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Resumen Las porfirias agudas son trastornos metabolicos graves asociados a una alteracion enzimatica del metabolismo del grupo hemo, desencadenado por factores precipitantes que pueden generar ataques agudos. A continuacion se reporta el caso de una paciente a la que se le realiza cirugia de reemplazo valvular mitral, desarrollando en el postoperatorio deterioro neurologico de instauracion progresiva asociado a parestesia en miembros inferiores, episodio convulsivo y posterior claudicacion respiratoria. Por medio de una prueba rapida para la deteccion de producto porfirinico en orina, se realiza el diagnostico temprano, el cual fue sorpresivo ante la baja posibilidad del mismo, sin embargo, fallece por exacerbacion de comorbilidades y ausencia de tratamiento.

Over the last decades aggressive interventions have been successful to improve nutritional outcomes in people with cystic fibrosis (CF). As a result, with improvement of life expectancy and new CFTR modulators, overweight and obesity are progressively becoming a source of concern for adult population and in developed countries.This was a multicenter, observational, cross-sectional study of 321 adults with CF at three large CF centers in Italy. Patients were divided into three groups according to BMI classes, overweight and obesity (OW) group including patients with BMI ≥25 kg/mWe demonstrated that prevalence of OW in adults with CF in Italy is 22%. OW status is independently associated with male sex (OR 3.520, P = 0.001), pancreatic sufficiency (OR 2.873, P = 0.014) and older age at diagnosis (1.015, P = 0.042). BMI correlated with ppFEV1 (r = 0.337; P0.0001) with median ppFEV1 significantly higher in patients with OW than comparisons. We also reported preliminary data on unfavorable cardiovascular risk factors in a subgroup of patients, where median blood levels [IQR] of cholesterol and systemic hypertension [%] were significantly higher in the OW group than in the NW and UW.People with CF and OW is a relevant patient group that might deserve better definition and proper clinical management.

The survival benefits of pulmonary thromboendarterectomy (PTE) for the treatment of chronic thromboembolic pulmonary hypertension have been well described. However, the significance of right heart hemodynamic changes and their impact on survival remains poorly understood. We sought to characterize the effects of these changes. We conducted a single center, retrospective review of 159 patients who underwent PTE between 1993 and 2015. Echocardiographic and right heart catheterization data were compared longitudinally before and after PTE in order to establish the extent of hemodynamic response to surgery. Kaplan Meier estimates were used to characterize patient survival over time. Univariable and multivariable Cox proportional hazards regression models were used to assess factors associated with long-term mortality. Among the 159 patients studied, 74 (46.5%) were male with a median age of 55 (IQR: 42-66). One-, 5-, 10-, and 15-year survival was 91.0% (95% CI: 86.6-95.6), 79.6% (73.5-86.3), 66.5% (59.2-74.7), and 56.2% (48.1-65.8). Of the 9 candidate risk factors that were evaluated, only advanced age and increased cardiopulmonary bypass time were found to be significantly associated with increased risk of mortality. Pre- and postsurgical echocardiographic imaging data, when available, revealed a median reduction in right ventricular systolic pressure of 29.0 mm Hg (P0.0001) and improvement of tricuspid regurgitation (P0.0001), both of which appeared to be sustained across long-term follow-up. Improvements in right heart hemodynamics and tricuspid valvular regurgitation persist on long term surveillance following PTE. While patient selection is often driven by the distribution of disease, close postoperative follow up may improve outcomes.

Connective tissue disorders (CTDs) are associated with esophageal dysmotility and gastroesophageal reflux disease, which may diminish survival after lung transplantation (LTx). We studied LTx outcomes in patients with a CTD stratified by esophageal motility. We identified patients who underwent bilateral LTx from 2012 to 2017. Patients with a CTD were classified by pre-LTx diagnosis: absent esophageal motility (AEM), ineffective esophageal motility (IEM), or preserved esophageal motility (PEM). The primary endpoint was 3-year survival. Sub-analysis compared survival between the AEM group and a propensity-matched (lung allocation score), non-CTD control group. Kaplan-Meier method and log-rank test were used. In total, 495 patients underwent LTx; 33 (6.7%) had a CTD. Median (IQR) age was 62 years (55.5-67.0); 24 (72.7%) were women. Survival trended lower for recipients with a CTD than without a CTD at 1-year (84.8% vs 91.8%; p = 0.2) and 3-years (66.7% vs 73.5%; p = 0.5). Within the CTD cohort, 1- and 3-year survival was significantly higher in the PEM (100%, 87.5%) and IEM (100%, 85.7%) groups than in the AEM group (50%, 20%; p0.001). The AEM group had significantly lower survival at 1-year (50% vs 92.5%) and 3-years (20% vs 65%) than a lung allocation score-matched cohort of patients without a CTD. LTx recipients with a CTD and AEM had significantly lower survival than those with PEM or IEM as well as significantly lower survival than that of a propensity-matched cohort of patients without a CTD. Patients with a CTD and AEM should be considered for LTx with extreme caution and counseled appropriately.

The benefit of avoiding lifelong anticoagulation therapy in patients with bioprosthetic heart valve implantation may potentially be offset by atrial fibrillation (AF); however, clinical impact of surgical AF ablation in such patients remains controversial. We enrolled 426 patients (aged 72.0 ± 7.8 years) with AF who underwent left-side valve replacement with bioprostheses between 2001 and 2018. Of these, 297 underwent concomitant surgical ablation (ablation group) and 129 underwent valve replacement alone (non-ablation group). Clinical outcomes were compared, and mortality was considered as a competing risk factor against valve-related complications. Inverse-probability weighting (IPTW) was adopted to reduce selection bias. The ablation group had lower baseline risk profiles than the non-ablation group. In crude analysis, early mortality rates were 3.4% and 7.0% in the ablation and non-ablation groups, respectively (P = 0.104). During follow-up (1521.9 patient-years), the ablation group showed lower AF-recurrence (P0.001) and anticoagulant medication rate (P = 0.021), and lower overall mortality risk (subdistribution hazard ratio [SHR], 0.63; 95% confidence interval [CI], 0.42-0.94), but higher risk of permanent pacemaker implantation (SHR, 4.67; 95% CI, 1.36-16.05). No significant difference in the risk of stroke (SHR, 1.27; 95% CI, 0.55-2.95) was observed between the groups. After baseline IPTW-adjustment, findings of the clinical outcomes were analogous to those from crude analyses. In patients undergoing bioprosthetic valve replacement, the addition of surgical ablation was associated with improved rhythm outcomes and survival but at the expense of a higher risk of pacemaker implantation. The underlying mechanism of improved survival by AF ablation needs further investigation.

Rationale Ventilator-associated event (VAE) surveillance provides an objective means to measure and compare complications that develop during mechanical ventilation by identifying patients with sustained increases in ventilator settings after a period of stable or decreasing ventilator settings. The impact of the coronavirus disease (COVID-19) pandemic on VAE rates and characteristics is unknown. Objectives To compare the incidence, causes, and outcomes of VAE during the COVID-19 pandemic year versus prepandemic years and among ventilated patients with and without COVID-19. Methods In this retrospective cohort study of mechanically ventilated adults at four academic and community hospitals in Massachusetts, we compared VAE incidence rates between March 1 and August 31 for each year from 2017 to 2020 (corresponding to the time frame of the pandemic first wave in 2020) and among COVID-19–positive and COVID-19–negative patients in 2020. The medical records of 200 randomly selected patients with VAEs in 2020 (100 with COVID-19 and 100 without COVID-19) were analyzed to compare conditions precipitating VAEs in patients with versus without COVID-19. Results VAEs per 100 episodes of mechanical ventilation were more common in 2020 than in prior years (11.2 vs. 6.7; P

The effect of acute kidney injury (AKI) on mid-term outcomes following thoracoabdominal aortic aneurysm (TAAA) repair is not well known. We hypothesized that postoperative AKI would reduce mid-term survival and aimed to analyze the effect of AKI on mid-term outcomes after TAAA repair. This retrospective study identified 294 consecutive TAAA repairs at Kobe University Hospital from October 1999 to March 2019. Patients with preexisting end-stage renal disease that required hemodialysis (n = 11) and patients who died intraoperatively (n = 2) were excluded. Finally, 281 patients were analyzed. AKI was defined according to Kidney Disease: Improving Global Outcomes guidelines (KDIGO) classification. Of the 281 patients, 178 (63.3%) developed AKI, of which 98 (34.9%) had mild, 34 (12.1%) had moderate, and 46 (16.4%) had severe AKI. Twenty-six patients (12.8%) required renal replacement therapy after surgery. Twenty-three in-hospital deaths (8.2%) were recorded, including 2 (0.7%) without AKI, 0 (0%) with mild AKI, 1 (0.4%) with moderate AKI, and 20 (7.1%) with severe AKI (p.001). The 4-year survival was 91.9 ± 3.0% for no AKI, 91.3 ± 3.2% for mild AKI, 72.4 ± 8.5% for moderate AKI and 32.6 ± 7.4% for severe AKI (p.001). Multivariable Cox-hazard regression analysis demonstrated that moderate and severe AKI, older age and emergency surgery were significant risk factors for mid-term survival. In patients undergoing TAAA repair, severe AKI was associated with an increase in in-hospital mortality and both moderate and severe AKI were negatively associated with mid-term survival. Preventing moderate/severe AKI may improve mid-term survival after TAAA repair.

Introduction Military personnel with a diagnosis of asthma report increased respiratory symptoms in the deployment and post-deployment periods. The long-term effect of deployment on pulmonary function in this population is unknown. This study sought to determine the effect of deployment on post-deployment pulmonary function in active duty military personnel with asthma. Materials and Methods A retrospective chart review of active duty military personnel with deployment to southwest Asia and an ICD-9 diagnosis of asthma with documented pre- and post-deployment spirometry was performed. Results A total of 642 active duty individuals with a diagnosis of asthma and documented spirometry with deployment to southwest Asia between 2006 and 2015 were identified. Of these, 76 individuals were identified with pre- and post-deployment spirometry. There was no significant change in the post-deployment forced expiratory volume at 1 second (% predicted), from 86.0 ± 14.8 to 87.6 ± 14.4 (P = .30). There was no significant change in post-deployment forced vital capacity (% predicted), from 93.8 ± 12.4 to 94.9 ± 12.1 (P = .42). The absolute change in forced expiratory volume at 1 second (L) after bronchodilator administration was decreased from pre-deployment to post-deployment (+0.31 ± 0.26 to +0.16 ± 0.23; P = .02). Conclusions There was no significant post-deployment change in spirometry in this military population with asthma deployed to southwest Asia. These findings suggest that deployment itself is not associated with any short-term deleterious effect on post-deployment spirometric measures of lung function in many military personnel with asthma.

Objective On November 24, 2017, Organ Procurement and Transplantation Network implemented a change to lung allocation replacing donor service area with a 250 nautical mile radius around donor hospitals. We sought to evaluate the experience of a small to medium size center following implementation. Methods Patients (47 pre and 54 post) undergoing lung transplantation were identified from institutional database from January 2016 to October 2019. Detailed chart review and analysis of institutional cost data was performed. Univariate analysis was performed to compare eras. Results Similar short-term mortality and primary graft dysfunction were observed between groups. Decreased local donation (68% vs 6%, p < 0.001), increased travel distance (145 vs 235 miles, p = 0.004), travel cost ($8,626 vs $14,482, p < 0.001), and total procurement cost ($60,852 vs. $69,052, p = 0.001) were observed post implementation. We also document an increase in waitlist mortality post-implementation (6.9 vs 31.6 per 100 patient years, p < 0.001). Conclusions Following implementation of the new allocation policy in a small to medium size center, several changes were in accordance with policy intention. However, concerning shifts emerged including increased waitlist mortality and resource utilization. Continued close monitoring of transplant centers stratified by size and location are paramount to maintaining global availability of lung transplantation to all Americans regardless of geographic residence or socioeconomic status. (Word Count: 219/250)

Background W1282X-CFTR variant (c.3846G>A) is the second most common nonsense cystic fibrosis (CF)-causing mutation in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene. Even though remarkable breakthroughs have been done towards CF treatment with the approval of four CFTR protein modulators, none of these are approved for patients with nonsense mutations. CRISPR gene editing tools can be of great value to permanently correct the genetic defects caused by these mutations. Methods We compared the capacity of homology-directed repair (HDR) mediated by Cas9 or Cas12a to correct W1282X CFTR mutation in the CFF-16HBEge W1282X CFTR cell line (obtained from CFF), using Cas9/gRNA and Cas12a/gRNA ribonucleoproteins (RNPs) and single strand DNA (ssODN) oligonucleotide donors. Results Cas9 shows higher levels of correction than Cas12a as, by electroporating cells with Cas9 RNPs and ssODN donor, nearly 18% of precise editing was achieved compared to just 8% for Cas12a. Such levels of correction increase the abundance of CFTR mRNA and protein, and partially restore CFTR function in the pool of edited cells to 18% of WT CFTR function. Moreover, homozygous corrected clones produced levels of mRNA, protein, and function comparable to those of cells expressing WT CFTR. Conclusion Altogether, this work demonstrates the potential of gene editing as a therapeutic strategy for CF directly correcting the root cause of the disease.

The public is placing increased emphasis on specialty specific rankings, thereby affecting patients' choices of clinical care programs. In the spirit of transparency, public reporting initiatives are underway or being considered by various surgical specialties whose databases rank programs based on short-term outcomes. Of concern, short-term risk avoidance excludes important comparative cases from surgical database participation and may adversely affect overall long-term oncologic treatment team results. To assess the validity of comparing short-term perioperative and long-term survival outcomes of all patients treated at major centers, we studied the correlations between these variables.The National Cancer Database was queried for patients diagnosed with non-small cell lung carcinoma (NSCLC) between 2008 and 2012, yielding 5-year follow-up data for all patients at centers treating at least 100 patients annually. Mortality (30- and 90-day), unplanned 30-day readmissions, and hospital length of stay were modeled using logistic regression with sex, race, age, Charlson-Deyo combined comorbidity, extent of surgery, income, insurance status, histology, grade, and analytic stage as predictors, all with 2-way interaction terms. The differences between the predicted rates and observed rates were calculated for each short-term outcome, and the average of these was used to create a short-term metric (STM). A similar approach was used to create a long-term metric (LTM) that used overall survival as a single dependent variable. Centers were ranked into deciles based on these metrics. Visual plotting as well as correlation coefficients were used to judge correlation between STM and LTM.A total of 298,175 patients from 541 centers were included in this analysis, of whom 102,860 underwent surgical resection for NSCLC. The correlation between STM and LTM was negative using parametric estimates (Pearson correlation coefficient = -0.09 [P = .03] and -0.22 [P .01]) and nonparametric estimates (Spearman rank correlation coefficient = -0.09 [P = .02] and -0.22 [P .01]) for squamous cell carcinoma and adenocarcinoma, respectively.Short-term perioperative outcome rankings correlate poorly with long-term survival outcome rankings when cancer treatment centers are compared. Factors explaining this discrepancy merit further study. Rankings based on short-term outcomes alone may be incomplete for public reporting.

Enhanced Recovery After Surgery (ERAS) pathways have improved clinical outcomes, cost-effectiveness, and patient satisfaction across multiple non-cardiac surgical specialties. Since the adaptation of ERAS in cardiac surgery is rapidly increasing yet still evolving, herein, we demonstrate early results of our implementation of ERAS cardiac guidelines. We retrospectively reviewed all patients who were managed with our institutional ERAS Cardiac Surgery guidelines between 5/2018 and 6/2019(N = 102). Postoperative primary outcomes (total ventilation times(hours), intensive-care unit(ICU) stay, and postoperative hospital length of stay (LOS)) were compared to 1:1 propensity matched controls from the pre ERAS era between January 2017 and March 2019. A total of 76 propensity-matched pairs were identified. Compared to the matched controls, ERAS patients had significantly shorter median ventilation times(3.5 vs. 5.3 hours, p = .01), ICU stays(median 28 vs 48 hours, p=.005) and postoperative hospital LOS (median 5 vs. 6 days, p = .03). There were no operative mortalities and no significant differences in 30-day readmission rates. There were also no significant differences in post-operative stroke, acute kidney injury, atrial fibrillation, and reoperation rates for bleeding. Two-year survival was also not statistically different between the two cohorts (p = .22). Our initial experience with implementation of ERAS protocols in cardiac surgery appear to demonstrate that these protocols are associated with shorter ventilation times, ICU stay, and hospital LOS without compromising patient outcomes. While these results are promising yet preliminary, further studies are warranted to demonstrate whether ERAS algorithms in cardiac surgery can consistently expedite postoperative recovery and improve outcomes.

We discuss the optimal timing of surgery for lung cancer, and propose 3 surgical strategies for pre- and minimally invasive lung adenocarcinoma to avoid "overdiagnosis" and "overtreatment." Benign disease should not be treated as malignancy, pre- and minimally invasive disease should not be treated as invasive disease, and indolent malignancy should not be treated as aggressive malignancy.

Resumen En el paciente criticamente enfermo, la falla hepatica aguda sobre cronica (FHAC) representa un reto clinico dado que las alternativas terapeuticas son limitadas, usualmente ineficaces y se enfocan en un abordaje sintomatico. El trasplante hepatico ortotopico (THO) es la opcion terapeutica mas adecuada, sin embargo, los escasos de donantes y la presencia de contraindicaciones es una limitante frecuente para este procedimiento. Frente a esta problematica, desde el ano 2000 se ha venido implementando el uso de soportes de asistencia hepatica extracorporea como Molecular Adsorbent Recirculating System (MARS), para la estabilizacion de la condicion clinica del paciente como puente a recuperacion espontanea o a THO. Presentamos la primera experiencia con este dispositivo de asistencia hepatica en Colombia. Presentamos el caso de un paciente de 69 anos con antecedente de cirrosis enolica y cuadro agudo de obstruccion intestinal llevado a cirugia, quien en el posoperatorio desarrollo una FHAC, con progresion de la encefalopatia, convulsiones y deterioro de la funcion renal. Ante la falta de respuesta al tratamiento medico estandar se realizaron tres sesiones de asistencia hepatica extracorporea con MARS como soporte peritrasplante (antes terapia puente), con mejoria de la encefalopatia y resolucion de las crisis convulsivas. La implementacion de un soporte de asistencia hepatica extracorporea, como el MARS, es una herramienta de gran ayuda, principalmente en el escenario de baja disponibilidad de donantes y en un subgrupo seleccionado de pacientes que cursan con falla hepatica aguda o falla hepatica aguda sobre cronica, como medida de mantenimiento como puente a resolucion espontanea o THO.

Spontaneous hemothorax caused by the rupture of a benign schwannoma has rarely been reported. Herein, we present the successful excision of an extremely rare case of mediastinal ancient schwannoma causing intrathoracic bleeding. A 27-year-old man was admitted to our emergency department because of back pain and dyspnea. Computed tomography revealed massive pleural effusion with a posterior mediastinal tumor. We performed a resection of the tumor which had ruptured, and the tumor was diagnosed as an ancient schwannoma.

Objective The aim of this study was to evaluate the prognostic factors affecting morbidity and mortality among patients who underwent surgery for giant pulmonary hydatid cysts in our center. Methods Data from 283 patients who underwent surgery in our center for pulmonary hydatid cyst between 2008 and 2018 were retrospectively analyzed. Cysts 10 cm in diameter or larger were considered giant hydatid cysts. Results There were 145 women (51.2%) and 138 men (48.8%). Giant cyst (≥10 cm) was present in 57 patients (20.1%), while the other 226 patients (79.9%) had cysts smaller than 10 cm. Operations were performed using videothoracoscopic approach in 68 patients (24%) and with thoracotomy in 215 patients (76%). Hydatid cysts were on the left side in 129 patients (45.6%), on the right side in 143 patients (50.5%), and bilateral in 11 patients (3.9%). Postoperative morbidity occurred in 29 patients (10.2%). Use of videothoracoscopic surgical approach did not affect morbidity. The mortality rate within the first 90 days was 0.35% (n = 1). Conclusion Giant cysts are more common in the young age group than in older adults. Regardless of cyst size, surgery should be performed as soon as possible after diagnosis to avoid potential complications.

Bleeding caused by coagulopathy is common in children undergoing cardiac surgery and causes adverse outcomes. Coagulation testing assists selection of treatments to stop bleeding but has an uncertain role for predicting bleeding. We aimed to evaluate how well prospective coagulation testing predicted excessive bleeding during and after cardiac surgery compared to prediction using clinical characteristics alone. The study was a single-center, prospective cohort study in children having a range of cardiac surgery procedures with coagulation testing at anesthetic induction and immediately after cardiopulmonary bypass. The primary outcome was clinical concern about bleeding (CCB), a composite of either administration of prohemostatic treatments in response to bleeding or a high chest drain volume after surgery. In 225 children, CCB occurred in 26 (12%) during surgery and in 68 (30%) after surgery. Multivariable fractional polynomial models using the clinical characteristics of the children alone predicted CCB during surgery (c-statistic 0.64; 95% confidence interval 0.53, 0.76) and after surgery (0.74; 0.67, 0.82). Incorporating coagulation test results into these models improved prediction (c-statistics 0.79; 0.70, 0.87, and 0.80; 0.74, 0.87, respectively). However, this increased the overall proportion of children classified correctly as CCB or not CCB during surgery by only 0.9% and after surgery by only 0.4%. Incorporating coagulation test results into predictive models had no effect on prediction of blood transfusion or postoperative complications. Prospective coagulation testing marginally improves prediction of CCB during and after cardiac surgery but the clinical impact of this is small when compared to prediction using clinical characteristics.

Resumen: Introducción y objetivos: La disfagia orofaríngea (DOF) ocurre en niños con parálisis cerebral. Es importante investigar su relación con algunas variables, y el objetivo de este estudio fue identificar factores asociados con la DOF. Material y métodos: Estudio de casos y controles en pacientes con parálisis cerebral de 8 meses a 15 años de edad, de noviembre de 2018 a noviembre de 2019, aprobado por el Comité de Ética. El diagnóstico de DOF se realizó por videofluoroscopia cuando hubo reflujo nasofaríngeo, estancamiento en valécula, en senos piriformes, penetración y aspiración. Las variables independientes fueron tipo de parálisis cerebral, afectación motora gruesa clasificada en cinco niveles, estado nutricional y comorbilidades. Se incluyó un caso con DOF, y el siguiente sin alteraciones en la videofluoroscopia fue control. Las variables se compararon con chi cuadrado (χ2) y t de Student. La asociación se midió con odds ratio. El intervalo de confianza fue del 95%. Resultados: Se estudiaron 30 pacientes con DOF y 30 sin DOF. El sexo, la edad, el peso al nacer y la edad gestacional tuvieron distribución similar en los dos grupos. De los datos percibidos por las madres al momento de la alimentación, la mayor frecuencia de la dificultad en el traslado del bolo alimenticio en el grupo con DOF mostró diferencia estadística significativa (p

Thoracic aortic aneurysms (TAA) may grow asymptomatically until they rupture, with a mortality over 90%. The true incidence and prevalence of this condition is uncertain and epidemiologic data is scarce, understudied and dispersed. Therefore, we aimed to conduct a systematic review and meta-analysis of the incidence and prevalence of TAAs in population-based studies. We searched MEDLINE, EMBASE and CENTRAL from inception to October 2020 for all population-based studies reporting on incidence and/or prevalence of TAAs. Data were pooled using a random effects model. The main outcome was the overall available worldwide incidence and prevalence of TAAs. The secondary outcomes were to evaluate the incidence of ruptured TAAs, differences in the location of these aneurysms (either ascending, arch or descending aorta) and differences in prevalence/incidence across different study designs. Twenty-two studies were included in the review and meta-analysis. The pooled incidence and prevalence of TAAs was 5.3 per 100,000 individuals/year (95% confidence interval [CI]: 3.0; 8.3) and 0.16% (95% CI: 0.12; 0.20), respectively. The pooled incidence of ruptured aneurysms was 1.6 per 100,000 individuals/year (95% CI: 1.3; 2.1). We found a significant difference of the prevalence in autopsy-only studies, which was 0.76% (95% CI: 0.47; 1.13) and the prevalence of TAAs dropped down to 0.07% (95% CI: 0.05;0.11) when these studies were excluded from the overall analysis. The current epidemiologic information provided serve as a base for future public-health decisions. The lack of well-design population-base studies and the limitations encountered serve as calling for future research in this field.

We sought to evaluate the feasibility of esophageal carcinoma (EC) surgery in cases requiring dialysis. Among 250 consecutive patients undergoing surgical resection for EC, three on maintenance dialysis were identified. We retrospectively analyzed their clinical characteristics. The three dialyzed patients were all males, 39-77 years old at EC surgery. The operations were thoracoscopic esophagectomy with nodal clearance (Case 1), cervical esophageal resection without thoracic procedures (Case 2), and thoracoscopic esophagectomy without reconstruction, emergently conducted for tumor bleeding (Case 3). Reoperation had been required for postoperative abdominal hematoma in Case 1. Postoperative tracheostomy had been performed due to severe pneumonia in Case 2. EC surgery for dialyzed patients, despite appearing to be feasible, might be associated with a high risk of life-threatening morbidities. To minimize surgical risk, therapeutic decision-making for such cases should be based on the balance between radicality and safety.

Summary Background The use of cyclophosphamide in patients with acute exacerbation of idiopathic pulmonary fibrosis (IPF) is unknown. Our study was designed to evaluate the efficacy and safety of four cyclophosphamide pulses in addition to high-dose methylprednisolone in this population. Methods In this double-blind, placebo-controlled trial done in 35 departments across 31 hospitals in France, adult patients (≥18 years) with acute exacerbation of IPF and those with suspected acute exacerbation of IPF were randomly assigned in a 1:1 ratio using a web-based system to receive either intravenous pulses of cyclophosphamide (600 mg/m2) plus uromitexan as haemorrhagic cystitis prophylaxis (200 mg/m2) at the time of cyclophosphamide administration and then again, 4 h later, or placebo at days 0, 15, 30, and 60. Random assignment was stratified according to the severity of IPF and was block-balanced with variable block sizes of four or six patients. Patients receiving mechanical ventilation, with active infection, with active cancer, or who were registered on the lung transplant waiting list were excluded. All patients received standardised high-dose glucocorticoids. The investigators, patients, and the sponsor were masked to the treatment assignments. The primary endpoint was 3-month all-cause mortality, analysed by a χ2 test adhering to an intention-to-treat principle. The trial is now complete and registered with ClinicalTrials.gov , NCT02460588 . Findings Between Jan 22, 2016, and July 19, 2018, 183 patients were assessed for eligibility, of whom 120 patients were randomly assigned and 119 patients (62 [52%] with severe IPF) received at least one dose of cyclophosphamide (n=60) or placebo (n=59), all of whom were included in the intention-to-treat analysis. The 3-month all-cause mortality was 45% (27/60) in patients given cyclophosphamide compared with 31% (18/59) in the placebo group (difference 14·5% [95% CI −3·1 to 31·6]; p=0·10). Similar results were found after adjustment by IPF severity (odds ratio [OR] 1·89 [95% CI 0·89–4·04]). The risk of death at 3 months, independent of the treatment received, was higher with severe than non-severe IPF (OR 2·62 [1·12–6·12]) and was lower with the use of antifibrotic therapy (OR 0·33 [0·13–0·82]). Adverse events were similar between groups by 6 months (25 [42%] in the cyclophosphamide group vs 30 [51%] in the placebo group) and their proportion, including infections, did not differ. Overall infection was the main adverse event and occurred in 20 (33%) of 60 patients in the cyclophosphamide group versus 21 (36%) of 59 patients in the placebo group. Interpretation In patients with acute exacerbation of IPF, adding intravenous cyclophosphamide pulses to glucocorticoids increased 3-month mortality. These findings provide evidence against the use of intravenous cyclophosphamide in such patients. Funding Programme Hospitalier de Recherche Clinique of the French Ministry of Health (PHRC 2014–502), Roche Pharmaceuticals.

Introduction and aims: Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. Materials and methods: An experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. Results: A total of 15 en bloc ESDs (5 with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90 min. Lesion size ranged from 15 to 50 mm (mean 30 mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). Conclusions: Our study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model. Resumen: Introducción y objetivos: La disección endoscópica de la submucosa (DES) es un tratamiento bien establecido para las neoplasias superficiales del tracto gastrointestinal y permite la resección en bloque. La tracción adecuada del tejido es importante para una disección efectiva y segura. La DES guiada por anclaje magnético (DES-AM) con imán de neodimio (simplificada) tiene beneficios potenciales en comparación con otros métodos actuales de tracción. Evaluamos la factibilidad de DES-AM simplificada en modelo porcino ex vivo. Materiales y métodos: Diseño experimental, se empleó la técnica estándar de DES. Para el anclaje magnético (AM), utilizamos un imán externo y un imán interno de neodimio. El imán interno de neodimio se fijó a una rama de un hemoclip con sutura seda 2-0. Después de la incisión, el clip con el imán interno se colocó al borde de la lesión y luego se maniobró un imán externo alrededor de la superficie para aplicar una tracción adecuada. Resultados: En total se realizaron 15 DES (5 sin AM y 10 con AM), de las cuales el 100% se completaron en bloque. En todos los casos la tracción y la disección fueron factibles. Todos los procedimientos se completaron en menos de 90 minutos. El tamaño de las lesiones fue de 15-50 mm (promedio 30 mm). Dos casos presentaron perforación puntiforme en el grupo con AM (13.3%). Conclusiones: Nuestro estudio mostró la factibilidad de la DES-AM simplificada en modelo porcino ex vivo y resección en bloque.

Despite the rapid adoption of transcatheter aortic replacement (TAVR), surgical TAVR valve explantation (TAVR-explant) and the clinical impact of explanted TAVR device type are not well described.TAVR-explant from 2016 to 2019 was queried using the Society of Thoracic Surgeons (STS) National Database. A total of 483 patients with documented explanted valve type, consisting of 330 (68%) patients with balloon-expandable and 153 (32%) patients with self-expandable devices, were identified. The primary outcome was 30-day mortality. The secondary outcome was the need for any simultaneous procedures with TAVR-explant.The mean age was 72.8 years, 38% of the patients were female, and 51% demonstrated New York Heart Association functional class III to IV symptoms. During TAVR-explant, 63% of patients required other simultaneous procedures, including aortic repair (27%), mitral procedures (22%), coronary artery bypass grafting (15%), and tricuspid procedures (7%). Patients with a self-expandable device underwent more frequent ascending aortic replacement (22% vs 9%; P.001) than those with a balloon-expandable device, whereas the aortic root replacement rate was similar (19% vs 24%; P = .22). The overall 30-day mortality was 18% without differences in the mortality or other major complications between the groups. Of the 157 patients with isolated surgical aortic valve replacement and available STS predicted risk of mortality score, the observed-to-expected (O/E) mortality ratio was 2.2.The TAVR-explant outcomes were comparable between patients with balloon-expandable devices and patients with self-expandable devices, whereas ascending aortic replacement was observed more frequently in patients with self-expandable devices. Younger patients undergoing TAVR should be informed of the future TAVR-explant risk that may accompany a higher O/E ratio and frequent morbid concurrent procedures.

To evaluate survival and quality of life of octogenarians after surgical aortic valve replacement (SAVR), up to 10 year of follow-up. Retrospective observational study on octogenarians operated for an isolated or combined SAVR in 2 centers between 2005 and 2011. Preoperative data were collected for each patient and updated regularly with last follow-up on July 2018. Early postoperative course was assessed for all patients. The primary outcome was late survival after discharge. Health-related quality of life was evaluated in all surviving patients using the Short-Form 12 questionnaire. Nine hundred and nine patients were included. The median age was 82 ± 2.6 years, with 400/909 females (44%). Isolated AVR was performed in 452/909 patients (49.7%). Early in-hospital mortality occurred in 71/909 patients (7.8%). Mean follow-up was 5.9 ± 3.4 years. Survival at 2, 5, and 10 years in the overall cohort was 89%, 70%, and 28%, respectively, without significant difference between isolated or combined AVR. Survival was significantly higher in patients with a Euroscore8% (P0.0001). Multivariate analysis found that older age at surgery, diabetes, history of myocardial infarction, atrial fibrillation and chronic renal failure were predictors of long-term mortality. Finally, the SF-12 physical score was 40.7 ± 10.4 and mental and emotional score was 52.7 ± 8.6 at last follow-up, which falls within the expected range for the general population (50 ± 10) with comparable age. SAVR remains an effective treatment for aortic valve disease in octogenarians, not only increasing life expectancy but also conferring a long-standing quality of life with excellent valve durability.

The evidence for use of direct oral anticoagulants (DOACs) in the management of post-operative cardiac surgery atrial fibrillation is limited and mostly founded on clinical trials that excluded this patient population. We performed a systematic review and meta-analysis of clinical trials and observational studies to evaluate the hypothesis that DOACs are safe compared to warfarin for the anticoagulation of patients with post-operative cardiac surgery atrial fibrillation. We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and the Cochrane Library for clinical trials and observational studies comparing DOAC with warfarin in patients ≥18 years old who had post-cardiac surgery atrial fibrillation. Primary outcomes included stroke, systemic embolization, bleeding, and mortality. We performed a random-effects meta-analysis of all outcomes. The meta-analysis for the primary outcomes showed significantly lower risk of stroke with DOAC use (6 studies, 7143 patients, RR 0.64; 95% CI 0.50–0.81, I2: 0.0%) compared to warfarin, a trend towards lower risk of systemic embolization (4 studies, 7289 patients, RR 0.64, 95% CI 0.41–1.01, I2: 31.99%) and similar risks of bleeding (14 studies, 10182 patients, RR 0.91; 95% CI 0.74–1.10, I2: 26.6%) and mortality (12 studies, 9843 patients, relative risk [RR] 1.01; 95% CI 0.74–1.37, I2: 26.5%). Current evidence suggests that DOACs, compared to warfarin, in the management of atrial fibrillation after cardiac surgery is associated with lower risk of stroke and a strong trend for lower risk of systemic embolization, and no evidence of increased risk for hospital readmission, bleeding and mortality.

Sepsis is the leading cause of acute respiratory distress syndrome (ARDS) in adults and carries a high mortality. Utilizing a previously validated porcine model of sepsis-induced ARDS, we sought to refine our novel therapeutic technique of in vivo lung perfusion (IVLP). We hypothesized that 2 hours of IVLP would provide non-inferior lung rehabilitation compared to 4 hours of treatment. Adult swine (n = 8) received lipopolysaccharide to develop ARDS and were placed on central venoarterial extracorporeal membrane oxygenation. Animals were randomized to 2 vs 4 hours of IVLP. The left pulmonary vessels were cannulated to IVLP using antegrade Steen solution. After IVLP treatment, the left lung was decannulated and reperfused for 4 hours. Total lung compliance and pulmonary venous gases from the right lung (control) and left lung (treatment) were sampled hourly. Biochemical analysis of tissue and bronchioalveolar lavage was performed along with tissue histologic assessment. Throughout IVLP and reperfusion, treated left lung PaO2/FiO2 ratio was significantly higher than the right lung control in the 2-hour group (332.2 ± 58.9 vs 264.4 ± 46.5, P = 0.01). In the 4-hour group, there was no difference between treatment and control lung PaO2/FiO2 ratio (258.5 ± 72.4 vs 253.2 ± 90.3, P = 0.58). Wet-to-dry weight ratios demonstrated reduced edema in the treated left lungs of the 2-hour group (6.23 ± 0.73 vs 7.28 ± 0.61, P = 0.03). Total lung compliance was also significantly improved in the 2-hour group. Two hours of IVLP demonstrated superior lung function in this preclinical model of sepsis-induced ARDS. Clinical translation of IVLP may shorten duration of mechanical support and improve outcomes.

Resumen: Introducción y objetivos: La disección endoscópica de la submucosa (DES) es un tratamiento bien establecido para las neoplasias superficiales del tracto gastrointestinal y permite la resección en bloque. La tracción adecuada del tejido es importante para una disección efectiva y segura. La DES guiada por anclaje magnético (DES-AM) con imán de neodimio (simplificada) tiene beneficios potenciales en comparación con otros métodos actuales de tracción. Evaluamos la factibilidad de la DES-AM simplificada en un modelo porcino ex vivo. Materiales y métodos: Diseño experimental, se empleó la técnica estándar de DES. Para el anclaje magnético (AM), utilizamos un imán externo y uno interno de neodimio. El imán interno de neodimio se fijó a una rama de un hemoclip con sutura seda 2-0. Después de la incisión, el clip con el imán interno se colocó al borde de la lesión y luego se maniobró un imán externo alrededor de la superficie para aplicar una tracción adecuada. Resultados: En total, se realizaron 15 DES (cinco sin AM y 10 con AM), de las cuales el 100% se completaron en bloque. En todos los casos, la tracción y la disección fueron factibles. Todos los procedimientos se completaron en menos de 90 minutos. El tamaño de las lesiones fue de 15 a 50 mm (promedio 30 mm). Dos casos presentaron perforación puntiforme en el grupo con AM (13.3%). Conclusiones: Nuestro estudio mostró la factibilidad de la DES-AM simplificada en un modelo porcino ex vivo y resección en bloque. Abstract: Introduction and aims: Endoscopic submucosal dissection (ESD) is a well-established treatment for superficial gastrointestinal tumors and enables en bloc resection. Adequate tissue tension is important for safe and effective dissection. Simplified magnetic anchor-guided ESD (MAG-ESD) with a neodymium magnet has potential benefits, compared with other current traction methods. We evaluated the feasibility of simplified MAG-ESD in an ex vivo porcine model. Materials and methods: An experimental study was conducted, utilizing the standard ESD technique. An external magnet and an internal magnet, both neodymium magnets, were used for the magnetic anchoring. The internal magnet was attached to an arm of a hemoclip with a 2-0 silk suture. After the incision, the clip with the internal magnet was placed at the edge of the lesion. The external magnet was maneuvered around the surface to apply adequate tension. Results: A total of 15 en bloc ESDs (five with no magnetic anchoring and 10 with magnetic anchoring) were carried out. Traction and dissection were feasible in all cases and the procedures were completed in fewer than 90 min. Lesion size ranged from 15 to 50 mm (mean 30 mm). Two cases in the group with magnetic anchoring presented with punctate perforation (13.3%). Conclusions: Our study demonstrated the feasibility of simplified MAG-ESD and en bloc resection in an ex vivo porcine model.

The impairment of intracellular calcium homeostasis plays an essential role during ischemia-reperfusion injury. Calcium release from sarcoplasmic reticulum which is triggered by myocardial ischemia is mainly mediated by ryanodine receptors. Dantrolene sodium is a ryanodine receptor antagonist. The objective of the present study was to evaluate the in-vivo impact of dantrolene sodium on myocardial ischemia-reperfusion injury in swine models. An in vivo, experimental trial comparing 10 experimental animals which received dantrolene sodium with 9 control swine models was conducted. Their left anterior descending coronary artery was temporarily occluded for 75 minutes via a vessel tourniquet, which was then released. Myocardial reperfusion was allowed for 24 hours. Dantrolene was administered at the onset of the reperfusion period and levels of troponin, creatine phosphokinase and creatine kinase myocardial band between the two groups were compared. Additionally, various other hemodynamic parameters and left ventricular morphology and function were examined. There were significantly lower values of troponin, creatine phosphokinase and creatine kinase myocardial band in the dantrolene group indicating less ischemia-reperfusion injury. Moreover, the postischemic cardiac index was also greater in the dantrolene group, whereas viable myocardium was also better preserved. In conclusion, the in vivo cardioprotective role of dantrolene sodium against ischemia-reperfusion injury in swine models was indicated in this study. Therefore, dantrolene sodium administration could be a promising treatment against ischemia-reperfusion injury in humans. However, large randomized clinical studies should be firstly carried out to prove this hypothesis.

OBJECTIVE: High rates of anxiety and depression exist among asthma patient populations. This scoping review will examine the existing interventional therapies that address depression and anxiety symptoms in patients with asthma. DATA SOURCES: Pubmed, Cochrane, Psychinfo, CINAHL, Google Scholar and EMBASE databases were searched using the following search terms: ‘anxiety asthma’, ‘panic disorder asthma’ and ‘depression asthma’ with a randomized clinical trial filter and additional filters to exclude exclusion criteria. STUDY SELECTIONS: Study selections included only randomized control trials with anxiety and/or depression and/or panic disorder outcomes as primary or secondary outcomes. Only full-text articles in the English language were included. RESULTS: This search yielded interventions from pharmacologic (n=3), psychological (n=7), lifestyle medicine (n=10) and complementary and alternative medicine (CAM; n=1) using a range of outcomes from physiologic to psychologic. While the pharmacologic and CAM studies were inconclusive, psychologic and lifestyle interventions showed improvements in asthma (quality of life, symptoms, asthma attacks) and psychological (anxiety, panic fear, depression) outcomes. Variations in selection methods, outcome measures and diagnostic criteria hindered a direct comparison of the studies. Most studies had small sample sizes, high attrition rates and short study durations. CONCLUSION: There is limited evidence on best approaches for managing co-morbid anxiety and/or depression in patients with asthma. Psychological and lifestyle medicine interventions are promising with improvements in both asthma and mental health outcomes. Well-designed randomized controlled studies with larger sample sizes, standardized outcomes and longer durations, are needed to better understand the role of depression and anxiety in adults with asthma.

A 76-year-old woman presented with a 2-hour history of pleuritic chest pain with no other associated symptoms. Blood investigations revealed raised inflammatory markers and an elevated white cell count. On chest radiograph, an airspace shadow indicative of a consolidation was prominent. This was followed by a CT scan of her thorax which showed a spiculated lesion in the right upper lobe, a lesion in the posterior segment of the left lower lobe and mildly enlarged right hilar lymph nodes. She was started on dual antibiotic therapy; however, the patient’s clinical status and inflammatory markers did not improve. A bronchoscopy was performed which excluded malignancy and atypical pathogens. CT-guided biopsy confirmed the presence of cryptogenic organising pneumonia. Prednisolone 50 mg daily was prescribed with quick resolution of symptoms.

Introduction Allergic rhinitis is a form of IgE mediated inflammation of the nasal mucosa in response to specific allergens, resulting in typical symptoms. Objectives This study was designed with the primary goal of comparing the clinical efficacy of posterior nasal neurectomy with or without pharyngeal neurectomy for the treatment of moderate-to-severe perennial allergic rhinitis. Secondary study aims included a comparison of the severity of comorbidities, including chronic cough and asthma, between patients in these two surgical treatment groups. Methods A total of 52 patients were enrolled in this randomized controlled trial and were assigned to either the control group (posterior nasal neurectomy) or the experimental group (posterior nasal neurectomy + pharyngeal neurectomy). The visual analog scale and rhinoconjunctivitis quality of life questionnaire were used to compare the differences in patient symptoms between baseline and 6-, 12-, and 24-months post-treatment. In addition, patient cough and asthma symptoms were monitored during follow-up via visual analog scale and asthma control test respectively. Results No significant differences in preoperative scores were evident between groups (p> 0.05). At 6-months post-treatment, there were significant differences in visual analog scale, rhinoconjunctivitis quality of life questionnaire, and asthma control test scores relative to baseline values in experimental group and control group patients (p< 0.05), and this remained true upon 12- and 24-month follow-up. No significant differences in visual analog scale, rhinoconjunctivitis quality of life questionnaire, or asthma control test scores were observed between the two treatment groups at any postoperative follow-up time point (p> 0.05), while coughing severity was found to be significantly reduced in the experimental group relative to the control group (p< 0.05). Conclusion posterior nasal neurectomy can be safely implemented with or without pharyngeal neurectomy in order to effectively treat allergic rhinitis. Combined posterior nasal neurectomy and pharyngeal neurectomy treatment may offer greater value than posterior nasal neurectomy alone for the treatment of allergic rhinitis patients with chronic cough. Resumo Introdução A rinite alérgica é uma forma de inflamação da mucosa nasal mediada por IgE em resposta a alérgenos específicos, resulta em sintomas típicos. Objetivos Comparar a eficácia clínica da neurectomia nasal posterior com ou sem neurectomia faríngea para o tratamento da rinite alérgica perene de moderada a grave. Além disso, comparar a gravidade das comorbidades, inclusive tosse crônica e asma, entre os pacientes nesses dois grupos de tratamento cirúrgico. Método Foram incluidos neste ensaio clínico randomizado e designados para o grupo controle (neurectomia nasal posterior) ou para o grupo experimental (neurectomia nasal posterior + neurectomia faríngea) 52 pacientes. A escala visual analógica e o questionário de qualidade de vida na rinoconjuntivite (rhinoconjunctivitis quality of life questionnaire) foram usados para comparar as diferenças nos sintomas dos pacientes entre o período inicial e 6, 12 e 24 meses após o tratamento. Além disso, a tosse e os sintomas de asma dos pacientes foram monitorados durante o acompanhamento por meio da escala visual analógica e do teste de controle da asma (asthma control test ), respectivamente. Resultados Nenhuma diferença significante nos escores pré‐operatórios foi evidenciada entre os grupos (p > 0,05). Aos seis meses pós‐tratamento, houve diferenças significantes nos escores da escala visual analógica, no questionário de qualidade de vida na rinoconjuntivite e no teste de controle de asma em relação aos valores basais dos pacientes no grupo experimental e no grupo controle (p < 0,05), o que permaneceu verdadeiro após 12 e 24 meses de acompanhamento. Não foram observadas diferenças significantes nos escores da escala visual analógica e nem no questionário de qualidade de vida para conjuntivite ou no teste de controle da asma entre os dois grupos de tratamento em qualquer momento do acompanhamento pós‐operatório (p > 0,05), enquanto a gravidade da tosse foi significantemente reduzida no grupo experimental em relação ao grupo controle (p < 0,05). Conclusão A neurectomia nasal posterior pôde ser feita com segurança com ou sem neurectomia faríngea para o tratamento eficaz da rinite alérgica. O tratamento combinado com neurectomia nasal posterior e neurectomia faríngea pode oferecer mais benefício do que a neurectomia nasal posterior isolada para o tratamento de pacientes com rinite alérgica e tosse crônica.

Introduction: Pulmonary and cardiac disorders are diagnosed in most patients presenting to the emergency department with dyspnea. Discrimination of pulmonary and cardiac pathologies from each other and early intervention have vital importance. Various methods have been used for assessment of peripheral perfusion, and the peripheral perfusion index) has gained popularity in recent years. This study aimed to investigate the contribution of peripheral perfusion index to the evaluation process in patients presenting with the complaint of dyspnea and diagnosed with either a pulmonary or cardiac pathology. Materials and Methods: We retrospectively reviewed the charts of patients who presented to emergency department with dyspnea between 1 July 2018 and 1 July 2019. Patients in whom the cause of dsypnea was determined to be a cardiac or pulmonary pathology were included in the study. The age, gender, peripheral perfusion index value at admission, the diagnosis, and the hospitalization status were recorded. Results: One hundred and ninety patients consisting of 106 (55.8%) males and 84 (44.2%) females were included in our study. While a pulmonary pathology was determined in 141 (74.2%) patients and a cardiac pathology in 49 (25.8%) patients, 72 (37.9%) patients were decided to be hospitalized. No difference was determined between patients with pulmonary and cardiac pathologies regarding peripheral perfusion index. When the patients were compared regarding hospitalization status and discharge from the emergency department, no significant difference was found to be present between the groups. Conclusion: Since peripheral perfusion index is a noninvasive, easy-to-perform, rapid, and reproducible test, it has been promising as a prognostic and diagnostic parameter. However, it has been realized that PPI was unsuccessful in the evaluation of patients with dyspnea, in the differential diagnosis of cardiac and pulmonary pathologies and prediction of hospitalization status in the emergency department.

Early cardiac arrhythmias are well-known complications of pediatric cardiac surgery. These arrhythmias are also a major cause of mortality and morbidity. Several reports have been published regarding late postoperative arrhythmias after pediatric cardiac surgeries. Nevertheless, data related to the early postoperative period after cardiac surgery in children are limited. Arrhythmias that may be easily tolerated in normal heart can have a major influence on hearts with congenital defects. Postoperative cardiac arrhythmias range from simple atrial or ventricular ectopies to major arrhythmias such as atrial flutter/fibrillation or ventricular tachycardia (VT). Other common arrhythmias are junctional ectopic tachycardia or complete atrioventricular block (CHB) after any manipulation on conduction system. Several factors, including myocardial dysfunction, electrolyte disturbances, adrenergic stimulation, sutures in the myocardium, residual hemodynamic impairment, as well as pain and anxiety, have been implicated in the pathogenesis of early postoperative arrhythmias in children. The aim of this chapter is to present an overview of the common cardiac arrhythmias occurring in immediate postoperative period.

Because of the significance of bronchial lesions as indicators of early lung cancer and squamous cell carcinoma, a critical need exists for early detection of bronchial lesions. Autofluorescence bronchoscopy (AFB) is a primary modality used for bronchial lesion detection, as it shows high sensitivity to suspicious lesions. The physician, however, must interactively browse a long video stream to locate lesions, making the search exceedingly tedious and error prone. Unfortunately, limited research has explored the use of automated AFB video analysis for efficient lesion detection. We propose a robust automatic AFB analysis approach that distinguishes informative and uninformative AFB video frames in a video. In addition, for the informative frames, we determine the frames containing potential lesions and delineate candidate lesion regions. Our approach draws upon a combination of computer-based image analysis, machine learning, and deep learning. Thus, the analysis of an AFB video stream becomes more tractable. Using patient AFB video, 99.5%/90.2% of test frames were correctly labeled as informative/uninformative by our method versus 99.2%/47.6% by ResNet. In addition, ≥97% of lesion frames were correctly identified, with false positive and false negative rates ≤3%.Clinical relevance-The method makes AFB-based bronchial lesion analysis more efficient, thereby helping to advance the goal of better early lung cancer detection.

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease that constitutes a major global health burden. A significant proportion of patients experience skeletal muscle wasting and loss of strength as a comorbidity of their COPD, a condition that severely impacts on their quality of life and survival. At present, the lung pathology is considered to be largely irreversible; however, the inherent adaptability of muscle tissue offers therapeutic opportunities to tackle muscle wasting and potentially reverse or delay the progression of this aspect of the disease, to improve patients' quality of life. Muscle wasting in COPD is complex, with contributions from a number of factors including inflammatory cytokines, oxidative stress, growth and anabolic hormones, nutritional status, and physical activity. In this review, we discuss current and emerging therapeutic approaches to treat muscle wasting in COPD, including a number of pharmacological therapies that are in development for muscle atrophy in other pathological states that could be of relevance for treating muscle wasting in COPD patients.

© 2020 Published by Elsevier España, S.L.U. on behalf of Sociedade Portuguesa de Pneumologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)., Introduction and objectives: Asthma is a chronic and heterogeneous disease that affects people of all ages and has a high estimated increase in prevalence worldwide. Asthma control represents a main goal in the disease management. International studies revealed low levels of disease control resulting in a significant burden for healthcare systems, not only in terms of quality of life, but also in terms of health costs. Modifiable and non-modifiable factors have been identified as relating to poor asthma control level. In this study we evaluated the distribution of asthma control levels in Portuguese adult population and examine the determinants associated with uncontrolled asthma. Materials and methods: Using a similar methodology to the one employed in the Asthma Insights and Reality in Europe (AIRE) survey, 327 active asthmatic patients were identified by random phone number and completed a questionnaire during 2011 to 2012. Asthma control was assessed by the evaluation of GINA based symptom control, by Asthma Control Test.äó (ACT) and by self-perception of control. To examine the relationship between uncontrolled asthma and its determinants, univariate logistic regression analysis, sequential multivariable regression and population attributable risk percentage were determinate. Results: 35.2% active asthmatic patients had uncontrolled asthma, 64.8% partially controlled and none of the individuals had total control of asthma assessed by ACT test. Factors significantly associated with poor asthma control scores were: age (OR 1.02 per year of age; 95% CI: 1.01.Çô1.03), female sex (OR 1.87; 95% CI: 1.15.Çô3.04), educational level (OR 0.5; 95% CI: 0.28.Çô0.89 at high school level or over), occupation (OR 4.92; 95% CI: 2.12.Çô11.42 if looking for a first job or unemployed) (OR 2.51; 95% CI: 1.35.Çô4.65 if being retired), income (OR 0.23; 95% CI: 0.07.Çô0.72 if >619 euros), BMI (OR 1.09 per BMI unit; 95% CI: 1.03.Çô1.14), having rhinitis symptoms (OR 4.40; 95% CI: 2.56.Çô7.58) and using inhaled corticosteroids (OR 0.44; 95%CI: 0.24.Çô0.82 if used in the past or never used). Looking for a first job or being unemployed, BMI and having rhinitis symptoms remained significant after multivariate adjustments. Conclusions: Uncontrolled asthma was associated with several determinants. Their identification can contribute to improve asthma care both from clinical and from public health perspectives., This study was supported by a grant from the General Directorate of Health (DGS) of the Portuguese Health Ministry and by a scientific grant from AstraZeneca Foundation.

RationalePulmonary tuberculosis (PTB) can cause post-TB lung disease (PTLD) associated with respiratory symptoms, spirometric and radiological abnormalities. Understanding of the predictors and natural history of PTLD is limited.ObjectivesTo describe the symptoms and lung function of Malawian adults up to 3 years following PTB-treatment completion, and to determine the evolution of PTLD over this period.MethodsAdults successfully completing PTB treatment in Blantyre, Malawi were followed up for 3 years and assessed using questionnaires, post-bronchodilator spirometry, 6 min walk tests, chest X-ray and high-resolution CT. Predictors of lung function at 3 years were identified by mixed effects regression modelling.Measurement and main resultsWe recruited 405 participants of whom 301 completed 3 years follow-up (mean (SD) age 35 years (10.2); 66.6% males; 60.4% HIV-positive). At 3 years, 59/301 (19.6%) reported respiratory symptoms and 76/272 (27.9%) had abnormal spirometry. The proportions with low FVC fell from 57/285 (20.0%) at TB treatment completion to 33/272 (12.1%), while obstruction increased from and 41/285 (14.4%) to 43/272 (15.8%) at 3 years. Absolute FEV1and FVC increased by mean 0.03 L and 0.1 L over this period, but FEV1decline of more than 0.1 L was seen in 73/246 (29.7%). Higher spirometry values at 3 years were associated with higher body mass index and HIV coinfection at TB-treatment completion.ConclusionSpirometric measures improved over the 3 years following treatment, mostly in the first year. However, a third of PTB survivors experienced ongoing respiratory symptoms and abnormal spirometry (with accelerated FEV1decline). Effective interventions are needed to improve the care of this group of patients.

The diagnosis of mast cell activation syndrome (MCAS) is defined by 3 criteria: (1) typical clinical signs and symptoms of acute, recurrent (episodic), and systemic mast cell activation (MCA); (2) increase in tryptase level to >20% + 2 ng/mL within 1-4 hours after onset of the acute crisis; and (3) response of MCA symptoms to antimediator therapy. Classification of MCAS requires highly sensitive and specific methodological approaches for the assessment of clonal bone marrow mast cells at low frequencies. The Spanish Network on Mastocytosis score has been used successfully as a predictive model for selecting MCAS candidates for bone marrow studies based on a high probability of an underlying clonal mast cell disorder. In this article, we propose a diagnostic algorithm and focus on the practical evaluation and management of patients with suspected MCAS. Key words: Anaphylaxis. Antimediator therapy. Mast cell activation syndrome. Mast cell mediator release–related symptoms. Tryptase.

Objectives To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist–led quality improvement and research that resulted in improved patient outcomes is provided. Data sources Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists. Study selection Not applicable. Data extraction Not applicable. Data synthesis Not applicable. Conclusions The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Objective The “Open Lung Approach” (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. Design A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. Setting Not applicable. Patients Fourteen RCTs were included in the study. Interventions Not applicable. Main variables of interest Not applicable. Results Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two “best” explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. Conclusions There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. Mortality effect of OLA is mediated by lung recruitment and mechanical power.

Personalized External Aortic Root Support (PEARS) is an evolving method of treatment for patients with a dilated aortic root or ascending aorta. This treatment is being adopted in an increasing number of centres. For the sake of the safety of the procedure a standardized surgical technique is necessary. The authors describe a surgical technique of implantation that is derived from their extensive experience.

© 2021, Springer Nature Switzerland AG.Purpose: Sleep apnea is a multifactorial illness which can be differentiated in various physiological phenotypes as a result of both anatomical and non-anatomical contributors (e.g., low respiratory arousal threshold, high loop gain). In addition, the frequency and duration of apneas, in the majority of patients with OSA, are influenced by sleeping position. Differences in characteristics between non-positional patients (NPP) and positional patients (PP) suggest another crucial phenotype distinction, a clinical phenotype focusing on the role of sleeping position on sleep apnea. Since this clinical phenotype distinction has therapeutic implications, further research is necessary to better understand the pathophysiology behind this phenotypic trait and to improve management of PP. Therefore, we suggest a standardized framework that emphasizes the role of sleeping position when reporting clinical and research data on sleep apnea. Methods: We identified 5 key topics whereby a standardized framework to report on the role of sleeping position would be of added value: (1) sleep study data, (2) anatomical, morphological and physiological factors, (3) drug-induced sleep endoscopy (DISE) findings, (4) sleep apnea management, and (5) effectiveness versus efficacy of positional therapy in sleep apnea management. We performed a literature search to identify evidence to describe and support the rationale behind these 5 main recommendations. Results: In this paper, we present the rationale behind this construct and present specific recommendations such as reporting sleep study indices (disease severity) and sleep time spent in various sleeping positions. The same is suggested for DISE findings and effect of treatment. Sleep study indices (disease severity), anatomical, morphological, and physiological factors in sleep apnea patients should be reported separately for PP and NPP. Conclusion: Applying these suggestions in future research will improve patient care, assist in better understanding of this dominant phenotype, and will enhance accurate comparisons across studies and future investigations.

Background Despite its popularity in recent years, segmentectomy still faces a challenge: the accurate delineation of the intersegmental plane, especially in complex segmentectomy. In this study, we describe a method using collateral ventilation to create an inflation-deflation line for video-assisted thoracoscopic surgery (VATS) segmentectomy and evaluated its efficacy in complex segmentectomy by comparing it with simple segmentectomy. Methods Enrolled in the study were 264 patients who underwent VATS segmentectomy from January 2017 to September 2018. We classified the clarity of the inflation-deflation line into 4 grades, and the procedures of grade 3 or 4 were considered successful. Meanwhile, we performed a propensity score matching analysis to compare complex and simple segmentectomy. Results Complete resection with free margins was achieved in all patients. In inflation-deflation line clarity evaluation, 245 patients were classified as grade 4 (92.8%), 10 as grade 3 (3.8%), 8 as grade 2 (3.0%), and 1 as grade 1 (0.4%). Procedural success (grade 3 or 4) was achieved in 255 patients (96.6%). Prolonged air leak (>5 days) was observed in 11 patients (4.2%). Propensity matching generated 83 pairs of well-matched patients. The proportion of procedural success and the incidence of prolonged air leak (>5 days) were similar in both groups. However, compared with simple segmentectomy, complex segmentectomy was associated with a longer median operative time (159 versus 135 minutes; P Conclusions Collateral ventilation method is simple, safe, and effective in VATS segmentectomy to identify the intersegmental plane, and also well-adapted for complex segmentectomy.

Lung cancer remains a major public health problem. There remain differences in mortality among socioeconomic and racial groups. Using The Society of Thoracic Surgeons General Thoracic Surgery database, we attempted to determine whether there were differences in treatment choices by thoracic surgeons based on patients' race or insurance.Using data from 2012 to 2017, we analyzed data from 75,774 patients with a diagnosis of lung cancer for whom complete information on race, insurance, or both was available, and who had undergone a pulmonary resection. We categorized 66,614 operations (87.9%) into standard (lobectomy, bilobectomy, or wedge excision) and 9160 (12.1%) into complex (pneumonectomy, sleeve or bronchoplastic resection, segmentectomy, or Pancoast resection) operations. Univariate and multiple variable logistic regression models were used to assess associations with receipt of a complex operation.Patients with private insurance had a higher incidence of complex operations (14.4%) compared with patients with government insurance (11.6%) (P.0001). We also found a higher incidence of complex operations in White patients (12.2%) compared with Nonwhite patients (11.3%; P = .0054). On multivariate analysis, patients with private insurance were significantly more likely to have a complex operation (odds ratio = 1.08; P.03) and Nonwhite patients were less likely to have a complex operation (odds ratio = 0.93; P = .04) respectively.In this cohort of patients from The Society of Thoracic Surgeons General Thoracic Surgery database, White patients and those with private insurance had a higher incidence of complex operations. Many factors affect the decision to proceed with a complex thoracic surgical operation; type of medical insurance and race may represent 2 of them.

BACKGROUND. The incidence and financial impact of persistent opioid use (POU) after open aortic surgery is undefined. METHODS. Insurance claim data from opioid-naïve patients who underwent aortic root replacement, ascending aortic replacement, or transverse arch replacement from 2011 to 2017 were evaluated. POU was defined as filling an opioid prescription in the perioperative period and between 90 and 180 days postoperatively. Postoperative opioid prescriptions, emergency department visits, readmissions, and health care costs were quantified. Multivariable logistic regression identified risk factors for POU, and quantile regression quantified the impact of POU on postoperative health care costs. RESULTS. Among 3240 opioid-naïve patients undergoing open aortic surgery, 169 patients (5.2%) had POU. In the univariate analysis, patients with POU were prescribed more perioperative opioids (375 vs 225 morphine milligram equivalents, P < .001), had more emergency department visits (45.6% vs 25.4%, P < .001), and had significantly higher health care payments in the 6 months postoperatively ($10,947 vs $7223, P < .001). Independent risk factors for POU in the multivariable logistic regression included preoperative nicotine use and more opioids in the first perioperative prescription (all P < .05). After risk adjustment, POU was associated with a $2439 increase in total health care costs in the 6 months postoperatively. CONCLUSIONS. POU is a challenge after open aortic operations and can have longer-term impacts on health care payments and emergency department visits in the 6 months after surgery. Strategies to reduce outpatient opioid use after aortic surgery should be encouraged when feasible.

Background Robotic surgery is an alternative to traditional and minimally invasive cardiac procedures. The adaption of robotics in congenital cardiac surgery has remained limited, however. We analyzed the early outcomes of our single-center experience in robotically assisted congenital cardiac surgery. Methods From May 2013 to February 2020, 242 robotic operations were done for secundum atrial septal defects (74.7%), sinus venous atrial septal defects (16.1%), partial anomalous pulmonary venous connections (10.7%), widely patent foramen ovale (3.7%), ostium primum defects (2.5%), unroofed coronary sinus (1.2%), partial atrioventricular canal defects (2.5%), residual septal defects after failed percutaneous closure (1.2%), ventricular septal defect (0.4%), cor triatriatum sinister (0.4%), subvalvular aortic stenosis (0.4%), common atrium (0.4%), and double-chambered right ventricle (0.4%) using the da Vinci system. Results There was no mortality. Mean age was 30.9 ± 12.1 years, and 132 (54.5%) patients were female. Thirty (12.3%) patients were pediatric (median, 16 years; range, 12-17 years). Mean cardiopulmonary bypass and aortic clamping times were 89.5 ± 30.0 and 44.9 ± 22.3 minutes, respectively. We noted a steady decrease in operation times during the first year. Conversion to larger thoracic incisions was needed in 2 (0.8%) patients. The postoperative rates of stroke, cardiac events, pulmonary complications, and reexploration were 0.4%, 2.4%, 4.1%, and 0.8%, respectively. Mean hospital stay was 3.5 ± 1.1 days. Conclusions Robotic technology can be utilized to perform suitable congenital cardiac procedures safely and effectively. With acceptable complication rates, robotic surgery can be an alternative to traditional, minimally invasive, and endoscopic approaches in adolescent and adult patients.

Rationale Mycobacterium abscessus is a significant threat to individuals with cystic fibrosis (CF) due to innate drug resistance and potential transmission between patients. Recent studies describe...

Background: Advances in aerosol technology have improved drug delivery efficiency during noninvasive ventilation (NIV). Clinical evaluation of the efficacy of aerosol therapy during NIV in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) is very limited. The aim of our study was to compare the efficacy of bronchodilators administered through a vibrating mesh nebulizer (VMN) and jet nebulizer (JN) during NIV in patients with acute exacerbation of COPD. Methods: Prospective randomized cross-over study included 30 patients treated with NIV for acute exacerbation of COPD in an acute care hospital. Patients were consented and enrolled after stabilization of acute exacerbation (3-5 days after admission). Subjects were randomly assigned into two treatment arms receiving salbutamol (2.5 mg): with VMN (Aerogen Solo) and JN (Sidestream) positioned between the leak port and the nonvented oronasal mask during bilevel ventilation with a single-limb circuit. Measurements (clinical data, pulmonary function tests [PFTs], and arterial blood gases) were performed at baseline, 1, and 2 hours after treatment. Results: All measured PFT parameters significantly increased in both groups, but numerically results were better after inhalation with VMN than with JN: for forced expiratory volume in 1 second (FEV1) (mean increase from baseline to 120 minutes-165 ± 64 mL vs. 116 ± 46 mL, p = 0.001) and for forced vital capacity (FVC) (mean increase-394 ± 154 mL vs. 123 ± 57 mL, p < 0.001). There was also a statistically significant reduction in respiratory rate and in Borg dyspnea score after therapy with VMN in comparison with the conventional JN. In both groups, there were improvements in PaCO2, but with VMN these changes were significantly higher. Conclusion: Bronchodilator administration in patients with acute exacerbation of COPD during NIV with VMN resulted in clinically significant improvements in FVC and in Borg dyspnea score. Additional studies required to determine the impact on clinical outcomes.

Rationale: Outdoor air pollution contributes to asthma development and exacerbations, yet its effects on airway pathology have not been defined in children. Objectives: To explore the possible link between air pollution and airway pathology, we retrospectively examined the relationship between environmental pollutants and pathological changes in bronchial biopsy specimens from children undergoing a clinically indicated bronchoscopy. Methods: Structural and inflammatory changes (basement membrane [BM] thickness, epithelial loss, eosinophils, neutrophils, macrophages, mast cells, and lymphocytes) were quantified in biopsy specimens by using immunohistochemistry. The association between exposure to particulate matter less than 10 μm in aerodynamic diameter (PM10), SO2 and NO2 and biopsy findings was evaluated by using a generalized additive model with Gamma family to allow for overdispersion, adjusted for atmospheric pressure, temperature, humidity, and wheezing. Results: Overall, 98 children were included (age 5.3 ± 2.9 yr; 53 with wheezing/45 without wheezing). BM thickness increased with prolonged exposure to PM10 (rate ratio [RR], 1.29; 95% confidence interval [CI], 1.09–1.52), particularly in children with wheezing. Prolonged exposure to PM10 was also associated with eosinophilic inflammation in children with wheezing (RR, 3.16; 95% CI, 1.35–7.39). Conversely, in children without wheezing, increased PM10 exposure was associated with a reduction of eosinophilic inflammation (RR, 0.12; 95% CI, 0.02–0.6) and neutrophilic inflammation (RR, 0.36; 95% CI, 0.14–0.89). Moreover, NO2 exposure was also linked to reductions in neutrophil infiltration (RR, 0.57; 95% CI, 0.34–0.93) and eosinophil infiltration (RR, 0.33; 95% CI, 0.14–0.77). Conclusions: Different patterns of association were observed in children with wheezing and in children without wheezing. In children without wheezing, exposure to PM10 and NO2 was linked to reduced eosinophilic and neutrophilic inflammation. Conversely, in children with wheezing, prolonged exposure to PM10 was associated with increased BM thickness and eosinophilic inflammation, suggesting that it might contribute to asthma development by promoting airway remodeling and inflammation.

Resumen Objetivo El objetivo de este estudio es analizar los datos actuales del nivel de conocimiento de la poblacion sobre la EPOC y evaluar algunas actuaciones diagnosticas, como el uso de espirometria. Material y metodos Estudio epidemiologico, observacional y transversal mediante entrevista telefonica, con marcacion aleatoria de numeros de telefono fijos, realizado en noviembre del 2019, con una muestra representativa a nivel nacional en adultos mayores de 40 anos. Resultados De un total de 51.079 contactos telefonicos se obtuvo un total de 1.920 encuestados. La edad media era 61,9 anos, con 31,6% de hombres. El 19,4% de ellos eran fumadores actuales y un 13,4% referia tener alguna enfermedad respiratoria (5% referia una EPOC). El 27,9% tenia conocimiento espontaneo sobre la EPOC, lo que supone un aumento relativo respecto al 17% observado en el 2011. El canal de informacion mas frecuente eran los medios de comunicacion (35,5%), con importante presencia de redes sociales e Internet (25,7%). Un 18,1% tenia sintomas respiratorios cronicos. De ellos, un 59,3% solicito atencion medica y un 66,2% se realizo la espirometria. La espirometria era realizada con menor frecuencia en sujetos atendidos en Atencion Primaria respecto a Neumologia (51,9% vs. 79,1%; p Conclusiones El conocimiento de la EPOC es todavia escaso y son necesarias estrategias para aumentar la concienciacion y la importancia de evaluar los sintomas respiratorios y el mayor uso de la espirometria.