A Gender-Bias-Mitigated, Data-Driven Precision Medicine System to Assist in the Selection of Biological Treatments of Grade 3 and 4 Knee Osteoarthritis: Development and Preliminary Validation of precisionKNEE.

Objective To identify key variables predictive of patient responses to microfragmented adipose tissue (MFAT) treatment in knee osteoarthritis (KOA) and evaluate its potential to delay or mitigate the need for total knee replacement (TKR). Methods We utilised a dataset comprising 329 patients treated with MFAT for KOA, incorporating variables such as gender, age, BMI, arthritic aetiology, radiological grade, and Oxford Knee Scores (OKS) pre- and post-treatment. We employed random forest regressors for model training and testing, with gender bias mitigation and outlier detection to enhance prediction accuracy. Model performance was assessed through root mean squared error (RMSE) and mean absolute error (MAE), with further validation in a TKR-suitable patient subset. Results The model achieved a test RMSE of 6.72 and an MAE of 5.38, reflecting moderate predictive accuracy across the patient cohort. Stratification by gender revealed no statistically significant differences between actual and predicted OKS improvements (p-values: males = 0.93, females = 0.92). For the subset of patients suitable for TKR, the model presented an increased RMSE of 9.77 and MAE of 7.81, indicating reduced accuracy in this group. The decision tree analysis identified pre-operative OKS, radiological grade, and gender as significant predictors of post-treatment outcomes, with pre-operative OKS being the most critical determinant. Patients with lower pre-operative OKS showed varying responses based on radiological severity and gender, suggesting a nuanced interaction between these factors in determining treatment efficacy. Conclusion This study highlights the potential of MFAT as a non-surgical alternative for KOA treatment, emphasising the importance of personalised patient assessments. While promising, the predictive model warrants further refinement and validation with a larger, more diverse dataset to improve its utility in clinical decision-making for KOA management.

A Quantum-Enhanced Precision Medicine Application to Support Data-Driven Clinical Decisions for the Personalized Treatment of Advanced Knee Osteoarthritis: The Development and Preliminary Validation of precisionKNEE_QNN.

Background Quantum computing and quantum machine learning (QML) are promising experimental technologies that can improve precision medicine applications by reducing the computational complexity of algorithms driven by big, unstructured, real-world data. The clinical problem of knee osteoarthritis is that, although some novel therapies are safe and effective, the response is variable, and defining the characteristics of an individual who will respond remains a challenge. In this study, we tested a quantum neural network (QNN) application to support precision data-driven clinical decisions to select personalized treatments for advanced knee osteoarthritis. Methodology After obtaining patients' consent and Research Ethics Committee approval, we collected the clinicodemographic data before and after the treatment from 170 patients eligible for knee arthroplasty (Kellgren-Lawrence grade ≥3, Oxford Knee Score (OKS) ≤27, age ≥64 years, and idiopathic aetiology of arthritis) treated over a two-year period with a single injection of microfragmented fat. Gender classes were balanced (76 males and 94 females) to mitigate gender bias. A patient with an improvement ≥7 OKS was considered a responder. We trained our QNN classifier on a randomly selected training subset of 113 patients to classify responders from non-responders (73 responders and 40 non-responders) in pain and function at one year. Outliers were hidden from the training dataset but not from the validation set. Results We tested our QNN classifier on a randomly selected test subset of 57 patients (34 responders, 23 non-responders) including outliers. The no information rate was 0.59. Our application correctly classified 28 responders out of 34 and 6 non-responders out of 23 (sensitivity = 0.82, specificity = 0.26, F1 Statistic = 0.71). The positive and negative likelihood ratios were 1.11 and 0.68, respectively. The diagnostic odds ratio was 2. Conclusions Preliminary results on a small validation dataset showed that QML applied to data-driven clinical decisions for the personalized treatment of advanced knee osteoarthritis is a promising technology to reduce computational complexity and improve prognostic performance. Our results need further research validation with larger, real-world unstructured datasets, as well as clinical validation with an artificial intelligence clinical trial to test model efficacy, safety, clinical significance, and relevance at a public health level.

Monomeric C-Reactive Protein: Current Perspectives for Utilization and Inclusion as a Prognostic Indicator and Therapeutic Target.

Monomeric C-reactive protein (mCRP), once thought to be a figment of the imagination and whose biological activity was ascribed to its sodium azide preservative, has now pronounced itself as a critical molecule playing a direct role in mediating many of the acute and chronic aberrant pathological responses to inflammation. In this focused mini review, we describe the currently attributed pathobiological interactions of mCRP in disease, where its tissue and cellular distribution and deposition have recently been clearly characterized and linked to inflammation and other pathway-associated progression of neurological and cardiovascular complications and deleterious outcomes. and focus upon current opinions as to the diagnostic and prognostic potential of mCRP-plasma circulating protein and define the possible future therapeutics including ongoing research attempting to block CRP dissociation with small molecule inhibitors or prevention of cell surface binding directly using antibodies or modified orphan drug targeting directed towards CRP, inhibiting its cellular interactions and signaling activation. There is no doubt that understanding the full influence of the biological power of mCRP in disease development and outcome will be considered a critical parameter in future stratified treatment.

Comparison of the Effect of MFAT and MFAT + PRP on Treatment of Hip Osteoarthritis: An Observational, Intention-to-Treat Study at One Year.

Hip osteoarthritis (OA) is a major contributor to reduced quality of life and concomitant disability associated with lost working life months. Intra-articular injection of various biological materials has shown promise in alleviating symptoms and potentially slowing down the degenerative process. Here, we compared the effects of treatment of a cohort of 147 patients suffering from grade 1-4 hip OA; with either micro-fragmented adipose tissue (MFAT), or a combination of MFAT with platelet-rich plasma (PRP). We found significant improvements in both the visual analogue score for pain (VAS) and Oxford hip score (OHS) that were similar for both treatments with over 60% having an improvement in the VAS score of 20 points or more. These results suggest a positive role for intra-articular injection of MFAT + PRP as a treatment for hip osteoarthritis which may be important particularly in low body mass index (BMI) patients where the difficulty in obtaining sufficient MFAT for treatment could be offset by using this combination of biologicals.

Virtual reality as a simulation tool for field hospital's and COVID-19 hospital's staff training / A virtuális valóság mint szimulációs módszer alkalmazása a telepített sürgosségi egységek, valamint COVID-19-kórházak személyzetének képzésében.

Összefoglaló. Bevezetés: A COVID-19-pandémia okozta nagyfokú betegszám-növekedés ellátásának érdekében az egészségügyi rendszerek gyakran a kórházak teljes átszervezésére kényszerültek. A szakállomány gyors és hatékony felzárkóztatása kulcsfontosságú ilyen körülmények között. A telepített kórházi egységek személyzetének felkészítésére a virtuális valóságban levezetheto csoportos gyakorlatozás ígéretes módszernek mutatkozik. Célkituzés: Célunk egy telepített kórház személyzetének felkészítésére alkalmazott virtuális szimulációs gyakorlatsorozat tapasztalatainak bemutatása, valamint a létrehozott és kipróbált virtuális gyakorlatcsomagok adaptálási lehetoségeinek elméleti bemutatása a COVID-19-kórházak személyzetének gyors felzárkóztatását szolgáló gyakorlatsorozat lehetséges kivitelezése érdekében. Módszer: Három, prototípusként eloállított virtuális gyakorlat került alkalmazásba két próbatanfolyam keretén belül. A virtuális színterek kialakítására az XVR szimulációs szoftvert használtuk. A gyakorlatok alkalmazhatóságának és hasznosságának kiértékelésére anonim kérdoíves felméréseket készítettünk. Az adatok feldolgozásában kereszttábla-elemzést és khi-négyzet-próbát alkalmaztunk. Eredmények: A két próbaképzésen nyolc ország képviseletében összesen 76 gyakornok vett részt. A résztvevok 63,9%-a szerint a módszer alkalmas ilyen jellegu gyakorlatok levezetésére, de további fejlesztéseket igényel. Véleményük, hogy technikai használata "elég könnyen" elsajátítható (59,7%), és interaktív (90,32%), valósághu (45,0%) szimulációs közeget biztosít. Megbeszélés: Eredményeink alapján a virtuális valóság egy alkalmazható módszer a telepített kórházak szakállományának valós bevetésekre való felkészítésére. A létrehozott virtuális gyakorlatcsomagok tartalma és szerkezete könnyen adaptálható egy COVID-19 ideiglenes egészségügyi egység sajátos munkakörülményeihez való gyors személyzeti felzárkóztatást szolgáló muhelygyakorlatok megszervezéséhez. Következtetés: A virtuális valóság ígéretes oktatási eszköz, amely kiegészítheti a nagy költségekkel és bonyolult szervezéssel járó terepgyakorlatokat, megközelítve azok oktatási hatásfokát. A virtuális térben megélt tapasztalatok valós szakmai élményekké alakulnak, és hozzájárulnak egy biztonságos és hatékony munkaközeg gyors kialakításához. Orv Hetil. 2021; 162(40): 1591-1600. INTRODUCTION: COVID-19 pandemic imposed sudden increase in hospital admissions, thus medical systems needed to reorganize entire hospitals quite often. Quick and efficient training is of outmost importance. Virtual reality team training is a promising tool for newly organized hospital units' staff. OBJECTIVE: Our goal was to present the usefulness and applicability of virtual simulation exercises for training of field hospital personnel and to evaluate the adaptability of these created and tested exercise packs for urgent staff training of COVID-19 hospitals. METHOD: Three prototypes of virtual reality exercises were assessed through two test courses. XVR simulation software was used to create virtual environments. Evaluation of exercise applicability and utility was performed by anonymous questionnaires. Statistical data-processing was performed using contingency table and chi-square tests. RESULTS: 76 trainees from eight countries participated in the two pilot courses. 63.9% of the participants stated that the method is suitable for conducting such exercises, but needs further development. Its technical use is "easy enough" to learn (59.7%) and provides an interactive (90.32%) and realistic (45.0%) working environment. DISCUSSION: Virtual reality is applicable to train field hospital staffs for real missions. The created virtual exercise packages are easily adaptable, both in content and structure, to workshops dedicated for quick training of specific COVID-19 temporary medical facility's personnel. CONCLUSION: Virtual reality is a promising educational tool that can complement the expensive and laborious field exercises, with comparable training efficiency. These virtual reality experiences may become real professional memories and create swiftly a secure and efficient professional milieu. Orv Hetil. 2021; 160(40): 1591-1600.

Short-Term Impact of Iron Deficiency in Different Subsets of Patients with Precapillary Pulmonary Hypertension from an Eastern European Pulmonary Hypertension Referral Center.

BACKGROUND: Over the last few decades, interest in the role of iron status in pulmonary hypertension (PH) has grown considerably due to its potential impact on symptoms, exercise capacity (as assessed by the 6-minute walk distance [6MWD]), prognosis, and mortality. The aim of the present study was to identify iron deficiency (ID) prevalence in specific precapillary PH subgroups of Romanian patients and its short-term impact on 6MWD. PATIENTS AND METHODS: Complete datasets from 25 precapillary PH adults were examined and included in the analysis. Data were collected at baseline and after continuous follow-up of an average of 13.5 months. Enrolled patients were assigned to group 1 (pulmonary arterial hypertension) or subgroup 4.1 (chronic thromboembolic pulmonary hypertension), and individualized targeted therapy was prescribed. General characteristics, World Health Organization functional class, 6MWD, pulse oximetry, laboratory parameters, and echocardiographic and hemodynamic parameters were recorded. Ferritin values and transferrin saturation were used to assess ID. RESULTS: At baseline, 16 out of 25 patients were iron deficient. The univariate linear regression analysis did not show a statistically significant impact of ID on 6MWD (p=0.428). In multivariate regression analysis, possible predictors of 6MWD, including ID, were not statistically significant at baseline or after an average of 13.5 months follow-up (p=0.438, 0.361, respectively) and ID indicates a negative impact on 6MWD independent of applied corrections. CONCLUSION: The results of this study demonstrate that 1.4.1 subgroup PAH patients have an increased prevalence of ID compared with other etiologies. ID has a negative impact on the functional status (assessed by 6MWD), in specific groups and subgroups of patients with precapillary PH, albeit not independently nor significant to other known predictors such as age, gender, oxygen saturation, and hemoglobin value. These data can be integrated with global research and are consistent with phenotypes of patients diagnosed with PH of different etiologies.

The Diagnostic and Prognostic Role of Vascular Endothelial Growth Factor C in Sepsis and Septic Shock.

INTRODUCTION: Variations in the expression of vascular endothelial growth factor (VEGF) could be used as a biomarker in critically ill patients with sepsis and septic shock. Inflammation potently upregulates VEGF-C expression via macrophages with an unpredictable response. This study aimed to assess one of the newer biomarkers (VEGF-C) in patients with sepsis or septic shock and its clinical value as a diagnostic and prognostic tool. MATERIAL AND METHODS: The study involved 142 persons divided into three groups. Group A consisted of fifty-eight patients with sepsis; Group B consisted of forty-nine patients diagnosed as having septic shock according to the Sepsis -3 criteria. A control group of thirty-five healthy volunteers comprised Group C. Severity scores, prognostic score and organ dysfunction score, were recorded at the time of enrolment in the study. The analysis included specificity and sensitivity of plasma VEGF-C for diagnosis of septic shock. Circulating plasma VEGF-C levels were correlated with the APACHE II, MODS and severity scores and mortality. RESULTS: The mean (SD) plasma VEGF-C levels in septic shock patients (1374(789) pg./m), on vasopressors at the time of admission to the ICU, were significantly higher 1374(789)pg./mL, compared the mean (SD) plasma VEGF-C levels in sepsis patients (934(468) pg./mL); (p = 0.0005, Student's t-test.) Plasma VEGF-C levels in groups A and B were shown to be significantly correlated with the APACHE II (r = 0.21, p = 0.02; r = 0.45, p = 0.0009) and MODS score (r = 0.29, p = 0.03; r = 0.4, p = 0.003). There was no association between plasma VEGF-C levels and mortality [p = 0.1]. The cut-off value for septic shock was 1010 pg./ml. CONCLUSIONS: VEGF-C may be used as a prognostic marker in sepsis and septic shock due to its correlation with APACHE II values and as an early marker to determine the likelihood of developing MODS. It could be used as an early biomarker for diagnosing patients with septic shock.

Evaluation of TNF-α genetic polymorphisms as predictors for sepsis susceptibility and progression.

BACKGROUND: The goal of the study was to evaluate a potential role for tumor necrosis factor alpha (TNF-α) genetic variability as biomarker in sepsis. In particular, we aimed to determine if single nucleotide polymorphisms (SNPs) of TNF-α gene are associated with sepsis in terms of risk, severity and outcome. METHODS: We performed a prospective study on 163 adult critically ill septic patients (septic shock 65, sepsis 98, further divided in 40 survivors and 123 deceased) and 232 healthy controls. Genotyping of TNF-α SNPs (-308G/A, -238G/A, -376G/A and +489G/A) was performed for all patients and controls and plasma cytokine levels were measured during the first 24 h after sepsis onset. RESULTS: TNF-α +489G/A A-allele carriage was associated with significantly lower risk of developing sepsis and sepsis shock (AA+AG vs GG: OR = 0.53; p = 0.004; 95% CI = 0.34-0.82 and OR = 0.39; p = 0.003; 95% CI = 0.21-0.74, respectively) but not with sepsis-related outcomes. There was no significant association between any of the other TNF-α promoter SNPs, or their haplotype frequencies and sepsis or septic shock risk. Circulating TNF-α levels were higher in septic shock; they were not correlated with SNP genotype distribution; GG homozygosity for each polymorphism was correlated with higher TNF-α levels in septic shock. CONCLUSIONS: TNF-α +489G/A SNP A-allele carriage may confer protection against sepsis and septic shock development but apparently does not influence sepsis-related mortality. Promoter TNF-α SNPs did not affect transcription and were not associated with distinct sepsis, septic shock risk or outcomes.

Precision Medicine and its Role in the Treatment of Sepsis: A Personalised View.

In recent years, a new form of medicine has become increasingly significant, namely, personalised medicine (PM). PM is a form of care in which treatment is tailored for an individual patient. PM is about using multiple data sets to create a digital human mapping. A person's biological traits are determined by the interactions of hundreds of genes and gene networks, as well as external factors such as diet and exercise. Combining and then investigating these multiple databases with powerful statistical tools, allows a new understanding of how genetic intricacy drives health and disease and so leads to a closer personalised medical approach that targets each individual's unique genetic make-up. Sepsis is a systemic inflammatory response to infection, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiple organ dysfunction syndromes (MODS). Sepsis is the most common cause of death in intensive care patients. Treatments in an ICU may need to be adapted to the continuous and rapid changes of the disease, making it challenging to identify a single target. PM is thus seen as the future of sepsis treatment in the ICU. The fact that individual patients respond differently to treatment should be regarded as a starting point in the approach to providing treatment. The disease itself comes secondary to this concept.

The role of interleukin-6 as an early predictor of sepsis in a murine sepsis model.

AIM: Evaluating the role of interleukin-6 (IL-6) as an early predictor of sepsis in a murine model. MATERIALS AND METHODS: The study divided 26 Wistar rats into two experimental groups in which sepsis was induced through the intraperitoneal injection of different Escherichia coli cultures [Group 1: Extended-spectrum beta-lactamase (ESBL)-producing culture and Group 2: Standardized ATCC35218 culture] and a control group. IL-6 levels were determined at 5 and 24 hours post-inoculation and immunohistochemistry (IHC) was performed on tissue samples from the sacrificed animals. RESULTS: Mean plasma IL-6 levels in Group 1 peaked at 5 hours [37.4 pg∕mL; standard deviation (SD) = 2.4 pg∕mL] and decreased at 24 hours (34 pg∕mL; SD=3.2 pg∕mL) after inoculation. IL-6 levels in Group 1 were elevated compared to Group 2, at 5 hours (33.7 pg∕mL; SD=3.3 pg∕mL; p=0.019) and non-significantly so at 24 hours (32.5 pg∕mL; SD=2.4 pg∕mL; p=0.233). The results did not show an increase over control levels at either 5 hours (37.6 pg∕mL; SD=3.4 pg∕mL) or 24 hours (40.8 pg∕mL; SD=2.9 pg∕mL) after inoculation. The IHC shows a varying degree of IL-6 expression across all organ types studied. No statistically significant correlations were found between the tissue level quantification of IL-6 and serum values at 24 hours in either group. CONCLUSIONS: For an early stage of infection/inflammation, serum levels of IL-6 are not correlated with tissue-level inflammation disproving a potential role of IL-6 as a very precocious diagnostic and predictor test. Accumulation of IL-6 in lung, kidney and spleen tissue can be observed from the beginning of inflammation.

Medical education in Romania: Tradition and innovation.

Romania is a country in south-east Europe, which has experienced major changes in political, educational, and healthcare systems. At the time of writing this paper, there are thirteen accredited Faculties of Medicine, which offer students from all over the world the possibility of becoming doctors. Students in Romania follow a six-year program of activity and there are courses taught in Romanian, English, French, and Hungarian. In this paper, we outline the organization of Romanian medical education at undergraduate and postgraduate levels and we indicate the opportunities for curriculum development.

Perioperative Stress-Induced (Takotsubo) Cardiomyopathy in Liver Transplant Recipients.

A comprehensive analysis of published cases of Takotsubo cardiomyopathy, occurred in liver transplant recipients in the perioperative period, has been attempted in this review. Predisposing factors, precipitating events, potential physiological mechanisms, acute and post-event management have been discussed.

Intestinal fatty acid-binding protein, as a marker of anastomotic leakage after colonic resection in rats.

AIM: The aim of this experimental study was to determine if the type of termino-terminal anastomosis of the colon affect the process of healing of the intestinal mucosa and if the severity of the anastomotic leakage (AL) can be predicted based on the circulating level of intestinal fatty acid-binding protein (I-FABP). MATERIALS AND METHODS: In 18 healthy Wistar rats, two types of open colon resection with termino-terminal anastomosis were performed: group A (n=9) - without inversing the vascularization and group B (n=9) - with inversing the vascularization. To assess the intestinal barrier function, circulating level of I-FABP was measured pre- and post-operatively. I-FABP tissue expression was immunohistochemically assessed in the anastomotic and perianastomotic colonic mucosa. The rats were sacrificed at three, five, and seven days after surgery. RESULTS: In both groups, the post-operative serum level of I-FABP increased 3-4 times at 3-5 days and seven times in the seventh post-operative day. In the six cases that showed AL, the increased level was significantly higher: seven times at three days (n=2) or five days (n=2) and 30 times at seven days (n=2). The I-FABP epithelial expression was lost in all cases from group B (as result of prolonged ischemia) and in cases with AL from group A. The I-FABP was translocated in the intraglandular mucus. CONCLUSIONS: The post-operative level of I-FABP can be appreciated based on the pre-operative value only. A 7-8 increased value in first five days might indicate a risk of AL. After seven days, a seven times increased value is an indicator of a proper healing process but an increasing amount higher that 30 times might predict risk for AL, fistula, peritonitis and septic shock. The risk of AL does not depend on the anastomotic method, although the level of ischemia is higher in anastomoses that involve vascular damage.

Communication skills in pediatrics - the relationship between pediatrician and child.

Interpersonal and communication skills are 2 essential qualities of every physician. These are separate and distinct parts of the professional character of every physician. In pediatrics these abilities present even a higher impact.We performed a survey-type prospective study based on questionnaires on 100 subjects, equally divided into 4 groups: 25 children, 25 pediatricians, 25 care-givers (parents, tutors, and relatives), and 25 health care staff, in a Tertiary Pediatric Clinic from Romania, between January 2017 and April 2017.We included 100 participants in our study, equally divided into 4 groups: pediatric patients, pediatricians, care-givers, and health care staff. The 1st group comprised 25 children diagnosed with different chronic conditions, presenting the age between 5 and 14 years. The male gender predominated among the children (57%). The lowest general average score for "Communication" section was encountered among pediatricians group, 3.8, while the other 3 groups presented the same average score for this section, that is, 4.6. The children and the health care staff offered the same average score for "Transparency," that is, 4.6, while the pediatricians offered a score of 4.5, and the care-givers of 4.7. The lowest average score for the item "Hospital environment" was given by the doctors, that is, 3.3, followed by care-givers with a score of 3.6, health care staff 3.7, and children with an average score of 3.8. All the 4 groups included in the study offered a general average of 4.9 out of 5 for the "Intercultural issues" section. The lowest average score for "Time management" section was offered by both children and pediatricians, that is, 4.1, while care-givers and health care staff had a slightly better perception regarding this item, offering 4.2 and 4.3, respectively.The opinion among the 4 groups included in the study was generally similar regarding the 5 items assessed by our questionnaires. Therefore, the main aspects that need to be improved in the health care system in downward order are the following: hospital environment, time management, communication, transparency, and intercultural issues.

Echocardiographic characteristics of pulmonary arterial hypertension in children with horizontally transmitted HIV.

BACKGROUND: The prevalence of primitive pulmonary arterial hypertension (PAH) in patients with human immunodeficiency virus infection (HIV) is estimated at approximately 0.5%, significantly higher than in the general population. OBJECTIVES: This study aimed to assess the echocardiographic modifications in HIV-associated pulmonary arterial hypertension (PAH). MATERIAL AND METHODS: A group of 117 patients, aged under 16, with horizontally transmitted HIV staged according to the U.S. Center for Disease Control and Prevention criteria, were included in this prospective study, with echocardiographic abnormalities in 79 children. The study group consisted of 27 HIV-infected patients with PAH, while the control group consisted of 38 patients with normal ultrasound features. The diagnostic criterion for PAH was the presence of a mean pulmonary artery pressure above 25 mm Hg, determined at 2 consecutive measurements having at least 6 months distance between them. All subjects underwent a complex echocardiographic assessment, including assessment of left and right ventricular hypertrophy and evaluation of left ventricular function, associated with determination of the immunological stage. RESULTS: We recorded the presence of PAH in 27 patients (23.08%), in whom an average value of 31.48 mm Hg was recorded for pulmonary artery pressure. All patients had mild forms of PAH. Age, gender and immunological stage showed no significant differences in the PAH group compared to patients in the control group. Right ventricular hypertrophy was encountered in 95.23% and left ventricular hypertrophy in 88.88% of the patients with PAH. Left ventricular dysfunction, a complication of pulmonary hypertension, was relatively rare (11.11%). CONCLUSIONS: In children with HIV infection, PAH is present in a relatively mild form and does not correlate with the clinical and immunological stage of HIV infection, evolving as a seemingly primitive condition.

Anaesthesia and Intensive Care Residents' Perception of Simulation Training in Four Romanian Centres.

INTRODUCTION: Simulation training offers an opportunity to educate anaesthesia and intensive care (AIC) residents safely. At present, it is not yet a mandatory part of residency curriculum.The aim of the study was to evaluate the residents' perception of the inclusion of simulation-based training in the Romanian AIC residency program. MATERIAL AND METHODS: Romanian AlCs in anaesthesia and intensive care from four training centres completed a twenty-question survey regarding their views on simulation during their residency training. Residents were divided into junior, in the first three years, or senior groups, in the last two years of residency training. The questionnaire included Likert-scale multiple-choice, open-ended, and "yes" or "no"questions regarding simulator learning, the frequency of simulation sessions, and the value of the simulation sessions in improving practice, skills or teamwork. The open-ended questions, asked which were the respondents' preferred topics to be included in simulation sessions. RESULTS: Fifty-six percent of residents completed and returned the questionnaire. Ninety-eight percent of them considered simulation-learning useful once a month or every three months especially in the first two years of training. All residents thought simulation sessions would improve their skills, communication abilities, and teamwork. Senior residents paid more attention to clinical scenarios (p=0.007), haemodynamic monitoring (p=0.017) and mechanical ventilation (p=0.004) as compared to juniors. All residents considered difficult airway management, and cardiac life support to be very important issues to be included in simulation sessions. CONCLUSION: The survey demonstrated that simulation-based training should play a greater role and eventually became compulsory in training program in AIC academic centres.

Perioperative Management of Lactic Acidosis in End-Stage Liver Disease Patient.

Lactic acidosis (LA) in end-stage liver disease (ESLD) patients has been recognized as one of the most complicated clinical problems and is associated with increased morbidity and mortality. Multiple-organ failure, associated with advanced stages of cirrhosis, exacerbates dysfunction of numerous parts of lactate metabolism cycle, which manifests as increased lactate production and impaired clearance, leading to severe LA-induced acidemia. These problems become especially prominent in ESLD patients, that undergo partial hepatectomy and, particularly, liver transplantation. Perioperative management of LA and associated severe acidemia is an inseparable part of anesthesia, post-operative and critical care for this category of patients, presenting a wide variety of challenges. In this review, lactic acidosis applied pathophysiology, clinical implications for ESLD patients, diagnosis, role of intraoperative factors, such as anesthesia and surgery-related, vasoactive agents impact, and also current treatment options and modalities have been discussed.