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Pressure support ventilation (PSV) should be titrated considering the pressure developed by the respiratory muscles (Pmusc) to prevent under- and over-assistance. The esophageal pressure (Pes) is the clinical gold standard for Pmusc assessment, but its use is limited by alleged invasiveness and complexity. The least square fitting method and the end-inspiratory occlusion method have been proposed as non-invasive alternatives for Pmusc assessment. The aims of this study were: (1) to compare the accuracy of Pmusc estimation using the end-inspiration occlusion (Pmusc,index) and the least square fitting (Pmusc,lsf) against the reference method based on Pes; (2) to test the accuracy of Pmusc,lsf and of Pmusc,index to detect overassistance, defined as Pmusc ≤ 1 cmH2O. We studied 18 patients at three different PSV levels. At each PSV level, Pmusc, Pmusc,lsf, Pmusc,index were calculated on the same breaths. Differences among Pmusc, Pmusc,lsf, Pmusc,index were analyzed with linear mixed effects models. Bias and agreement were assessed by Bland–Altman analysis for repeated measures. The ability of Pmusc,lsf and Pmusc,index to detect overassistance was assessed by the area under the receiver operating characteristics curve. Positive and negative predictive values were calculated using cutoff values that maximized the sum of sensitivity and specificity. At each PSV level, Pmusc,lsf was not different from Pmusc (p = 0.96), whereas Pmusc,index was significantly lower than Pmusc. The bias between Pmusc and Pmusc,lsf was zero, whereas Pmusc,index systematically underestimated Pmusc of 6 cmH2O. The limits of agreement between Pmusc and Pmusc,lsf and between Pmusc and Pmusc,index were ± 12 cmH2O across bias. Both Pmusc,lsf ≤ 4 cmH2O and Pmusc,index ≤ 1 cmH2O had excellent negative predictive value [0.98 (95% CI 0.94–1) and 0.96 (95% CI 0.91–0.99), respectively)] to identify over-assistance. The inspiratory effort during PSV could not be accurately estimated by the least square fitting or end-inspiratory occlusion method because the limits of agreement were far above the signal size. These non-invasive approaches, however, could be used to screen patients at risk for absent or minimal respiratory muscles activation to prevent the ventilator-induced diaphragmatic dysfunction.

The most beneficial effect of corticosteroid therapy in COVID-19 patients has been shown in subjects receiving invasive mechanical ventilation (IMV), corresponding to a score of 6 on the World Health Organization (WHO) COVID-19 Ordinal Scale for Clinical Improvement (OSCI). The aim of this observational, single-center, prospective study was to assess the association between corticosteroids and hospital mortality in coronavirus disease 2019 (COVID-19) patients who did not receive IMV (OSCI 3-5). Included were 1,311 COVID-19 patients admitted to nonintensive care wards, and they were divided in two cohorts: (i) 480 patients who received corticosteroid therapy and (ii) 831 patients who did not. The median daily dose was of 8 mg of dexamethasone or equivalent, with a mean therapy duration of 5 (3-9) days. The indication to administer or withhold corticosteroids was given by the treating physician. In-hospital mortality was similar between the two cohorts after adjusting for possible confounders (adjusted odds ratio (ORadj) 1.04, 95% confidence interval (CI), 0.81-1.34, P = 0.74). There was also no difference in Intensive Care Unit (ICU) admission (ORadj 0.81, 95% CI, 0.56-1.17, P = 0.26). COVID-19 patients with noninvasive mechanical ventilation (NIMV) had a lower risk for ICU admission if they received steroid therapy (ORadj 0.58, 95% CI, 0.35-0.94, P = 0.03). In conclusion, corticosteroids were overall not associated with a difference in hospital mortality for patients with COVID-19 with OSCI 3-5. In the subgroup of patients with NIMV (OSCI 5), corticosteroids reduced ICU admission, whereas the effect on mortality requires further studies.

BACKGROUND: The ratio of dead space to tidal volume (VD/VT) is associated with mortality in patients with ARDS. Corrected minute ventilation ([Formula: see text]) is a simple surrogate of dead space, but, despite its increasing use, its association with mortality has not been proven. The aim of our study was to assess the association between [Formula: see text] and hospital mortality. We also compared the strength of this association with that of estimated VD/VT and ventilatory ratio.METHODS: We performed a retrospective study with prospectively collected data. We evaluated 187 consecutive mechanically ventilated subjects with ARDS caused by novel coronavirus disease (COVID-19). The association between [Formula: see text] and hospital mortality was assessed in multivariable logistic models. The same was done for estimated VD/VT and ventilatory ratio.RESULTS: Mean ± SD [Formula: see text] was 11.8 ± 3.3 L/min in survivors and 14.5 ± 3.9 L/min in nonsurvivors (P < .001) and was independently associated with mortality (adjusted odds ratio 1.15, P = .01). The strength of association of [Formula: see text] with mortality was similar to that of VD/VT and ventilatory ratio.CONCLUSIONS: [Formula: see text] was independently associated with hospital mortality in subjects with ARDS caused by COVID-19. [Formula: see text] could be used at the patient's bedside for outcome prediction and severity stratification, due to the simplicity of its calculation. These findings need to be confirmed in subjects with ARDS without viral pneumonia and when lung-protective mechanical ventilation is not rigorously applied.

The sacroiliac joints connect the base of the sacrum to the ilium. When inflamed, they are suspected to cause low back pain. Inflammation of the sacroiliac joints is called sacroiliitis. The severity of the pain varies and depends on the degree of inflammation. Sacroiliitis is a hallmark of seronegative spondyloarthropathies. The presence or absence of chronic sacroiliitis is an important clue in the diagnosis of low back pain. This article aims to provide a concise overview of the anatomy, physiology, and molecular biology of sacroiliitis to aid clinicians in the assessment and management of sacroiliitis. For this narrative review, we evaluated articles in English published before August 2019 in PubMed. Then, we selected articles related to the painful manifestations of the sacroiliac joint. From the retrieved articles, we found that chronic sacroiliitis may be caused by various forms of spondyloarthritis, such as ankylosing spondyloarthritis. Sacroiliitis can also be associated with inflammatory bowel disease, Crohn’s disease, gout, tuberculosis, brucellosis, and osteoarthritis, indicating common underlying etiological factors. The pathophysiology of sacroiliitis is complex and may involve internal, environmental, immunological, and genetic factors. Finally, genetic factors may also play a central role in progression of the disease. Knowing the genetic pre-disposition for sacroiliitis can be useful for diagnosis and for formulating treatment regimens, and may lead to a substantial reduction in disease severity and duration and to improved patient performance.

BACKGROUND: ARDS in patients with coronavirus disease 2019 (COVID-19) is characterized by microcirculatory alterations in the pulmonary vascular bed, which could increase dead-space ventilation more than in non-COVID-19 ARDS. We aimed to establish if dead-space ventilation is different in patients with COVID-19 ARDS when compared with patients with non-COVID-19 ARDS.METHODS: A total of 187 subjects with COVID-19 ARDS and 178 subjects with non-COVID-19 ARDS who were undergoing invasive mechanical ventilation were included in the study. The association between the ARDS types and dead-space ventilation, compliance of the respiratory system, subjects' characteristics, organ failures, and mechanical ventilation was evaluated by using data collected in the first 24 h of mechanical ventilation.RESULTS: Corrected minute ventilation (V˙E), a dead-space ventilation surrogate, was higher in the subjects with COVID-19 ARDS versus in those with non-COVID-19 ARDS (median [interquartile range] 12.6 [10.2-15.8] L/min vs 9.4 [7.5-11.6] L/min; P < .001). Increased corrected V˙E was independently associated with COVID-19 ARDS (odds ratio 1.24, 95% CI 1.07-1.47; P = .007). The best compliance of the respiratory system, obtained after testing different PEEPs, was similar between the subjects with COVID-19 ARDS and the subjects with non-COVID-19 ARDS (mean ± SD 38 ± 11 mL/cm H2O vs 37 ± 11 mL/cm H2O, respectively; P = .61). The subjects with COVID-19 ARDS received higher median (interquartile range) PEEP (12 [10-14] cm H2O vs 8 [5-9] cm H2O; P < .001) and lower median (interquartile range) tidal volume (5.8 [5.5-6.3] mL/kg vs 6.6 [6.1-7.3] mL/kg; P < .001) than the subjects with non-COVID-19 ARDS, being these differences maintained at multivariable analysis. In the multivariable analysis, the subjects with COVID-19 ARDS showed a lower risk of anamnestic arterial hypertension (odds ratio 0.18, 95% CI 0.07-0.45; P < .001) and lower neurologic sequential organ failure assessment score (odds ratio 0.16, 95% CI 0.09-0.27; P < .001) than the subjects with non-COVID-19 ARDS.CONCLUSIONS: Indirect measurements of dead space were higher in subjects with COVID-19 ARDS compared with subjects with non-COVID-19 ARDS. The best compliance of the respiratory system was similar in both ARDS forms provided that different PEEPs were applied. A wide range of compliance is present in every ARDS type; therefore, the setting of mechanical ventilation should be individualized patient by patient and not based on the etiology of ARDS.

OBJECTIVES: Early tracheotomy, defined as a procedure performed within 10 days from intubation, is associated with more ventilator free days, shorter ICU stay, and lower mortality than late tracheotomy. During the coronavirus disease 2019 pandemic, it was especially important to save operating room resources and to have a shorter ICU stay for patients, when ICUs had insufficient beds. In this context of limited resources, early percutaneous tracheostomy could be an effective way to manage mechanically ventilated patients. Nevertheless, current recommendations suggest delaying or avoiding the tracheotomy in coronavirus disease 2019 patients. Aim of the study was to analyze the hospital mortality of coronavirus disease 2019 patients who had received early percutaneous tracheostomy and factors associated with removal of tracheostomy cannula at ICU discharge.DESIGN: Cohort study.SETTING: Coronavirus disease 2019 ICU.PATIENTS: Adult patients with coronavirus disease 2019 3 days after ICU admission.INTERVENTIONS: None.MEASUREMENTS AND MAIN RESULTS: Three days after ICU admission, 164 patients were present in ICU and included in the analysis. One-hundred and twenty-one patients (74%) were tracheostomized, whereas the other 43 (26%) were managed with translaryngeal intubation only. In multivariable analysis, early percutaneous tracheostomy was associated with lower hospital mortality. Sixty-six of tracheostomized patients (55%) were discharged alive from the hospital. Age and male sex were the only characteristics that were independently associated with mortality in the tracheostomized patients (45.5% and 62.8% in tracheostomized and nontracheostomized patients, respectively; p = 0.009). Tracheostomy tube was removed in 47 of the tracheostomized patients (71%). The only variable independently associated with weaning from tracheostomy at ICU discharge was a faster start of spontaneous breathing after tracheotomy was performed.CONCLUSIONS: Early percutaneous tracheostomy was safe and effective in coronavirus disease 2019 patients, giving a good chance of survival and of weaning from tracheostomy cannula at ICU discharge.

Since the start of the novel coronavirus 2019 (COVID-19) pandemic, corticosteroid use has been the subject of debate. The available evidence is uncertain, and knowledge on the subject is evolving. The aim of our cohort study was to evaluate the association between corticosteroid therapy and hospital mortality, in patients hospitalized with COVID-19 after balancing for possible confounders. One thousand four hundred forty four patients were admitted to our hospital with a positive RT-PCR test for SARS-CoV-2, 559 patients (39%) were exposed to corticosteroids during hospital stay, 844 (61%) were not exposed to corticosteroids. In the cohort of patients exposed to corticosteroids, 171 (30.6%) died. In the cohort of patients not exposed to corticosteroids, 183 (21.7%) died (unadjusted p p = 0.25). Patients in the corticosteroids cohort had a reduced risk of ICU admission (adjusted p

BACKGROUND: A recent systematic review recommends against the use of any of the current COVID-19 prediction models in clinical practice. To enable clinicians to appropriately profile and treat suspected COVID-19 patients at the emergency department (ED), externally validated models that predict poor outcome are desperately needed.OBJECTIVE: Our aims were to identify predictors of poor outcome, defined as mortality or ICU admission within 30 days, in patients presenting to the ED with a clinical suspicion of COVID-19, and to develop and externally validate a prediction model for poor outcome.METHODS: In this prospective, multi-center study, we enrolled suspected COVID-19 patients presenting at the EDs of two hospitals in the Netherlands. We used backward logistic regression to develop a prediction model. We used the area under the curve (AUC), Brier score and pseudo-R2 to assess model performance. The model was externally validated in an Italian cohort.RESULTS: We included 1193 patients between March 12 and May 27 2020, of whom 196 (16.4%) had a poor outcome. We identified 10 predictors of poor outcome: current malignancy (OR 2.774; 95%CI 1.682-4.576), systolic blood pressure (OR 0.981; 95%CI 0.964-0.998), heart rate (OR 1.001; 95%CI 0.97-1.028), respiratory rate (OR 1.078; 95%CI 1.046-1.111), oxygen saturation (OR 0.899; 95%CI 0.850-0.952), body temperature (OR 0.505; 95%CI 0.359-0.710), serum urea (OR 1.404; 95%CI 1.198-1.645), C-reactive protein (OR 1.013; 95%CI 1.001-1.024), lactate dehydrogenase (OR 1.007; 95%CI 1.002-1.013) and SARS-CoV-2 PCR result (OR 2.456; 95%CI 1.526-3.953). The AUC was 0.86 (95%CI 0.83-0.89), with a Brier score of 0.32 and, and R2 of 0.41. The AUC in the external validation in 500 patients was 0.70 (95%CI 0.65-0.75).CONCLUSION: The COVERED risk score showed excellent discriminatory ability, also in an external validation. It may aid clinical decision making, and improve triage at the ED in health care environments with high patient throughputs.

Background The evaluation of patient effort is pivotal during pressure support ventilation, but a non-invasive, continuous, quantitative method to assess patient inspiratory effort is still lacking. We hypothesized that the concavity of the inspiratory flow-time waveform could be useful to estimate patient’s inspiratory effort. The purpose of this study was to assess whether the shape of the inspiratory flow, as quantified by a numeric indicator, could be associated with inspiratory effort during pressure support ventilation. Methods Twenty-four patients in pressure support ventilation were enrolled. A mathematical relationship describing the decay pattern of the inspiratory flow profile was developed. The parameter hypothesized to estimate effort was named Flow Index. Esophageal pressure, airway pressure, airflow, and volume waveforms were recorded at three support levels (maximum, minimum and baseline). The association between Flow Index and reference measures of patient effort (pressure time product and pressure generated by respiratory muscles) was evaluated using linear mixed effects models adjusted for tidal volume, respiratory rate and respiratory rate/tidal volume. Results Flow Index was different at the three pressure support levels and all group comparisons were statistically significant. In all tested models, Flow Index was independently associated with patient effort (p Flow Index prediction of inspiratory effort agreed with esophageal pressure-based methods. Conclusions Flow Index is associated with patient inspiratory effort during pressure support ventilation, and may provide potentially useful information for setting inspiratory support and monitoring patient-ventilator interactions.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has led to widespread use of hydroxychloroquine and azithromycin despite the lack of conclusive evidence for their safety and efficacy. We evaluated the association between treatment with hydroxychloroquine and/or azithromycin and hospital mortality as the primary outcome. We compared the hospital mortality of patients treated with hydroxychloroquine alone, azithromycin alone, or their combination to the mortality of patients who received neither drug. A logistic multivariate model with overlap weight propensity score was used for estimation of odds ratios (ORs) with 95% confidence intervals (95% CIs). One thousand four hundred and three patients with SARS-CoV-2 infection were admitted to the hospital. At the time of the analysis, the outcome was available for 1376 (98%) of them. Five hundred and eighty-seven patients (42%) received azithromycin and 377 patients (27%) received hydroxychloroquine, alone or in combination. In-hospital mortality was 26%. After the adjusted analysis, azithromycin alone was associated with lower mortality (OR 0.60, 95% CI 0.42&ndash, 0.85) compared to no treatment. Hydroxychloroquine alone (OR 0.76, 95% CI 0.53&ndash, 1.08) and the combination of azithromycin and hydroxychloroquine (OR 1.13, 95% CI 0.77&ndash, 1.69) were not associated with hospital mortality. In this cohort of patients, azithromycin alone was associated with lower hospital mortality but hydroxychloroquine was not associated with increased or reduced mortality. While we await randomized clinical trials, these data support the use of azithromycin in novel coronavirus disease 2019 (COVID-19) and can contribute to better understanding of its role in further meta-analyses.

BackgroundSince the start of the novel coronavirus 2019 (COVID-19) pandemic, corticosteroid use has been the subject of debate. The available evidence is uncertain, and knowledge on the subject is evolving. The aim of our cohort study was to evaluate the association between corticosteroid therapy and hospital mortality, in patients hospitalized with COVID-19 after balancing for possible confounders.ResultsOne thousand four hundred forty four patients were admitted to our hospital with a positive RT-PCR test for SARS-CoV-2, 559 patients (39%) were exposed to corticosteroids during hospital stay, 844 (61%) were not exposed to corticosteroids.In the cohort of patients exposed to corticosteroids, 171 (30.6%) died. In the cohort of patients not exposed to corticosteroids, 183 (21.7%) died (unadjusted p ConclusionsTreatment with corticosteroids did not affect hospital mortality in patients with COVID-19 after balancing for confounders. A possible advantage of corticosteroid therapy was to reduce Intensive Care Unit admission, which could be useful in reducing pressure on the Intensive Care Units in times of limited resources, as during the COVID-19 pandemic.

BACKGROUND: Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) infection is associated with hypercoagulability caused by direct invasion of endothelial cells and\or proinflammatory cytokine release. Thromboprophylaxis with enoxaparin is recommended by current guidelines, but evidence is still weak. The aim of this study was to assess the impact of thromboprophylaxis with enoxaparin on hospital mortality in patients admitted for Coronavirus disease 2019 (COVID-19). The effects of enoxaparin on intensive care admission and hospital length-of-stay were evaluated as secondary outcomes.METHODS: Observational cohort study, with data collected from patients admitted to Poliambulanza Foundation with positive real time reverse transcription polymerase chain reaction (RT-PCR) for SARS-CoV-2 from 20th February to 10th May 2020. Multivariate logistic regression with overlap weight propensity score was used to model hospital mortality and intensive care admission, hospital length-of-stay was analyzed with a multivariate Poisson regression. Seven hundred and ninety nine (57%) patients who received enoxaparin at least once during the hospitalization were included in the enoxaparin cohort, 604 (43%) patients who did not were included in the control cohort.FINDINGS: At the adjusted analysis enoxaparin was associated with lower in-hospital mortality (Odds Ratio 0·53, 95% C.I. 0·40-0·70) compared with no enoxaparin treatment. Hospital length-of-stay was longer for patients treated with enoxaparin (Incidence Rate Ratios 1·45, 95% C.I. 1·36-1·54). Enoxaparin treatment was associated with reduced risk of intensive care admission at the adjusted analysis (Odds Ratio 0·48, 95% C.I. 0·32-0·69).INTERPRETATION: This study shows that treatment with enoxaparin during hospital stay is associated with a lower death rate and, while results from randomized clinical trials are still pending, this study supports the use of thromboprophylaxis with enoxaparin in all patients admitted for COVID-19. Moreover, when enoxaparin is used on the wards, it reduces the risk of Intensive Care Unit admission.

Objective The aim of our study was to determine the incidence, characteristics, and clinical outcomes of patients with the novel coronavirus (COVID-19) infection who had presented with and been treated for acute limb ischemia (ALI) during the 2020 coronavirus pandemic. Methods We performed a single-center, observational cohort study. The data from all patients who had tested positive for COVID-19 and had presented with ALI requiring urgent operative treatment were collected in a prospectively maintained database. For the present series, successful revascularization of the treated arterial segment was defined as the absence of early ( Results We evaluated the data from 20 patients with ALI who were positive for COVID-19. For the period from January to March, the incidence rate of patients presenting with ALI in 2020 was significantly greater than that for the same months in 2019 (23 of 141 [16.3%] vs 3 of 163 [1.8%]; P Conclusions In our preliminary experience, the incidence of ALI has significantly increased during the COVID-19 pandemic in the Italian Lombardy region. Successful revascularization was lower than expected, which we believed was due to a virus-related hypercoagulable state. The use of prolonged systemic heparin might improve surgical treatment efficacy, limb salvage, and overall survival.

ObjectiveSingle cases and small series of Guillain-Barré syndrome (GBS) have been reported during the SARS-CoV-2 outbreak worldwide. We evaluated incidence and clinical features of GBS in a cohort of patients from two regions of northern Italy with the highest number of patients with COVID-19.MethodsGBS cases diagnosed in 12 referral hospitals from Lombardy and Veneto in March and April 2020 were retrospectively collected. As a control population, GBS diagnosed in March and April 2019 in the same hospitals were considered.ResultsIncidence of GBS in March and April 2020 was 0.202/100 000/month (estimated rate 2.43/100 000/year) vs 0.077/100 000/month (estimated rate 0.93/100 000/year) in the same months of 2019 with a 2.6-fold increase. Estimated incidence of GBS in COVID-19-positive patients was 47.9/100 000 and in the COVID-19-positive hospitalised patients was 236/100 000. COVID-19-positive patients with GBS, when compared with COVID-19-negative subjects, showed lower MRC sum score (26.3±18.3 vs 41.4±14.8, p=0.006), higher frequency of demyelinating subtype (76.6% vs 35.3%, p=0.011), more frequent low blood pressure (50% vs 11.8%, p=0.017) and higher rate of admission to intensive care unit (66.6% vs 17.6%, p=0.002).ConclusionsThis study shows an increased incidence of GBS during the COVID-19 outbreak in northern Italy, supporting a pathogenic link. COVID-19-associated GBS is predominantly demyelinating and seems to be more severe than non-COVID-19 GBS, although it is likely that in some patients the systemic impairment due to COVID-19 might have contributed to the severity of the whole clinical picture.

Background Post-traumatic cerebral infarction (PTCI) is common after traumatic brain injury (TBI). It is unclear what the occurrence of a PTCI is, how it impacts the long-term outcome, and whether it adds incremental prognostic value to established outcome predictors. Methods This was a prospective multicenter cohort study of moderate and severe TBI patients. The primary objective was to evaluate if PTCI was an independent risk factor for the 6-month outcome assessed with the Glasgow Outcome Scale (GOS). We also assessed the PTCI occurrence and if it adds incremental value to the International Mission for Prognosis and Clinical Trial design in TBI (IMPACT) core and extended models. Results We enrolled 143 patients, of whom 47 (32.9%) developed a PTCI. In the multiple ordered logistic regression, PTCI was retained in both the core and extended IMPACT models as an independent predictor of the GOS. The predictive performances increased significantly when PTCI was added to the IMPACT core model (AUC = 0.73, 95% C.I. 0.66–0.82; increased to AUC = 0.79, 95% CI 0.71–0.83, p = 0.0007) and extended model (AUC = 0.74, 95% C.I. 0.65–0.81 increased to AUC = 0.80, 95% C.I. 0.69–0.85; p = 0.00008). Patients with PTCI showed higher ICU mortality and 6-month mortality, whereas hospital mortality did not differ between the two groups. Conclusions PTCI is a common complication in patients suffering from a moderate or severe TBI and is an independent risk factor for long-term disability. The addition of PTCI to the IMPACT core and extended predictive models significantly increased their performance in predicting the GOS. Trial registration The present study was registered in ClinicalTrial.gov with the ID number NCT02430324.

Background: Post-traumatic cerebral infarction (PTCI) is common in patients dying after a traumatic brain injury (TBI). It is unclear what the occurrence of a PTCI is, how it impacts the long-term outcome, and whether it adds incremental prognostic value to established outcome predictors. Methods: This was a prospective multicenter cohort study of moderate and severe TBI patients admitted to nine Italian intensive care units (ICUs). The primary objective was to evaluate if PTCI was an independent risk factor for the 6-month outcome assessed with the Glasgow Outcome Scale (GOS). We also assessed the PTCI occurrence and if it adds incremental value to the International Mission for Prognosis and Clinical Trial design in TBI (IMPACT) core and extended models. Findings: We enrolled 143 patients; 47 (32·9%) developed a PTCI for a total of 94. The mean (SD) onset time of a PTCI was 6·2 (11·4). In the multiple ordered logistic regression, PTCI was retained in both the core and extended IMPACT models as an independent predictor of the GOS. The predictive performances increased significantly when PTCI was added to the IMPACT core model (AUC=0·73, 95% C.I. 0·66-0·82; increased to AUC=0·79, 95% CI 0·71-0·83, p=0·0007) and extended model (AUC=0·74, 95% C.I.: 0·65-0·81 increased to AUC=0·80, 95% C.I. 0·69-0·85; p=0·00008). Patients with a PTCI showed higher ICU mortality (10 patients [21·3%] vs one patient [1·0%], p

The purpose of this study was to evaluate early and midterm results of tibial bypasses comparing precuffed expanded polytetrafluoroethylene (PTFE) graft (Distaflo) and heparin-bonded PTFE graft (Propaten) with a distal vein patch.This is a retrospective cohort analysis evaluating patients who underwent PTFE femorocrural bypasses between April 2004 and December 2010 at the Vascular Surgery Division of the Poliambulanza Foundation Hospital (Brescia, Italy). Results were analyzed in terms of primary and secondary graft patency, limb salvage, and survival with univariate (Kaplan-Meier curves and log-rank test) and multivariate (Cox regression) analyses.After analyzing many patients, we found 79 femorotibial bypass PTFE grafts. We used a Propaten graft and vein patch in 40 patients and a Distaflo graft in 39 patients. The two groups were comparable for main risk factors, except for age. Indication for surgical revascularization was critical limb ischemia in all patients. In 54 cases (68%), it was a redo bypass because of a previously failed revascularization. Perioperative mortality within 30 days from intervention was 2.5%, whereas overall mortality during follow-up was 29%, with a 36-month survival rate of 58% (95% confidence interval [CI]: 0.44-0.77) on life table analysis. We observed a significant difference between two groups in terms of survival at 36 months (Propaten: 0.84 [95% CI: 0.69-1]; Distaflo: 0.21 [95% CI: 0.07-0.63]; P0.001; 95% CI: 0.07-0.63; odds ratio [OR]: 0.21). At 24 months, the two groups (Propaten vs. Distaflo) were equivalent in terms of primary patency (Propaten: 0.33 [95% CI: 0.21-0.53]; Distaflo: 0.47 [95% CI: 0.32-0.70]; P = 0.793), secondary patency (Propaten: 0.36 [95% CI: 0.23-0.57]; Distaflo: 0.49 [95% CI: 0.33-0.72]; P = 0.855), and limb salvage (Propaten: 0.65 [95% CI: 0.51-0.84]; Distaflo: 0.57 [95% CI: 0.41-0.79]; P = 0.18). At Cox regression analysis, age of80 years (P0.04; 95% CI: 0.23-0.95; OR: 0.47), peroneal artery distal anastomosis (P0.04; 95% CI: 1.04-5.62; OR: 2.42), simultaneous adjunctive procedures (P0.02; 95% CI: 1.21-17.74; OR: 4.64), and redo bypass (P0.05; 95% CI: 1-6.26; OR: 2.5) were associated with long-term poorer primary patency rates. Postoperative treatment with warfarin therapy compared with antiplatelet therapy was independently associated with better secondary patency (P0.04; 95% CI: 0.20-0.95; OR: 0.44) and limb salvage (P0.03; 95% CI: 0.11-0.87; OR: 0.32) rates.Distaflo and Propaten with a distal vein patch in our experience have similar patency and limb salvage results, although further randomized and larger studies are necessary. Postoperative anticoagulation therapy seems better than antiplatelet therapy in terms of patency and limb salvage rate.

Objective The history of left ventricular reconstruction has demonstrated that the full spectrum of recoverable physiologic parameters is essential for a good functional result. We report the long-term outcome of a new surgical technique that arranges myocardial fibers in a near-normal disposition, also recovering left ventricular twisting. Methods Between May 2006 and October 2013, 29 consecutive patients with previous anterior myocardial infarction and heart failure symptoms underwent physiologic left ventricular reconstruction surgery and coronary revascularization. Patients were examined by means of standard echocardiography and 2-dimensional speckle tracking at 8 time steps until 7 years after surgery. Ten geometric and functional parameters were evaluated at each step and analyzed by the linear mixed model test. Results Hospital mortality was 0%. The mean percentage of indexed end-diastolic and end-systolic volume reduction was 45.7% and 50.9%, respectively. Ejection fraction and all of the volumes were significantly different in the postoperative period with a steady correction during time. Diastolic parameters were not worsened by surgical reconstruction. Ejection fraction and deceleration time showed a significant improvement during time. Left ventricular torsion increased immediately after the surgical correction from 2.8 ± 4.4 degrees to 8.7 ± 3.9 degrees ( P = .02) and was still present 4 years after surgery. Conclusions Surgical conduction of ventricular reconstruction should be standardized to achieve the full spectrum of recoverable physiologic parameters. The renewal of ventricular torsion should be pursued as an adjunctive element of ventricular efficiency, mainly in ventricles that work at a critical level in the Frank–Starling relationship and pressure-volume loop.

We compared the risk of pulmonary aspiration in patients whose lungs were mechanically ventilated through a laryngeal mask airway (35 630 procedures) or tracheal tube (30 082 procedures). Three cases of pulmonary aspiration occurred with the laryngeal mask airway and seven with the tracheal tube. There were no deaths related to pulmonary aspiration. The incidence and outcome of pulmonary aspiration detected in this study were similar to those previously reported. The adjusted odds ratio (OR) for pulmonary aspiration with the laryngeal mask airway was 1.06 (95% CI 0.20-5.62). Unplanned surgery (OR 30.5, 95% CI 8.6-108.9) and male sex (OR 8.6, 95% CI 1.1-68) were associated with an increased risk of aspiration and age < 14 years with a reduced risk (OR 0.21, 95% CI 0.07-0.64). There were contraindications and exclusions to the use of the laryngeal mask airway but in this selected population the use of an laryngeal mask airway was not associated with an increased risk of pulmonary aspiration compared with a tracheal tube.

Background The ProSeal™ laryngeal mask airway (PLMA) may have advantages over the laryngeal mask airway (LMA† †LMA® is the property of Intavent Limited.) in obese patients. We tested this hypothesis in a clinical setting. Methods Sixty obese patients (BMI >30) were randomized to receive mechanical ventilation (tidal volume 7 ml kg−1, PEEP 10 cm H2O), through either the PLMA or the LMA. A gastric tube was used in all patients. Cuff pressure was set at 60 cm H2O and increased progressively until excessive leak occurred. The incidence of sore throat was assessed at recovery and after 1 week. Results The mean leak fraction was 6.1 (sd 2.9)% with the LMA and 6.4 (3.5)% with the PLMA (P=0.721). With the PLMA, with no sign of ventilation problems, the drainage tube was not patent in three patients. The cuff pressure was >100 cm H2O in 38% of the LMA group and 7% of the PLMA group (P=0.05). The incidence of sore throat was similar in both groups and it was similarly scored in the recovery room and 1 week after surgery. Conclusions Both the PLMA and the LMA can be used for mechanical ventilation of obese patients. The patency of the PLMA drainage tube needs to be checked constantly even when an optimal airtight seal is present. In obese patients the LMA requires a greater cuff pressure than the PLMA, but sore throat is not related to the cuff pressure. Sore throat assessment in the recovery room appears as reliable as assessment later.

In reply: We are grateful to Dr Appendini and colleagues for their comment and appreciation. The similar expiratory time used in patients with high and low auto-PEEP levels does not diminish the lack of relationship between auto-PEEP and expiratory time (if anything, it made the statistical

Study objective To compare the frequency of airway seal and sore throat with the LMA-ProSeal™ (PLMA) and the standard Laryngeal Mask Airway™ (LMA) during laparoscopic surgery. Design Prospective, controlled, randomized, nonblinded clinical study. Setting University-affiliated hospital. Patients 60 adult, ASA physical status I, II, and III patients undergoing laparoscopic surgery with general anesthesia, without contraindication to the use of the laryngeal mask. Inteventions Patients were randomized to receive mechanical ventilation [tidal volume ( V T ) 7 mL/kg -1 ; positive end-expiratory pressure (PEEP) 10 cmH 2 O] through the PLMA or the standard LMA, both equipped with a gastric tube. Measurements Heart rate, arterial pressure, inspiratory and expiratory V T , airway pressure, end-tidal CO 2 partial pressure, and pulse oximetry were recorded. The leak fraction was calculated as the difference between the inspiratory and expiratory V T divided by the inspiratory V T . Postoperative sore throat frequency was scored in the recovery room ("early") and 1 week after surgery ("late"). Main results All patients were successfully ventilated through the assigned laryngeal mask. The leak fraction was 7 ± 3% with the LMA and 7 ± 4% with the PLMA ( p = 0.731). In one patient, the PLMA drainage tube was not patent despite a leak fraction of 5%, and there was no clinically detectable air leak. During the recovery room stay, the frequency of sore throat was scored as mild in 13% and 10% of patients with the standard LMA and the PLMA, respectively, and was absent in the remaining patients ( p = 0.99, between groups). There were no differences in the frequency of sore throat between the "early" and "late" evaluations ( p = 0.99). Conclusions The PLMA and the LMA show similar airtight efficiency during laparoscopy. The patency of the PLMA drainage tube should always be confirmed. The sore throat evaluation performed in recovery room appears as reliable as later evaluations.

BACKGROUND Ventilation during interventional rigid bronchoscopy (IRB) under general anaesthesia (jet ventilation, positive pressure ventilation and spontaneous assisted ventilation) may offer some difficulties. This study compares the effectiveness during IRB of intermittent negative pressure ventilation (INPV) and spontaneous assisted ventilation (SAV). METHODS Thirty-eight patients submitted to IRB were randomised into two groups: SAV or INPV. All patients received a total intravenous anaesthesia; INPV patients were paralysed. Pre- and intra-operative arterial blood gases and O2 flow through a rigid bronchoscope were assessed. The endoscopist applying a subjective score evaluated the operating conditions. RESULTS Patients of the INPV group, as compared to the SAV group, required a lower dosage of fentanyl (2.6 +/- 1.8 micrograms.kg-1.h-1 vs. 6.6 +/- 4.8 micrograms.kg-1.h-1), a lower O2 supply (3.3 +/- 2.8 l/min vs. 11.6 +/- 3.4 l/min), a shorter recovery time (5.4 +/- 2.9 min vs. 9.8 +/- 7.1 min) and no manually assisted ventilation (0 +/- 0 vs. 1 +/- 1.1 n degree/procedure). Intraoperative PaCO2 was higher in the SAV (8.1 +/- 1.3 kPa) than in the INPV group (5.0 +/- 1.6 kPa) and intraoperative pH differed in the two groups (7.26 +/- 0.05, SAV vs. 7.47 +/- 0.08, INPV). Operating conditions, as assessed by a subjective score, were considered better with INPV than with SAV (4.9 vs. 4.3). CONCLUSIONS As compared to SAV, INPV in paralysed patients during IRB reduces administration of opioids, shortens recovery time, prevents respiratory acidosis, excludes the need for manually assisted ventilation, reduces O2 need and affords optimal surgical conditions. INPV appears a safe, non-invasive and effective ventilatory management during IRB.

The treatment of tracheo-bronchial diseases with rigid bronchoscopy requires general anaesthesia without tracheal intubation. Spontaneous assisted ventilation is a safe modality of ventilation. In this study the use of remifentanil and fentanyl is compared during rigid bronchoscopy with spontaneous assisted ventilation. Ninety high-risk patients received fentanyl or remifentanil with propofol for general anaesthesia. During the maintenance fentanyl was delivered at 6.1 +/- 4.6 micrograms kg-1 h-1 and remifentanil at 0.15 +/- 0.07 microgram kg-1 min-1. The same degree of intra-operative respiratory acidosis with similar good operating conditions resulted in both groups. Patients treated with remifentanil recovered more quickly compared with those in the fentanyl group (3.8 +/- 2 vs. 10.4 +/- 9.2 min, P < 0.001). In conclusion, the use of remifentanil during rigid bronchoscopy under general anaesthesia with spontaneous assisted ventilation is safe and assures good operating conditions. Moreover, remifentanil permits a more rapid recovery than fentanyl. The dose of remifentanil is higher than previously described for spontaneously breathing patients.

Background Mean arterial pressure above 65 mmHg is recommended for critically ill hypotensive patients whereas they do not benefit from supranormal cardiac output values. In this study we investigated if the increase of mean arterial pressure after volume expansion could be predicted by cardiovascular and renal variables. This is a relevant topic because unnecessary positive fluid balance increases mortality, organ dysfunction and Intensive Care Unit length of stay. Methods Thirty-six hypotensive patients (mean arterial pressure < 65 mmH) received a fluid challenge with hydroxyethyl starch. Patients were excluded if they had active bleeding and/or required changes in vasoactive agents infusion rate in the previous 30 minutes. Responders were defined by the increase of mean arterial pressure value to over 65 mmHg or by more than 20% with respect to the value recorded before fluid challenge. Measurements were performed before and at one hour after the end of fluid challenge. Results Twenty-two patients (61%) increased arterial pressure after volume expansion. Baseline heart rate, arterial pressure, central venous pressure, central venous saturation, central venous to arterial PCO2 difference, lactate, urinary output, fractional excretion of sodium and urinary sodium/potassium ratio were similar between responder and non-responder. Only 7 out of 36 patients had valuable dynamic indices and then we excluded them from analysis. When the variables were tested as predictors of responders, they showed values of areas under the ROC curve ranging between 0.502 and 0.604. Logistic regression did not reveal any association between variables and responder definition. Conclusions Fluid challenge did not improve arterial pressure in about one third of hypotensive critically ill patients. Cardiovascular and renal variables did not enable us to predict the individual response to volume administration. Trial registration ClinicalTrials.gov: NCT00721604.

INTRODUCTION: The beneficial effect of low tidal volume (TV) ventilation strategy on mortality in patients with acute respiratory distress syndrome (ARDS) has been attributed to the protective effect on ventilator-induced lung injury, and yet its effect on cardiovascular function might also play an important role. The aim of this study was to assess whether low TV ventilation improves cardiac output and oxygen delivery compared with high TV ventilation strategy in patients with ARDS. METHODS: In this crossover randomized clinical trial 16 ARDS patients were recruited in an intensive care unit at a university-affiliated hospital. Each patient was ventilated for 30 min with low (6 mL/kg) and 30 min with high (12 mL/kg) TV. The two experimental periods, applied in random order and with allocation concealment, were separated by 30 min of basal ventilation. Minute ventilation was constantly maintained by appropriate respiratory rate changes. RESULTS: Compared with high TV ventilation, low TV ventilation showed decreased pH (7.37 vs. 7.41, P = 0.001) and increased PaCO₂ (49 vs. 43 mmHg; P = 0.002). Cardiac index and oxygen delivery index were increased with low compared with high TV ventilation (3.9 vs. 3.5 L.min⁻¹.m⁻², P = 0.012, and 521 vs. 463 mL.min⁻¹.m⁻², P = 0.002, respectively), while oxygen extraction ratio decreased (0.36 vs. 0.44, P = 0.027). In four patients oxygen extraction ratio was >0.5 during high TV but not during low TV strategy. The magnitude of the change in cardiac index was positively associated with PaCO₂ variation (P = 0.004), while it was unrelated to the magnitude of changes in TV and airway pressure. The decrease of cardiac index was predicted by PaCO₂ reduction, with and area under ROC curve of 0.72. CONCLUSIONS: Our findings suggest that a low TV ventilation strategy increases cardiac index and oxygen delivery, thus supporting the hypothesis that the beneficial effect of low TV ventilation in patients with ARDS could be partially explained by hemodynamic improvement. In other words, low tidal volume ventilation could be protective also for the cardiovascular system and not only for the lung. The slight increase of PaCO₂ during low TV ventilation seems to predict the increase of cardiac index. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00713713.