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Background: The aim was to investigate whether preoperative weight loss results in improved clinical outcomes in surgical patients with clinically significant obesity. Methods: This was a systematic review and aggregate data meta‐analysis of RCTs and cohort studies. PubMed, MEDLINE, Embase and CINAHL Plus databases were searched from inception to February 2018. Eligibility criteria were: studies assessing the effect of weight loss interventions (low‐energy diets with or without an exercise component) on clinical outcomes in patients undergoing any surgical procedure. Data on 30‐day or all‐cause in‐hospital mortality were extracted and synthesized in meta‐analyses. Postoperative thromboembolic complications, duration of surgery, infection and duration of hospital stay were also assessed. Results: A total of 6060 patients in four RCTs and 12 cohort studies, all from European and North American centres, were identified. Most were in the field of bariatric surgery and all had some methodological limitations. The pooled effect estimate suggested that preoperative weight loss programmes were effective, leading to significant weight reduction compared with controls: mean difference –7·42 (95 per cent c.i. –10·09 to –4·74) kg (P < 0·001). Preoperative weight loss interventions were not associated with a reduction in perioperative mortality (odds ratio 1·41, 95 per cent c.i. 0·24 to 8·40; I2 = 0 per cent, P = 0·66) but the event rate was low. The weight loss groups had shorter hospital stay (by 27 per cent). No differences were found for morbidity. Conclusion: This limited preoperative weight loss has advantages but may not alter the postoperative morbidity or mortality risk. Possible, but how much is enough? [ABSTRACT FROM AUTHOR]

Nicola Ielapi,1,2,&ast; Michele Andreucci,3,&ast; Umberto Marcello Bracale,4 Davide Costa,1,5 Egidio Bevacqua,6 Nicola Giannotta,1,6 Maria Grazia Bevacqua,7 Giuseppe Filiberto Serraino,7 Pasquale Mastroroberto,7 Michele Provenzano,6 Raffaele Serra1,6 1Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology” at the Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy; 2Department of Public Health and Infectious Disease, Sapienza University of Rome, Rome, Italy; 3Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy; 4Department of Public Health, Vascular Surgery Unit, University Federico II of Naples, Naples, Italy; 5Department of Law, Economics and Sociology, University Magna Graecia of Catanzaro, Catanzaro, Italy; 6Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, 88100, Italy; 7Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy&ast;These authors contributed equally to this workCorrespondence: Raffaele SerraDepartment of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy, Email rserra@unicz.itBackground: Venous return in the circulatory system of lower limbs results from the interaction of several mechanisms and reflects the balance between blood inflow and outflow. Blood outflow improves during the lying position especially with leg elevation both in patients with chronic venous disease (CVD) and in healthy subjects in sedentary settings with short-term immobilization. This study evaluated the level of comfort of hospital inpatients, without CVD, lying with a moderate leg elevation during hospital stay.Methods: This was a clinical trial examining 60 consecutive patients referred to vascular surgery, cardiac surgery, and nephrology units. After inclusion, patients were randomly assigned to two groups: A (leg elevation) in which patients were made to lie in the hospital bed with moderate elevation of the legs, and B (no leg elevation) in which patients were made to lie in the hospital bed without leg elevation.Results: The whole population consisted of 40 patients undergoing leg elevation (group A) and 20 without leg elevation (group B). During each day of hospitalization, measurements such as ankle and calf circumference, heart rate, blood pressure, and body temperature were collected. Subjective data such as perceived heaviness in the lower limbs, comfort perception and hours of sleep were also collected. In this study, patients of group A recorded a decrease in calf and ankle circumference (delta in ankle and calf circumference (difference between end of study visit and baseline visit) were significantly decreased in group A vs group B (p< 0.001 for both sides), and patients perceived less leg heaviness and even reported more leg comfort compared to patients of Group B (p< 0.001)). Among patients of group A, the bigger advantage in terms of comfort perception was recorded in patients with 15° leg elevation.Conclusion: Moderate leg elevation during hospital stay seems to effectively improve leg comfort in hospitalized patients.Keywords: venous system, lower limb, circulation, leg elevation, hospital stay, vein symptoms, leg discomfort

Raffaele Serra,1,2,&ast; Umberto Marcello Bracale,3,&ast; Nicola Ielapi,4 Luca Del Guercio,3 Maria Donata Di Taranto,5 Maurizio Sodo,3 Ashour Michael,6 Teresa Faga,6 Egidio Bevacqua,7 Federica Jiritano,7 Giuseppe Fliberto Serraino,7 Pasquale Mastroroberto,7 Michele Provenzano,8 Michele Andreucci6 1Interuniversity Center of Phlebolymphology (CIFL), “Magna Graecia” University, Catanzaro, Italy; 2Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy; 3Department of Public Health, University of Naples “Federico II”, Naples, Italy; 4Department of Public Health and Infectious Disease, “Sapienza” University of Rome, Roma, 00185, Italy; 5Department of Molecular Medicine and Medical Biotechnology, University Federico II of Naples, Naples, Italy; 6Department of Health Sciences, “Magna Graecia” University, Catanzaro, Italy; 7Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, 88100, Italy; 8Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, Italy&ast;These authors contributed equally to this workCorrespondence: Raffaele SerraDepartment of Surgical and Medical Sciences, Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Viale Europa, Catanzaro, 88100, ItalyTel +39 09613647380Email rserra@unicz.itAbstract: Chronic kidney disease (CKD) is a clinical condition characterized by high morbidity and mortality. Globally, CKD is also increasing in prevalence and incidence. The two principal kidney measures namely estimated glomerular filtration rate (eGFR) and albuminuria have been found to be predictors of renal and cardiovascular (CV) endpoints including peripheral artery disease (PAD). The prevalence of PAD was increased in CKD patients and, particularly, in patients with more severe CKD stages. Despite the fact that revascularization strategies are suitable in CKD patients in similar fashion to non-CKD patients, few CKD patients underwent these procedures. In fact, if it is true that revascularization improves prognosis in PAD patients irrespective of baseline eGFR, it was also demonstrated that CKD patients, who underwent revascularization, were at higher risk for amputations, mortality, re-intervention and perioperative complications. With the present review article, we have examined the association between CKD, PAD and peripheral revascularization highlighting data about epidemiology, pathophysiologic mechanisms, and results from previous observational and intervention studies. We have also examined the future perspectives and challenges of research around the association between CKD and PAD.Keywords: chronic kidney disease, CKD, peripheral artery disease, PAD, ESKD, amputations, albuminuria

Background: The aim of this large retrospective study was to provide a logistic risk model along an additive score to predict early mortality after surgical treatment of patients with heart valve or prosthesis infective endocarditis (IE)., Methods: From 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers. The relationship between early mortality and covariates was evaluated with logistic mixed effect models. Fixed effects are parameters associated with the entire population or with certain repeatable levels of experimental factors, while random effects are associated with individual experimental units (centers)., Results: Early mortality was 11.0% (298/2715); At mixed effect logistic regression the following variables were found associated with early mortality: age class, female gender, LVEF, preoperative shock, COPD, creatinine value above 2mg/dl, presence of abscess, number of treated valve/prosthesis (with respect to one treated valve/prosthesis) and the isolation of Staphylococcus aureus, Fungus spp., Pseudomonas Aeruginosa and other micro-organisms, while Streptococcus spp., Enterococcus spp. and other Staphylococci did not affect early mortality, as well as no micro-organisms isolation. LVEF was found linearly associated with outcomes while non-linear association between mortality and age was tested and the best model was found with a categorization into four classes (AUC=0.851)., Conclusions: The following study provides a logistic risk model to predict early mortality in patients with heart valve or prosthesis infective endocarditis undergoing surgical treatment, called "The EndoSCORE"., (Copyright © 2017. Published by Elsevier B.V.)

Objectives: We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design., Methods: Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study., Results: Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P  = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P  < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P  < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P  = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P  = 0.03), renal insufficiency (OR = 2.1; P  = 0.05), triple valve surgery (OR = 6.9; P  = 0.004) and shock (OR = 4.5; P  < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P  < 0.001), Enterococcus (OR = 2.3; P  = 0.01) and female sex (OR = 1.5; P  = 0.03) independently predicted complications, whereas ejection fraction was protective., Conclusions: PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patient's haemodynamic status and microbiological factors., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Viscoelastic point-of-care tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients. We updated existing meta-analyses that have evaluated the clinical effectiveness of viscoelastic point-of-care tests vs the current standard of care for the management of cardiac surgery patients at risk of coagulopathic bleeding. Randomized controlled trials comparing viscoelastic point-of-care diagnostic testing with standard care in cardiac surgery patients were sought. All-cause mortality, blood loss, reoperation, blood transfusion, major morbidity, and intensive care unit and hospital length of stay were analysed using random-effects modelling. Fifteen trials that randomized a total of 8737 participants were included for the analysis. None of the trials was classified as low risk of bias. The use of thromboelastography- (TEG®) or thromboelastometry (ROTEM®)-guided algorithms did not reduce mortality [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.28-1.10] without heterogeneity (I2=1%), reoperation for bleeding, stroke, ventilation time, or hospital length of stay compared with standard care. Use of TEG® or ROTEM® resulted in reductions in the frequency of red blood cell (Risk Ratio 0.88, 95% Confidence Interval 0.79-0.97; I2=43%) and platelet transfusion (Risk Ratio 0.78, 95% Confidence Interval 0.66-0.93; I2=0%). Group Reading Assessment and Diagnostic Evaluation (GRADE) assessment demonstrated that the quality of the evidence was low or very low for all estimated outcomes. Routine use of viscoelastic point-of-care tests did not improve important clinical outcomes beyond transfusion in adults undergoing cardiac surgery., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.)

In the modern era, stroke remains a main cause of morbidity after cardiac surgery despite continuing improvements in the cardiopulmonary bypass (CPB) techniques. The aim of the current work was to numerically investigate the blood flow in aorta and epiaortic vessels during standard and pulsed CPB, obtained with the intra-aortic balloon pump (IABP). A multi-scale model, realized coupling a 3D computational fluid dynamics study with a 0D model, was developed and validated with in vivo data. The presence of IABP improved the flow pattern directed towards the epiaortic vessels with a mean flow increase of 6.3% and reduced flow vorticity.