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Pulmonary thrombo-embolism (PTE) is life threatening manifestation of disease known as venous thrombo-embolism (VTE). VTE is traditionally considered to be very rare in Indian population as compared to westerns. The belief of rarity and/ or ignorance about this disease entity in India had resulted into very little contribution to literature of VTE from this part of the World. Here we present descriptive study of fatal PTE cases autopsied at a Medical Teaching Institute in central India. The predisposing factors observed were prolonged sitting for long distance ground travel, postpartum period after cesarean delivery, carcinoma of uterine cervix, and trauma. The symptoms of PTE appeared suddenly and rapidly progressed to death. Venous stasis was the most important observed risk factor for thrombosis and PTE. [ABSTRACT FROM AUTHOR]

Author(s): C S Manno; V R Arruda; G F Pierce; B Glader; M Ragni; J Rasko; M C Ozelo; K Hoots; P Blatt; B Konkle; M Dake; R Kaye; M [...]

An analysis of cases of violent asphyxial deaths for 10 years at Dr Shankarrao Chavan Government Medical College, Nanded, Maharashtra State, India is presented. Total 554 violent asphyxial deaths were grouped for study purpose, which comprises 5.9 % of all medico-legal autopsies performed during January 2001 to December 2010. Males constitute 63.2% of all the cases with male:female ratio 1.71:1. The study showed the highest deaths in the age group of 21-30 years (31.9%). Drowning (49.1%) and hanging (46.6%) constitute major cause of death among violent asphyxial deaths followed by ligature strangulation (2.5%), Throttling (0.5%), Smothering (0.5%), Traumatic asphyxia (0.5%) and choking (0.2%). The distribution of manner of death showed commonest method of asphyxiation was suicide (57.4%), followed by accidental (30.68%) and homicidal (5.05%). [ABSTRACT FROM AUTHOR]

Injuries by sharp weapon to neck region are possible by many ways but the dilemma to determine its manner of infliction produces mind-numbing challenges in front of autopsy surgeons. Growing urbanization and increased use of locomotives have definitely increased the health hazards especially that of vehicular accidents and deaths. Additional cause of increased vehicular accidents is negligence of driver towards the traffic rules. Cut throat injuries are one of the well known methods of homicide and suicide but accidental cut throat injuries are not infrequent. The manner of causation of cut throat injuries is very crucial part of investigation and many times false allegations and situations are put forth in such cases. The situation further worsens in case of undisturbed crime scene, absence of suicide note and suspicious circumstances. We present here a case of cut throat injury caused by vehicular accident in which manner of death was decided by detailed history, autopsy findings and accurate information about crime scene. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy of covered stents for the treatment of transjugular intrahepatic portosystemic shunt (TIPS) obstruction in human subjects with identified or suspected biliary fistulae.Methods: Five patients were treated for early failure of TIPS revisions. All had mid-shunt thrombus, and four of these had demonstrable biliary fistulae. Three patients also propagated thrombus into the native portal venous system and required thrombolysis. TIPS were revised in four patients using a custom-made polytetrafluoroethylene (PTFE)-covered Wallstent, and in one patient using a custom-made PTFE-covered Gianturco Z-stent.Results: All identified biliary fistulae were successfully sealed. All five patients maintained patency and function of the TIPS during follow-up ranging from 2 days to 21 months (mean 8.4 months). No patient has required additional revision. Thrombosis of the native portal venous system was treated with partial success by mechanical thrombolysis.Conclusion: Early and recurrent failure of TIPS with mid-shunt thrombosis, which may be associated with biliary fistulae, can be successfully treated using covered stents. Stent-graft revision appears to be safe, effective, and potentially durable. [ABSTRACT FROM AUTHOR]

Choking is one of the common accidents that usually occur in the pediatric and geriatric age group patients. In most of the cases the objects causing blockage of internal airway gets coughed out due to natural cough reflex but at times it can cause death. Such deaths occur suddenly without any obvious signs and symptoms raising suspicion about manner of death. We present here two cases at two extreme ages; which were brought with some superstition and suspicion about cause of death and on careful autopsy they turn out to be cases of choking. The importance of careful examination of internal airway is highlighted. [ABSTRACT FROM AUTHOR]

To assess the performance of a self-expanding stent specifically designed for veins (VENOVO Venous Stent) for the treatment of iliac and femoral vein occlusions. The intent-to-treat population included 170 patents, 93 postthrombotic syndrome patients (PTS) and 77 non-thrombotic iliac vein lesion patients (NIVL). [Extracted from the article]

BACKGROUND Patients with chronic limb-threatening ischemia (CLTI) require revascularization to improve limb perfusion and thereby limit the risk of amputation. It is uncertain whether an initial strategy of endovascular therapy or surgical revascularization for CLTI is superior for improving limb outcomes. METHODS In this international, randomized trial, we enrolled 1830 patients with CLTI and infrainguinal peripheral artery disease in two parallel-cohort trials. Patients who had a single segment of great saphenous vein that could be used for surgery were assigned to cohort 1. Patients who needed an alternative bypass conduit were assigned to cohort 2. The primary outcome was a composite of a major adverse limb event -- which was defined as amputation above the ankle or a major limb reintervention (a new bypass graft or graft revision, thrombectomy, or thrombolysis) -- or death from any cause. RESULTS In cohort 1, after a median follow-up of 2.7 years, a primary-outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endovascular group (hazard ratio, 0.68; 95% confidence interval [CI], 0.59 to 0.79; P<0.001). In cohort 2, a primary-outcome event occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years. The incidence of adverse events was similar in the two groups in the two cohorts. CONCLUSIONS Among patients with CLTI who had an adequate great saphenous vein for surgical revascularization (cohort 1), the incidence of a major adverse limb event or death was significantly lower in the surgical group than in the endovascular group. Among the patients who lacked an adequate saphenous vein conduit (cohort 2), the outcomes in the two groups were similar. (Funded by the National Heart, Lung, and Blood Institute; BEST-CLI ClinicalTrials.gov number, NCT02060630.). [ABSTRACT FROM AUTHOR]

Rapid Fluorescence Focus Inhibition Test (RFFIT) is the most widely used cell-based assay to measure the potency of recombinant human rabies monoclonal antibodies. Nonetheless, RFFIT assay is time-consuming and it requires well-equipped biosafety level 2 facility, virulent live rabies virus cultures, permissive cell lines, and well-trained manpower. Therefore, the development of alternative methods to the RFFIT has been encouraged by the World Health Organization (WHO) expert working groups to overcome these barriers. An In-vitro ELISA test has been developed as an alternative to the RFFIT assay, for quantifying the rabies monoclonal antibody (mAb) potency using inactivated rabies virus vaccine (Rabivax-S). It is based on the specific interaction between the antigen and the antibody, that induces neutralizing antibody response to rabies virus. The ELISA was validated involving accuracy and precision within 20 % coefficient of variance. The validation has been done by 4PL standard curve with linearity r 2 ˃ 0.98 and LLOQ of 0.3 μg/mL indicating high assay sensitivity. The specificity of the assay was ascertained by challenging with another homologous non-rabies humanized mAb, which does not show binding with the rabies virus. The indirect ELISA developed here, is precise, robust, and accurate to quantitate the potency of rabies monoclonal antibody. It is highly sensitive and has a broad range of detection. It is easy to perform, and it has a short turnaround time (results available in few hours). Furthermore, it is cost effective and can be performed with low-cost resource setting, as there is no requirement of handling the live cells and live virus and also BSL-2 Facility., Competing Interests: Declaration of competing interest “Serum Institute of India Pvt Ltd has filed a patent on indirect ELISA based potency quantification of both Rabishield main species monoclonal antibody as well as Rabishild monoclonal antibody charge variants with Ambika Divase, Sambhaji Pisal, Chandrashekhar Kamat, Peddi Reddy, and Rajeev Dhere as inventors.” Other authors have declared that no competing interests exist. Rather than above issue, all the authors we have contributed for this research article have no conflict of interest, all co-authors have seen and agree with the contents of the manuscript and certify that the submission is original work and is not under review at any other publication., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Intervention on type B dissection frequently requires landing the proximal edge of the stent graft between the left common carotid artery and left subclavian artery (LSA). The GORE TAG thoracic branch endoprosthesis is a technology that allows LSA preservation with a single internal branch., Methods: This study was a prospective nonrandomized single-arm clinical trial of patients with type B aortic dissection who were treated with the single-branched device. Patients with operative indications for acute, chronic, or residual type B dissections that originated distal to the origin of an LSA suitable for branch graft placement were eligible for the study. Native aortic and surgical graft proximal landing zones were eligible., Results: Of the 132 patients, there were 25 (18.9%) acute type B dissections, 79 (59.8%) chronic type B dissections, and 28 (21.1%) residual dissections after previous open type A repair. Percutaneous access was used in 105 (79.5%) patients. Overall, 30-day mortality occurred in 6 patients (4.5%). The overall 30-day stroke rate was 2 of 132 (1.5%), and the 1-year freedom from stroke was 96.8%. Device technical success and procedural success were achieved in 129 of 132 (97.7%) and 110 of 132 (83.3%) patients, respectively, and there was 1 instance of loss of side branch patency. No persistent antegrade false lumen flow was observed., Conclusions: In this study of a novel branched endograft device to preserve the LSA in patients with type B dissection undergoing thoracic endovascular aortic repair, we demonstrate acceptable safety and efficacy outcomes at 1 year., Competing Interests: Disclosures Dr Desai reports a relationship with W. L. Gore and Associates that includes: consulting or advisory, speaking and lecture fees, and travel reimbursement. Dr Brinkman reports consulting and clinical trial participation with W. L. Gore, Terumo Aortic, and Artivion. Dr Coselli consults for and receives royalties and a departmental educational grant from Terumo Aortic; consults and participates in clinical trials for Medtronic and W. L. Gore & Associates; and participates in clinical trials for Abbott Laboratories, Artivion, CytoSorbents, and Edwards Lifesciences. Dr Patel reports being a consultant for and co-patent holder with W. L. Gore. Dr Dake is a scientific advisory board member for W. L. Gore. Dr Fleischman reports consulting and clinical trial participation with W. L. Gore, Terumo Aortic, and Artivion and consulting relationships with Edwards and Cook. Dr Panneton reports a consulting relationship with Endospan, Terumo Aortic, Medtronic, and W. L. Gore & Associates. Dr Matsumura reports contracted grant/research with University of Colorado. Dr Leshnower reports being a consultant for Medtronic and Endospan. Dr Sanchez is a consultant for W. L. Gore. Dr Bavaria reports consulting and clinical trial participation with W. L. Gore, Terumo Aortic, and Artivion., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Vaccine-induced immunity may impact subsequent de novo responses to drifted epitopes in SARS-CoV-2 variants, but this has been difficult to quantify due to the challenges in recruiting unvaccinated control groups whose first exposure to SARS-CoV-2 is a primary infection. Through local, statewide, and national SARS-CoV-2 testing programs, we were able to recruit cohorts of individuals who had recovered from either primary or post-vaccination infections by either the Delta or Omicron BA.1 variants. Regardless of variant, we observed greater Spike-specific and neutralizing antibody responses in post-vaccination infections than in those who were infected without prior vaccination. Through analysis of variant-specific memory B cells as markers of de novo responses, we observed that Delta and Omicron BA.1 infections led to a marked shift in immunodominance in which some drifted epitopes elicited minimal responses, even in primary infections. Prior immunity through vaccination had a small negative impact on these de novo responses, but this did not correlate with cross-reactive memory B cells, arguing against competitive inhibition of naïve B cells. We conclude that dampened de novo B cell responses against drifted epitopes are mostly a function of altered immunodominance hierarchies that are apparent even in primary infections, with a more modest contribution from pre-existing immunity, perhaps due to accelerated antigen clearance.

The genome of Ignatzschineria sp. strain RMDPL8A was sequenced and analyzed. This draft genome sequence was 2,175,527 bp long, with a GC content of 45.12% and 1,890 protein coding genes., Competing Interests: The authors declare no conflict of interest.

The landfill is a convenient and affordable method of municipal solid waste (MSW) management. Landfill leachate contains a heavy load of pollutants and pathogens. Discharge of untreated leachate is the leading cause of surface and groundwater contamination and a threat to public and environmental health. To develop an efficient leachate treatment technology, an in-depth understanding of landfill chemistry and microbiology is essential. In the present manuscript, we conducted a comparative study of three different landfill leachate samples using cultivation-based and culture-independent molecular studies. We cultivated 85 species of aerobic, anaerobic bacteria and archaea from leachate represented by a total of 200 strains using extensive culturomics approaches. Twelve out of 200 cultivated strains of bacteria showed very low 16S rRNA gene sequence similarity (84-98.6%) with their closest relatives and could be the potential novel taxa, the first time cultivated from leachate. Members of the six genera only have 2-5 representatives from past studies from other habitats but first time cultivated from leachate. In addition to bacteria, we also cultivated and characterized different groups of methanogenic archaea. Our chemistry data indicate that leachate is a highly stressed ecosystem with an assemblage of many toxic wastes like sulfur, zinc, mercury, chromium, etc. 16S rRNA gene-based amplicon analysis showed the dominance of (30-55%) methanogens and haloarachaea. Our data suggest that archaea are the significant regulators of leachate ecology, and more in-depth studies with multiple leachate samples are required to understand their role in leachate nutrient cycling and the development of effective leachate treatment technology., Competing Interests: Declaration of competing interest There is no conflict of interest among the authors for this manuscript., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have shown high efficacy, but immunocompromised participants were excluded from controlled clinical trials. In this study, we compared immune responses to the BNT162b2 mRNA Coronavirus Disease 2019 vaccine in patients with solid tumors (n = 53) who were on active cytotoxic anti-cancer therapy to a control cohort of participants without cancer (n = 50). Neutralizing antibodies were detected in 67% of patients with cancer after the first immunization, followed by a threefold increase in median titers after the second dose. Similar patterns were observed for spike protein-specific serum antibodies and T cells, but the magnitude of each of these responses was diminished relative to the control cohort. In most patients with cancer, we detected spike receptor-binding domain and other S1-specific memory B cell subsets as potential predictors of anamnestic responses to additional immunizations. We therefore initiated a phase 1 trial for 20 cancer cohort participants of a third vaccine dose of BNT162b2 ( NCT04936997 ); primary outcomes were immune responses, with a secondary outcome of safety. At 1 week after a third immunization, 16 participants demonstrated a median threefold increase in neutralizing antibody responses, but no improvement was observed in T cell responses. Adverse events were mild. These results suggest that a third dose of BNT162b2 is safe, improves humoral immunity against SARS-CoV-2 and could be immunologically beneficial for patients with cancer on active chemotherapy., (© 2021. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Vaccines against SARS-CoV-2 have shown high efficacy, but immunocompromised participants were excluded from controlled clinical trials. We compared immune responses to the Pfizer/BioNTech mRNA vaccine in solid tumor patients (n=53) on active cytotoxic anti-cancer therapy to a control cohort (n=50) as an observational study. Using live SARS-CoV-2 assays, neutralizing antibodies were detected in 67% and 80% of cancer patients after the first and second immunizations, respectively, with a 3-fold increase in median titers after the booster. Similar trends were observed in serum antibodies against the receptor-binding domain (RBD) and S2 regions of Spike protein, and in IFN γ + Spike-specific T cells. Yet the magnitude of each of these responses was diminished relative to the control cohort. We therefore quantified RBD- and Spike S1-specific memory B cell subsets as predictors of anamnestic responses to additional immunizations. After the second vaccination, Spike-specific plasma cell-biased memory B cells were observed in most cancer patients at levels similar to those of the control cohort after the first immunization. We initiated an interventional phase 1 trial of a third booster shot (NCT04936997); primary outcomes were immune responses with a secondary outcome of safety. After a third immunization, the 20 participants demonstrated an increase in antibody responses, with a median 3-fold increase in virus-neutralizing titers. Yet no improvement was observed in T cell responses at 1 week after the booster immunization. There were mild adverse events, primarily injection site myalgia, with no serious adverse events after a month of follow-up. These results suggest that a third vaccination improves humoral immunity against COVID-19 in cancer patients on active chemotherapy with no severe adverse events., Competing Interests: Competing interests: Sana Biotechnology has licensed intellectual property of D.B. and Washington University in St. Louis. D.B. is a co-founder of Clade Therapeutics. B.J.L. has a financial interest in Cofactor Genomics, Inc. and Iron Horse Dx. P.C. receives research funding from Pfizer, BioAtla, Zentalis, Genentech, Eli-Lilly, Phoenix Molecular Designs, Amgen, Radius Pharmaceuticals, Carrick Therapeutics, and Angiochem and served on advisory boards for Novartis, Eli Lilly, Zentalis, Astra-Zeneca, Amgen, Bayer, Asthenex, Prosigna, Heron, Puma Biotechnology and Oncosec. R.T.S. receives research funding from Merck, Rafael Pharmaceuticals, ImmunoVaccine, Bayer, SeaGen, Exelixis, Pieris, LOXO Oncology, Novocure, NuCana, QED and has served as a consultant/advisor to Merck, Servier, Astra-Zeneca, EMD Serono, Taiho, QED, Incyte, Genentech, Basilea.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) worldwide has increased the importance of computational tools to design a drug or vaccine in reduced time with minimum risk. Earlier studies have emphasized the important role of RNA-dependent RNA polymerase (RdRp) in SARS-CoV-2 replication as a potential drug target. In our study, comprehensive computational approaches were applied to identify potential compounds targeting RdRp of SARS-CoV-2. To study the binding affinity and stability of the phytocompounds from Phyllanthus emblica and Aegel marmelos within the defined binding site of SARS-CoV-2 RdRp, they were subjected to molecular docking, 100 ns molecular dynamics (MD) simulation followed by post-simulation analysis. Furthermore, to assess the importance of features involved in the strong binding affinity, molecular field-based similarity analysis was performed. Based on comparative molecular docking and simulation studies of the selected phytocompounds with SARS-CoV-2 RdRp revealed that EBDGp possesses a stronger binding affinity (-23.32 kcal/mol) and stability than other phytocompounds and reference compound, Remdesivir (-19.36 kcal/mol). Molecular field-based similarity profiling has supported our study in the validation of the importance of the presence of hydroxyl groups in EBDGp, involved in increasing its binding affinity toward SARS-CoV-2 RdRp. Molecular docking and dynamic simulation results confirmed that EBDGp has better inhibitory potential than Remdesivir and can be an effective novel drug for SARS-CoV-2 RdRp. Furthermore, binding free energy calculations confirmed the higher stability of the SARS-CoV-2 RdRp-EBDGp complex. These results suggest that the EBDGp compound may emerge as a promising drug against SARS-CoV-2 and hence requires further experimental validation., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

Background: The potential advantages of clinical variation reduction are improved patient outcomes and cost reduction through optimizing and standardizing care. Malignant pleural effusion (MPE) is a common condition encountered by thoracic surgeons that has significant variation in cost and outcomes. The purpose of this investigation was to assess the opportunity of improving patient outcomes and reducing cost by using a standardized treatment algorithm based on evidenced-based care., Methods: Patients treated for MPE using a standardized treatment algorithm at the study institution over a 2 year period were identified and propensity matched to MPE patients from 1 of 6 affiliated hospitals with comprehensive oncology and thoracic surgery services. Matched patients were treated at their physicians' discretion. Factors used in propensity matching were age, performance status, and tumor histology. The 2 cohorts were then compared for interventions, admissions and readmissions, morbidity, and pleural effusion-associated costs. Patients who desired only comfort or hospice care were excluded., Results: From 2016 through 2018, 60 patients were treated using the standardized algorithm. These patients were propensity matched and the 2 cohorts compared. Patients treated with the algorithm experienced significantly fewer hospital admissions, readmissions, interventions, and costs while having a comparable procedural morbidity., Conclusions: An evidence-based treatment algorithm for MPE produces superior clinical outcomes to individualized therapy while significantly reducing the costs of care., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: To quantify the hemodynamic consequences of thoracic endovascular aortic repair (TEVAR) by comparing the preoperative and postoperative wall shear stress (WSS) and vorticity profiles on computational fluid dynamics (CFD) simulations., Materials and Methods: The pre- and postoperative computed tomography (CT) scans from 20 consecutive patients (median age 69 years, range 20-87) treated for different thoracic aortic pathologies (11 aneurysms, 5 false aneurysms, 3 penetrating ulcers, and 1 traumatic aortic rupture) were segmented to construct patient-specific CFD models using a meshless code. The simulations were run over the cardiac cycle, and the WSS and vorticity values measured at the proximal and distal landing zones were compared., Results: The CFD runs provided 4-dimensional simulations of blood flow in all patients. WSS and vorticity profiles at the proximal landing zone (located in zones 0-3 in 15 patients) varied in 18 and 20 of the cases, respectively; WSS was increased in 11 cases and the vorticity in 9. Pre- and postoperative WSS median values were 4.19 and 4.90 Pa, respectively. Vorticity median values were 40.38 and 39.17 Hz, respectively., Conclusion: TEVAR induces functional alterations in the native thoracic aorta, though the prognostic significance of these changes is still unknown. CFD appears to be a valuable tool to explore aortic hemodynamics, and its application in a larger series would help define a predictive role for these hemodynamic assessments.

Background: Open surgical closure and small-bore suture-based preclosure devices have limitations when used for transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or percutaneous thoracic endovascular aortic aneurysm repair. The MANTA vascular closure device is a novel collagen-based technology designed to close large bore arteriotomies created by devices with an outer diameter ranging from 12F to 25F. In this study, we determined the safety and effectiveness of the MANTA vascular closure device., Methods and Results: A prospective, single arm, multicenter investigation in patients undergoing transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, or thoracic endovascular aortic aneurysm repair at 20 sites in North America. The primary outcome was time to hemostasis. The primary safety outcomes were accessed site-related vascular injury or bleeding complications. A total of 341 patients, 78 roll-in, and 263 in the primary analysis cohort, were entered in the study between November 2016 and September 2017. For the primary analysis cohort, transcatheter aortic valve replacement was performed in 210 (79.8%), and percutaneous endovascular abdominal aortic aneurysm repair or thoracic endovascular aortic aneurysm repair was performed in 53 (20.2%). The 14F MANTA was used in 42 cases (16%), and the 18F was used in 221 cases(84%). The mean effective sheath outer diameter was 22F (7.3 mm). The mean time to hemostasis was 65±157 seconds with a median time to hemostasis of 24 seconds. Technical success was achieved in 257 (97.7%) patients, and a single device was deployed in 262 (99.6%) of cases. Valve Academic Research Consortium-2 major vascular complications occurred in 11 (4.2%) cases: 4 received a covered stent (1.5%), 3 had access site bleeding (1.1%), 2 underwent surgical repair (0.8%), and 2 underwent balloon inflation (0.8%)., Conclusions: In a selected population, this study demonstrated that the MANTA percutaneous vascular closure device can safely and effectively close large bore arteriotomies created by current generation transcatheter aortic valve replacement, percutaneous endovascular abdominal aortic aneurysm repair, and thoracic endovascular aortic aneurysm repair devices., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02908880.

Innovation has been the cornerstone of interventional radiology since the early years of the founders, with a multitude of new therapeutic approaches developed over the last 50 years. What is the future holding for us? This article presents an overview of the in-coming developments that are catching on at this moment, particularly focusing on three items: the new applications of existing techniques, particularly embolotherapy and interventional oncology; the cutting-edge devices; the imaging technologies at the forefront of the image-guidance. Besides this, clinical vision and patient relation remain crucial for the future of the discipline.

Background: Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients., Methods: Patients who underwent esophageal stent placement for an acute perforation but required conversion to another form of therapy were identified from a prospectively collected institutional database. Excluded were patients whose perforation was associated with a malignancy. Patient demographics, operative and nonoperative invasive procedures, morbidities, mortality, and 6-month follow-up after discharge were reviewed., Results: Between 2008 and 2015, 26 patients who failed to seal their esophageal leak after stent placement were identified. Eighteen (69%) of these patients required an operative repair with primary closure of the perforation. Four (15%) primary repairs had a persistent leak controlled with subsequent stent placement. Four (15%) patients required an esophagectomy with cervical esophagostomy. Three patients (11%), because of comorbid conditions, were referred for hospice care. One patient (3%) refused operative repair and developed a chronic fistula that resolved with subsequent stent placement., Conclusions: Esophageal stent placement continues to be a safe and effective treatment for acute esophageal perforation. Patients whose perforation does not seal with initial stent placement can be treated with primary surgical repair or esophagectomy without increasing their morbidity or mortality or compromising their prognosis., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Palliative care is a medical specialty focused on improving the quality of life of patients and their families with life threatening illness by preventing or relieving suffering. An assessment of a thoracic surgery service was performed to identify the scope and frequency of care that was considered palliative and any implications the findings might have on the current thoracic surgery residency curriculum., Methods: A retrospective review of a prospectively collected database of general thoracic surgery procedures performed over a 5-year period at a single institution was performed. Procedures considered palliative were reviewed for demographics, diagnoses, palliative prognosis score, treatment, morbidity, operative mortality, and survival. Excluded were referrals from thoracic surgery to other specialties for palliative procedures., Results: During the study period, 3842 procedures were performed of which 884 (23%) were palliative. Indications included pleural or pericardial effusion or both, dysphagia, hemoptysis, tracheobronchial obstruction, bronchopleural fistula, and tracheoesophageal fistula. The majority was related to a malignancy. Only 127 patients (14%) had a palliative care assessment before thoracic surgery consultation. Mean survival following thoracic surgery intervention was 110 days for patients with malignancy., Conclusions: This investigation found that thoracic surgeons commonly care for patients when the intention or indication or both is palliation. Most of these patients have an associated malignancy, a poor performance status and a projected significantly decreased survival compared with the general population. Thoracic surgeons should be familiar with the concepts of palliative care and consideration should be given to expanding exposure to the principles of palliative care in the cardiothoracic residency training curriculum., (Copyright © 2017. Published by Elsevier Inc.)

Condensed Abstract: The factors that impact the clinical effectiveness of bare nitinol stents in claudicants with symptomatic femoropopliteal atherosclerosis are incompletely known. The authors analyzed variables that may influence stent durability and provide a benchmark for their effectiveness. Data analyzed from six studies (999 patients) included baseline noninvasive hemodynamic tests, angiographic characteristics, ultrasound defined stent patency and target lesion revascularization through 12-months. Baseline ankle-brachial index and lesion length predicted stent patency and target lesion revascularization and when combined interacted significantly to better predict outcomes. This meta-analysis provides an important comparator against which emerging therapies that treat claudicants with femoropopliteal atherosclerosis can be assessed., Subject Code: Peripheral Artery Disease BACKGROUND: The performance of bare metal nitinol stents in patients with symptomatic femoropopliteal peripheral artery disease (PAD) is not well defined., Methods: Patient-level data from six large prospective trials sponsored by medical device manufacturers was abstracted and analyzed to identify a cohort of patients with claudication and femoropopliteal artery occlusive disease. Twelve-month binary patency and target lesion revascularization (TLR) rates were primary outcomes. Stent patency was assessed by duplex ultrasonography (DUS) and TLR was a clinically driven intervention. To characterize the effects of patient characteristics on the outcomes, meta-regression was performed via mixed effects logistic regression models with patient-level covariates., Results: About 999 patients were analyzed; the mean ABI was 0.68 ± 0.18, the mean lesion length was 84 ± 53 mm, the mean lesion stenosis was 78%, and nearly two thirds of patients had mild to severe calcification. The mean Rutherford clinical category was 2.7 ± 0.6 and ranged from 2.6 to 2.8 in all studies. The 12-month patency across all studies was 69.8% and TLR rates ranged from 9.2% to 19.7%. Multivariable analysis demonstrated that baseline ABI and baseline target lesion length predicted both primary patency and TLR. Further, these two variables interacted significantly to better predict TLR outcomes when used in combination., Conclusion: The 12-month clinical effectiveness of bare nitinol stents to treat patients with symptomatic femoropopliteal PAD is acceptable and is impacted by clinical and lesion-specific characteristics. These data provide an important and useful benchmark to compare the clinical benefit of emerging endovascular PAD therapies. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: Focal aortic rupture may result from expanding aneurysms, penetrating aortic wall ulcerations, or virulent infections. An urgent repair of paravisceral focal aortic rupture is associated with high morbidity. A staged repair approach may provide an alternative option., Case Report: A 64-year-old woman presented with acute focal rupture of the posterior paravisceral aortic wall and was progressing to hemorrhagic shock and mesenteric ischemia. Given the patient's dire condition, an endovascular approach was used to plug her focal aortic wall defect using a ventricular septal defect occluder device. Subsequently, the patient underwent resuscitation, stabilization, and operative exploration. Postoperatively, she recovered well from this staged approach., Conclusions: This case provides an example of a staged endovascular plugging of an acute paravisceral focal aortic rupture. In select cases, this type of repair strategy is feasible, until off-the-shelf endovascular repair options become a reality., (Published by Elsevier Inc.)

Background: A prospective, multidisciplinary care conference (MDC) has been shown to result in measurable benefits for patients with non-small cell lung cancer (NSCLC). However whether a MDC also results in a difference in resource utilization and cost as well as whether these benefits persist across a multiinstitutional system has not been reported. This investigation compared propensity-matched patients with NSCLC whose care was coordinated through a MDC to patients without access to an MDC across a geographically diverse system of hospitals., Methods: The Premiere database (Premier Inc, Charlotte, NC) for a health system's 70 hospitals was used to identify patients undergoing treatment for NSCLC during a 5-year period. Propensity matching was used to populate an MDC and non-MDC cohort. The two cohorts were compared for the costs of staging and diagnosis as well as the timeliness and quality of care metrics., Results: Between 2008 and 2013, 13,254 patients were propensity matched. Patient demographics and Charlson comorbidity scores were comparable after matching. Significant differences were identified in adherence to national guidelines (p < 0.0001) for staging and treatment (p < 0.0001), timeliness of care (p < 0.0001), and costs (p < 0.0001) between the two groups., Conclusions: This investigation found that patients with NSCLC realize improved quality and timeliness of care when that care is coordinated through an MDC. The use of an MDC was also associated with a significant reduction in cost. These differences persisted across a geographically diverse set of hospitals, providers, and patients. Prospective MDCs should be considered integral and compulsory for patients with NSCLC., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Esophageal stent for the treatment of a perforation or anastomotic leak has been shown to be effective and safe. However, the optimal timing for stent removal is in question. This purpose of this investigation was to identify a time for stent removal in patients treated for an acute perforation or anastomotic leak that resulted in sealing of the leak while minimizing the incidence of stent-related complications., Methods: Patients undergoing esophageal stent placement for the treatment of an acute perforation or intrathoracic anastomotic leak were identified from a single institution's prospectively collected database. Patient outcomes were recorded and analyzed. Complications were segregated by stent dwell time., Results: During the study period, 162 patients underwent esophageal stent placement for an acute perforation (n = 117) or anastomotic leak (n = 45). Patients whose stent was removed in less than 28 days after placement for an acute perforation realized a stent complication rate that was independently reduced by 39% (odds ratio, 0.61; 95% confidence interval, 0.54 to 0.78; p < 0.01), whereas patients whose stent was removed in less than 14 days after placement for an acute perforation realized a stent complication rate that was independently reduced by 56% (odds ratio, 0.44; 95% confidence interval, 0.38 to 0.69; p < 0.001)., Conclusions: Endoluminal esophageal stent placement is a safe and effective treatment for patients with an acute esophageal perforation or intrathoracic anastomotic leak after esophagectomy. Removal of stents at 2 weeks for anastomotic leak or 4 weeks for perforation has the potential to significantly decrease the incidence of complications associated with stent use., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Esophageal stent placement has been shown to be a safe and effective treatment for acute esophageal perforation in selected patients. However, a comparison between surgical repair and stent placement has not been reported. This investigation compares the outcomes and costs of the 2 treatment modalities., Methods: The Premiere database for a single health system's hospitals was used to identify patients undergoing treatment for an acute intrathoracic esophageal perforation over a 4-year period. Patient cohorts for stent placement or surgical repair were formed using propensity matching. The 2 cohorts were compared for length of stay, morbidity, mortality, and costs., Results: Between 2009 and 2012, 60 patients undergoing esophageal stent placement or surgical repair were propensity matched. Mean patient age and Charlson comorbidity scores did not differ significantly (P = .4 and P = .4, respectively). Significant differences in morbidity (4% vs 43%; P = .02), mean length of stay (6 vs 11 days; P = .0007), time to oral intake (3 vs 8 days; P = .0004), and cost ($91,000 vs $142,000; P < .0001) were identified in the esophageal stent cohort when compared with patients receiving surgical repair. Operative mortality did not differ significantly., Conclusions: Esophageal stent placement for the treatment of an acute esophageal perforation seems to be as effective as surgical repair when compared between propensity-matched patients. However, stent placement resulted in a shorter length of stay, lower rates of morbidity, and lower costs when compared with traditional surgical repair., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)