to a maximum of 4 measurements. A multivariable regression analysis was performed and generalizing estimating equations were used to analyze longitudinal trend of cytokines with mortality. Results: There were 47 patients with ARDS on ECMO, of which 31 (68.9%) survived at 30 days and 2 were lost to follow up. Initial IL-2 levels were found to be significantly higher among those who were alive compared to those who died at 30 days (2720 ± 2432 pg/ml vs.
International Performance Measures of South Australian Universities: Information Systems Shortcomings
Nicholas C. Mangos
International Journal of Business and Management , 2009,
Abstract: This exploratory study identifies problems with the Information System used to generate international performance output of South Australian Universities This paper represents a case study covering the three Universities in South Australia for the year 2004 which include University of Adelaide, University of South Australia and Flinders University. What the current study identifies is the lack of financial disclosures by Universities in providing specific financial productivity measures of international off-shore diversification performance and correspondingly international on-shore diversification performance. The study identifies that performance disclosure by Universities is primarily non-financial in nature for international diversification performance an issue that requires attention. What is suggested in the future is an information system change that can adequately measure international performance for Universities in effective monetary terms. What is recommended is an improved information system that can generate more sophisticated and meaningful financial productivity measures of international performance of Universities.
The Global Weather Research and Forecasting (GWRF) Model: Model Evaluation, Sensitivity Study, and Future Year Simulation  [PDF]
Yang Zhang, Joshua Hemperly, Nicholas Meskhidze, William C. Skamarock
Atmospheric and Climate Sciences (ACS) , 2012, DOI: 10.4236/acs.2012.23024
Abstract: Global WRF (GWRF) is an extension of the mesoscale Weather Research and Forecasting (WRF) model that was developed for global weather research and forecasting applications. GWRF is being expanded to simulate atmospheric chemistry and its interactions with meteorology on a global scale. In this work, the ability of GWRF to reproduce major boundary layer meteorological variables that affect the fate and transport of air pollutants is assessed using observations from surface networks and satellites. The model evaluation shows an overall good performance in simulating global shortwave and longwave radiation, temperature, and specific humidity, despite large biases at high latitudes and over-Arctic and Antarctic areas. Larger biases exist in wind speed and precipitation predictions. These results are generally consistent with the performance of most current general circulation models where accuracies are often limited by a coarse grid resolution and inadequacies in sub-filter-scale parameterizations and errors in the specification of external forcings. The sensitivity simulations show that a coarse grid resolution leads to worse predictions of surface temperature and precipitation. The combinations of schemes that include the Dudhia shortwave radiation scheme or the Purdue Lin microphysics module, or the Grell-Devenyi cumulus parameterization lead to a worse performance for predictions of downward shortwave radiation flux, temperature, and specific humidity, as compared with those with respective alternative schemes. The physical option with the Purdue Lin microphysics module leads to a worse performance for precipitation predictions. The projected climate in 2050 indicates a warmer and drier climate, which may have important impacts on the fate and lifetime of air pollutants.
Aortic Sinus of Valsalva Aneurysm Isolation by Radiofrequency Ablation in Outflow Tract Ventricular Tachycardia  [PDF]
Nicholas Olson, Scott W. Ferreira, Peter C. Mikolajczak, Ali Mehdirad
World Journal of Cardiovascular Diseases (WJCD) , 2014, DOI: 10.4236/wjcd.2014.44019
Abstract: Idiopathic monomorphic ventricular tachycardia and premature ventricular complexes (PVCs) commonly arise from the right and left ventricular outflow tracts (VOT). Their mechanism is most commonly triggered activity from delayed after-depolarizations and successful ablation is performed at the site of earliest endocardial activation. Re-entrant mechanisms have been rarely described. We report a case of an otherwise healthy patient who ultimately underwent six electro-physiology studies (EPS) and suffered numerous implantable cardiac defibrillator (ICD) discharges prior to the successful radiofrequency ablation (RFA) of two idiopathic VOT tachycardias. During the sixth EPS, a proximal aortogram demonstrated a left aortic sinus of valsalva (LASV) aneurysm. Subsequntly, a novel and successful RFA strategy of aneurysm isolation was undertaken. The presence of multiple clinical or inducible VT morphologies and the characterization of a VT as re-entrant should raise concerns that a complex arrhythmogenic substrate is present and defining the anatomy with angiography or an alternative imaging modality is essential in achieving a successful ablation strategy.
A Simulation for Flavivirus Infection Decoy Responses  [PDF]
James K. Peterson, Alison M. Kesson, Nicholas J. C. King
Advances in Microbiology (AiM) , 2015, DOI: 10.4236/aim.2015.52013
Abstract: In this work, we discuss the development of simulation code for a model of the cross-reactive adaptive immune response seen in flavivirus infections. The model specifically addresses flavivirus pathogen virulence in G0?vs G1?cell states. The MHC-I upregulation of resting cells (G0 state) allows the T-cells generated for flavivirus peptide antigens to attack healthy cells also. The cells in G1?state are not upregulated as much and so virus hides in them and hence is propagated upon rupture. Hence, this type of model is referred to as a decoy model because the immune system is decoyed into preferentially recognizing the upregulated cells while the virus actively propagates in another small, but important, cell population. We show that the generic assumption of upregulation via a model which includes the?G0/G1?differential upregulation leads to immunopathological consequences. We outline the details behind the simulation code decisions and provide some theoretical justification for our model of collateral damage and upregulation.
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